bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of clinical risk factor profile vs. atrial fibrillation phenotype on outcome after pulmonary vein isolation
Authors: Wittmer S , Chollet L , Baldinger S , Servatius H , Seiler J , Madaffari A , Kueffer T , Muehl A , Asatryan B , Lam A , Noti F , Haeberlin A , Roten L , Tanner H , Reichlin T
Published: October 2021

Aims

Catheter ablation for atrial fibrillation (AF) is increasingly performed. Both clinical risk factors as well as the AF phenotype have been shown to influence ablation outcomes. The inter-relationship of the two however is incompletely understood.

Methods

In a retrospective analysis of a prospective registry of patients undergoing a first pulmonary vein isolation, the association of 8 predefined clinical risk factors (age >70 years, female gender, hypertension, BMI >30 kg/m2, coronary artery disease, heart failure, chronic kidney disease (CKD; eGFR<60ml/min/1.73m2) and diabetes mellitus) and the AF phenotype (paroxysmal vs. persistent AF) were assessed as well as their impact on AF recurrence during follow-up.

Results

Overall, 715 patients were enrolled (median age 63 years, 27% females, 69% paroxysmal AF). The prevalence of obesity, hypertension, heart failure and CKD was significantly higher in persistent AF, while female gender was more prevalent in paroxysmal AF. After 2 years of follow-up, overall freedom from recurrence was 46%, and was higher in paroxysmal AF compared to persistent AF (54.1% vs. 29.1%, p<0.001). Of the clinical risk factors, obesity (p=0.02), CKD (p=0.01) and heart failure (p=0.01) were significantly associated with lower arrhythmia-free survival, and there was a trend for hypertension and coronary artery disease (both p<0.2). A risk score composed of those 5 factors was associated with recurrences in patients with paroxysmal AF (p=0.04, Figure 1), but not in those with persistent AF (p=0.85, Figure 2).

Conclusion

Clinical risk factors predict outcome after pulmonary vein isolation in patients with paroxysmal, but not persistent AF. This is likely due to a strong association of those risk factors with the occurrence of persistent AF.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
A multicentered evaluation of the waiting period after PVI guided by the Ablation Index
Authors: De Campos D , Sousa P , Adao L , Primo J , Khoueiry Z , Lebreiro A , Fonseca P , Lagrange P , Elvas L , Goncalves L
Published: October 2021

Background

Since the widespread availability of contact-force sensing catheters the need of a waiting period has not been reassessed in paroxysmal atrial fibrillation (AF) ablation.

Objective

The purpose of this study was to evaluate if pulmonary vein isolation (PVI) guided by the Ablation Index (AI) could spare the need for a waiting phase.

Methods

This multicentre, prospective, randomized study consecutively recruited patients referred for first-time catheter ablation of symptomatic drug-refractory paroxysmal AF from May 2019 to February 2020. Patients performed PVI tailored to different AI values according to the different left atrium walls (550 for anterior, 500 for roof, 450 for inferior and 400 for posterior). Patients were enrolled in 1:1 ratio to PVI and 20 min of waiting time versus PVI without a waiting period. Acute reconnection (either spontaneous or after adenosine) and 1-year arrhythmia freedom were analyzed.

Results

The study included 124 patients (61 in the waiting period group and 63 in the group without the waiting period). There was no significant differences between groups regarding baseline characteristics, echocardiographic and procedure data. There were no significant differences between both groups regarding the first-pass PV isolation (P=0.49) and the presence of low voltage areas (P=0.71). Median PVI time (P=0.40), median fluoroscopy time (P=0.35) and median overall procedure time (P=0.70) were also similar between groups. The acute PVR rate was similar between both groups (8.2% for the waiting period group vs 11.1% in the group without a waiting phase, P=0.40). After a median follow-up of 14 (IQR 12–18) months, there was no significant difference on the arrhythmia recurrence between groups (4.9% for the waiting group vs 12.7% for the group without a waiting phase, P=0.13). Both groups presented a similar arrhythmia freedom over time (log rank P of 0.109). The waiting period time was not a predictor of recurrence during follow-up (p=0.13).

Conclusion

PVI guided by Ablation Index preclude the need of a waiting phase. Adding a 20-minute waiting period did not significantly increase the acute PV reconnection, neither improve the 1-year arrhythmia freedom.

Funding Acknowledgement

Type of funding sources: None.
Rotational activity presence and its impact in persistent atrial fibrillation follow-up
Authors: Rios-Munoz G R , Soto N , Avila P , Datino T , Atienza F , Gonzalez-Torrecilla E , Fernandez-Aviles F , Arenal A
Published: October 2021

Introduction

Treatment of atrial fibrillation (AF) remains sub-optimal, with low success in pulmonary vein isolation (PVI) ablation procedures in long-standing-persistent AF patients. The maintenance mechanisms of AF are still under debate. Rotational activity (RA) events, also known as rotors, may play a role in perpetuating AF. The characterisation of these drivers during electroanatomical (EA) guided ablation procedures in relationship with follow-up and recurrence ratios in AF patients is necessary to design new ablation strategies to improve the AF treatment success.

Purpose

We report an AF patient cohort of endocardial mapping and PVI ablation procedures with additional RA events detected during the EA study. We aim to study the presence and distribution of RA in AF patients and its impact on AF recurrence when only PVI ablation is performed.

Methods

75 persistent consecutive AF patients (age 60.7±9.8, 74.7% men) underwent EA mapping and RA detection with an automatic algorithm. The presence of RA was annotated on the EA map based on the unipolar electrograms (EGMs) registered with a 20-pole catheter. RA presence was analysed at different left atrial locations (37.2±14.8 sites per patient). AF recurrence was evaluated in follow-up after treatment.

Results

At follow-up (9±5 months), 50% of the patients presented AF recurrence. Patients with RA had more dilated atria in terms of volumes (p=0.002) and areas (p=0.001). Patients with RA exhibited higher mean voltage EGMs 0.6±0.3 mV vs 0.5±0.2 mV (p=0.036), with shorter cycle lengths 169.1±26.0 ms vs. 188.4±44.2 ms (p=0.044). Finally, patients with RA presented more AF recurrence rates than patients with no RA events (p=0.007). No significant differences were found in terms of comorbidities, e.g., heart failure, hypertension, COPD, stroke, SHD, or diabetes mellitus.

Conclusions

The results show that patients with more RA events and those with RA outside the PVI ablated regions presented higher AF recurrence episodes than those with no RA or events inside the areas affected by radio-frequency ablation. The study suggests that further ablation treatment of the areas harboring RA might be necessary to reduce the recurrence ratio in AF patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III; Sociedad Española de Cardiología
Long-term outcomes of catheter ablation for ventricular arrhythmias in post- myocarditis patients; Insights from a meta-analysis of current datv
Authors: Androulakis E , Briasoulis A , Falconer D , Lim W , Siasos G , Ahluwalia N , Graham A , Papageorgiou N
Published: October 2021

Background

In the past decade, catheter ablation (CA) has become a rapidly expanding treatment option for ventricular tachycardia (VT), however it is not commonly utilized for patients with post-myocarditis VT. We aimed to systematically review up-to-date evidence regarding feasibility, effectiveness, and safety of CA, with a specific focus on long-term relapse rate and procedural complications.

Methods

A structured electronic database search (PubMed, Embase, Cochrane) of the scientific literature was performed for studies describing outcomes at up to 7.3 years after CA. The primary outcome measured was VT recurrence post-ablation. Procedural success was defined as freedom of ventricular arrhythmias (at the end of follow-up after an ablation procedure). The secondary outcome was significant procedural complications which included procedural death, stroke, cardiac tamponade, acute myocardial infarction, major vascular complications, and major bleeding, assessed on a study-by-study basis.

Results

A total of 186 patients were included in analysis with most patients (88%) being male.

Over the follow up period there was a 18% relapse rate (n=34) (Confidence Interval (CI); 0.12–0.24, I2≈0, p=0.77) with the majority of patients remaining VT free for the duration of follow up. Only one study recorded the percentage of re-do procedures. The overall procedural complication rate was 3.0% (n=7, (CI; 0.01–0.07, I2≈0, p=0.44) and of note, there were no peri-procedural deaths or heart transplant surgeries reported. However, a single study reported a mortality of 10% (n=2) during the follow up period.

Conclusions

CA is an effective and durable long-term therapeutic strategy for post myocarditis VT patients with limited relapse rate and very low complication rates based on these non-randomised data. Larger randomised-controlled trials with standardised treatment and long follow-up are required to compare CA versus conventional treatment in the post-acute myocardial phase.

Funding Acknowledgement

Type of funding sources: None. Relapse rate during follow-upProcedural complication rate
A tertiary centre experience comparing new temperature-controlled high-power short-duration ablation technology with standard radiofrequency and cryo-energy ablation
Authors: Mavilakandy A , Sidhu B , Man S , Antoun I , Vali Z , Almeida T P , Li X , Lazdam M , Ibrahim M , Chin S H , Sandilands A , Somani R , Stafford P , Ng A
Published: October 2021

Introduction

Pulmonary vein isolation (PVI) is an established treatment strategy for atrial fibrillation (AF). Radiofrequency (RF) ablation technology has evolved over the last decade with the very high-power short-duration (vHPSD) temperature-controlled ablation approach emerging as the latest development. The aim of this study was to determine the procedural efficacy, metrics and safety of vHPSD ablation with conventional power-controlled RF (PCRF) ablation and cryo-energy ablation (CRYO).

Methods

A prospective single tertiary centre analysis was performed on patients undergoing first time PVI ablation from 2019 to 2020. The population was divided in to 4 treatment arms; vHPSD, high-power short-duration (HPSD), PCRF and CRYO. Demographics, clinical and procedural metrics such as PVI duration, ablation time and sedation requirement were collated. Patients were monitored for perioperative complications.

Results

One hundred patients underwent ablation with 25 cases conducted in each arm. Complete PVI was attained in all study subjects. For the vHPSD group, PVI procedural duration, ablation and fluoroscopy times were 71.7±6.35 min, 9.21±0.76 min and 15.1±1.50 min respectively. The HSPD group exhibited total PVI, burn and fluoroscopy times of 90.2±5.59 min (p=0.03), 10.3±2.40 min (p<0.0001) and 34.1±1.67 min (p=0.1) respectively. In comparison, the PCRF group exhibited longer procedure duration, ablation and fluoroscopy times of 93.3±6.50 min (p=0.01), 15.2±1.73 min (p<0.0001), 37.8±2.47 min (p=0.870). Whereas procedural and fluoroscopy times of 96.3±7.1 min (p=0.01) and 18.8±1.31 (p=0.05) were observed in the cryo-ablation group. Procedural doses of morphine and midazolam for the vHPSD, HPSD, PCRF and CRYO group were 11.3 mg + 4.00 mg, 15.5 mg (p=0.0003) + 9.33 mg (p=0.0003), 15.7 mg (p=0.0002) + 8.03 mg (p=0.02), and 8.19 mg (p=0.01) + 4.84 mg (p=0.303) respectively. No adverse procedural events were recorded for the vHPSD while 2 pericardial effusions occurred in the PCRF group, 1 cardiac tamponade in the HPSD group and 2 transient ischaemic attacks in the CRYO group.

Conclusion

With the emergence of vHPSD RF ablation, preliminary findings indicate significant potential in reduction of procedural and ablation time. Further analysis is ongoing in order to ascertain longer-term efficacy and patient safety.

Funding Acknowledgement

Type of funding sources: None. Intraprocedural outcomesIntraprocedural outcomes
Clinical impact of high density mapping in atypical atrial flutters ablation: outlining critical circuits in complex atrial tachycardias
Authors: Di Cori A , Mazzocchetti L , Parollo M , Della Volpe S , Barletta V , Cellamaro T , Segreti L , Viani S , De Lucia R , Paperini L , Giannotti M , Canu A , Soldati E , Zucchelli G , Bongiorni M G
Published: October 2021

Introduction

Mapping and ablation of atypical atrial flutter (AFL) continue to be a challenge for clinical electrophysiologists. The advent of high-density (HD) mapping has allowed the generation of electro-anatomic maps with a very high resolution level.

Purpose

In this single center retrospective analysis, we evaluated the clinical impact of the ultra HD activation sequence mapping compared with the standard low density (LD) ablation catheter mapping technique in the treatment of AFLs.

Methods

We performed a 7 years-single center retrospective analysis of patients undergoing radiofrequency ablations (RFA) for right and left atypical AFL. We evaluated procedural and clinical outcomes of patients approached with a Low Density (LD) electro-anatomical (EAM) strategy compared with patients mapped with new automatic multipolar HD Mapping (HD Group).

Results

Seventy-five patients were included. Patients were almost male (60%), relatively old (65±8 years), with a moderate CHA2DS2Vasc score (2.3±1.3), a preserved ejection fraction (58±6) and moderate atrial dilatation (44±7 mm). Baseline clinical characteristics were comparable between groups (p=NS). Among 88 AFLs, 10 (11%) were located in the right and 78 (89%) in the left atrium, including 22 (28%) roof dependent and 37 (47%) mitral dependent (p=NS). Regarding procedural outcomes, Sinus rhythm restoration during ablation was more frequently observed in the HD Group (79% vs 56%, p=0.037), even if no differences in mapping time, procedural time and radiological dose were observed (p=NS). Freedom from AFL/atrial fibrillation (AF) at 1-year was lower in the HD Group (83% vs 45%, p=0.009) with an increased trend for AF recurrences during long term follow-up (17% vs 23% at 1 and 3-years respectively, p=0.059). At the multivariate analysis, HD map (OR 0,17; 95% CI 0,04–0,66) and younger age (OR 1,09; 95% CI 1,01–1,19) were identified as independent predictors of ablation success at 1 year.

Conclusions

Acute procedural success of ablation of atypical atrial flutter is higher in case of HD mapping strategy. Patient age and HD strategy resulted independent predictors of overall atrial arrhythmias recurrences. During follow-up, AFL recurrences are rare beyond 12 months, differently from AF which continues to show increasing trends.

Funding Acknowledgement

Type of funding sources: None. Procedural outcomesAtypical atrial flutter HD map
Secondary prevention implantable cardioverter-defibrillator (ICD) therapy in octogenarians: effective and safe
Authors: Hauck C , Schober A D , Schober A L , Fredersdorf-Hahn S , Hubauer U , Keyser A , Maier L S , Jungbauer C G , Uecer E
Published: October 2021

Aims

Implantable cardioverter-defibrillator is well established for secondary prevention, but there is a lack of studies showing efficacy and safety in the elderly. The current study compared the outcome of octogenarians after ICD implantation to other age groups.

Methods

Data was achieved from a local ICD registry. Patients who received ICD implantation for secondary prevention were included. All-cause mortality, appropriate ICD therapy and acute adverse events requiring surgical intervention were compared between different age groups.

Results

519 patients were enrolled. 34 patients were ≥80 years. Over a median follow-up of 35 months after ICD implantation 129 patients (annual mortality rate 5.0%) died, including 16 patients in the age group ≥80 years (annual mortality rate 9.4%). Mortality rate in the age group ≥80 years was significantly higher than in the age groups ≤69 years (p<0.001) but no difference could be seen compared to age groups 70–79 y. Age at the time of ICD implantation was an independent predictor of all-cause mortality (p<0.001). 29.7% of patients had appropriate ICD therapy with no difference between age groups. Acute adverse events leading to surgical intervention were low (n=13) and not age-related.

Conclusion

Age is an independent predictor of mortality after ICD implantation for secondary prevention. No difference in mortality rate could be seen between octogenarians and other elderly from 70 – 79 years. Appropriate ICD therapy and acute adverse events leading to surgical intervention were not age-related. Implantable cardioverter-defibrillator for secondary prevention seems to be an effective and safe therapy in octogenarians.

Funding Acknowledgement

Type of funding sources: None.
Multipoint left ventricular pacing effects on hemodynamic parameters and functional status: HUMVEE single-arm clinical trial
Authors: Konstantinou K , Xydis P , Antoniou C K , Magkas N , Manolakou P , Chrysohoou C , Dilaveris P , Gatzoulis K , Tsioufis K
Published: October 2021

Objectives

The aim of this study was to assess the capacity of optimized multipoint pacing (MPP) over optimized cardiac resynchronization therapy (CRT), in terms of clinical, functional, and echocardiographic parameters among dyssynchronous heart failure patients.

Methods

Eighty patients (Caucasian, 77.5% male, 68.4±10.1 years, 53.8% ischemic cardiomyopathy) sequentially received optimized CRT and optimized MPP over 6 and 12-month periods, in a single-arm clinical trial. Clinical, laboratory and echocardiographic assessment was conducted at baseline and following completion of each step.

Results

Significant additive effects of optimized MPP over optimized CRT were noted regarding 6-minute walking distance (baseline/optCRT/optMPP: 293±120m vs 367±94m vs 405±129m, p<0.001), NYHA class (2.36 vs 2.19 vs 1.45, p<0.001), VTIlvot (14.25±3.2cm vs 16.2±4cm vs 17.5±3.4cm, p<0.001), stroke volume (48±13.5ml vs 55±15ml vs 59±15ml, p<0.001), LVEF (29%±7.1% vs 33%±7.3% vs 37%±7.7%, p<0.001), maximal left atrial volume (77.2±34.2ml vs 74.2±39.5ml vs 67.7±32ml, p=0.02), pulmonary artery systolic pressure (35.9mmHg vs 33.5mmHg vs 31mmHg, p<0.001), and right ventricular strain (−8.3%±6.9% vs −8.8%±6.6% vs −11.8%±6.1%, p=0.022). Regarding VAC SW and CP as percentages of maximal, there was significant difference detected compared to baseline for both CRT and MPP. Additive effects persisted only if suitable MPP dipoles were present. Exploratory analysis revealed that ischemic cardiomyopathy continued to exhibit significant differences favoring MPP, whereas nonischemic cardiomyopathy had similar findings regarding total left atrial strain and quality of life.

Conclusions

Optimized MPP showed significant improvements on hemodynamic parameters and ventricular function, in heart failure patients over optimized CRT. The beneficial effect was more prominent in men and in those with rather reduced LVEF, consistent with findings suggesting a beneficial trend in VAC and CP with the more homogenous depolarization offered by optimized MPP

Funding Acknowledgement

Type of funding sources: None.
Predictors and outcomes of TLE via femoral vein bailout
Authors: Shafir Y , Massalha E , Milman A , Luria D , Glikson M , Sabbag A , Beinart R , Nof E , Leshem E
Published: October 2021

Background

Transvenous Lead Extraction (TLE) is usually performed via a superior approach. Predictors and outcomes of TLE via femoral vein bailout are ill defined.

Methods

A single tertiary center cohort of 426 consecutive patients who underwent TLE between May 2010 and February 2020 were analyzed. Venography was routinely performed before system upgrade to identify occluded veins. Patients were divided into 2 groups on the basis of the need for femoral bailout extraction. Predictors for TLE requiring femoral bailout and outcomes were analysed.

Results

A total of 928 leads were extracted and femoral bailout approach was needed in 49 patients (11.5%). A higher proportion of RV leads required femoral bailout approach [51/499 (10.2%)]. Femoral bailout was more common among younger patients, longer lead dwell time, more pocket entries, higher number of extracted leads, presence of abandoned leads [14/49 (28.6%)], and among patients with occluded veins [10/22 (45.5%)]. The presence of abandoned leads, vascular occlusion and age remained a significant predictor for femoral bailout in multivariate analysis. Femoral bailout TLE resulted in a relatively higher rate of major complications [5/49 (10.2%) vs 9/377 (2.4%); p=0.02) but had no related intra-procedural mortality (0/3) and no additional 30 day mortality [2/49 (4.1%) vs 33/377 (8.8%); p=0.4].

Conclusion

TLE of abandoned leads, occluded veins and younger age were found to be predictors of femoral bailout requirement. Despite higher rates of major complications in femoral TLE bailout this did not result in increased mortality. Venography before TLE should be considered for procedure planning.

Funding Acknowledgement

Type of funding sources: None.
Same-day discharge vs hospital admission after cardiac device implantations: a systematic review and meta-analysis
Authors: Trongtorsak A , Kewcharoen J , Thangjui S , Worapongsatitaya P , Yodsuwan R , Navaravong L
Published: October 2021

Background

Due to the increasing need for cardiac device implantations, the cost of healthcare has been rising. This includes the cost of hospital stay after the procedure. Thus, we conducted this systematic review and meta-analysis to assess the safety and feasibility of same-day discharge (SDD) after cardiac device implantations.

Methods

We searched MEDLINE, and Embase databases from inception to March 2021 to identify studies that compared clinical outcomes between SDD group and hospital overnight stay (HO) group after cardiac device implantations. Outcomes included complications after the procedure, mortality, and rehospitalization. Data from each study were combined using the random-effects model to calculate pooled odds ratio (OR) with 95% confidence interval (CI).

Results

Six studies (1 randomized control trial, 1 prospective cohort study and 4 retrospective cohort studies) with a total of 59,312 patients were included. SDD was not associated with more procedure-related complications. The pooled ORs for wound problems, pneumothorax, hematoma, and lead dislodgement/repositioning were 0.86 (95% CI: 0.2–3.68, p=0.834), 1.36 (95% CI: 0.26–7.12, p=0.718), 0.35 (95% CI: 0.01–9.85, p=0.534), and 1.71 (95% CI: 0.64–4.54, p=0.281) respectively. Readmission rate (pooled OR= 1.38, 95% CI: 0.51–3.69, p=0.524) and mortality rate (pooled OR= 0.86, 95% CI: 0.62–1.2, p=0.383) were similar between both groups. As shown in figure 1.

Conclusions

Our meta-analysis suggested that same-day discharge after cardiac device implantations is a safe and feasible alternative to a hospital overnight stay strategy.

Funding Acknowledgement

Type of funding sources: None.
Atrial fibrillation as a risk factor of severe course of COVID-19
Authors: Mielczarek A , Kasprzak J D , Plewka M
Published: October 2021

Background

Coronavirus disease (COVID-19), the pandemic caused by severe acute respiratory syndrome coronavirus, influences on morbidity and mortality and results in changes of human life. It seems that comorbidities play a vital role in severe course of COVID- 19. Nevertheless, how chronic diseases affect respiratory failure is poorly validated.

Purpose

Our aim was to compare the severity of the course of COVID-19 and the prognosis in patient with and without atrial fibrillation (AF).

Methods

We analyzed 199 patients (72 female, mean age 67±13 years) with COVID-19 hospitalized in our Department since November 2020, including, 68 patients with AF (28 female, mean age 74.5±8 years). Although, only 45 patients took anticoagulants before, the treatment was initiated to all patients with AF on admission to the hospital. Patients with AF were characterized by lower left ventricle ejection fraction than those without AF (49% vs. 54%, p=0.0007).

Results

The severe course of COVID, defined as saturation below 90%, lung involvement above 50% in computer tomography, the need for high- flow oxygen therapy, was noticed in 98 patients (36 pts with AF, 32 pts without AF, p=0.27). Moreover, there was no difference between the groups among separately the need for high- flow oxygen therapy, saturation below 90% and lung involvement above 50% in computer tomography. The absence of atrial fibrillation, with a significance of p=0.01, predisposes to a better prognosis based on the patient's discharge. In multivariate analysis, the factors suggesting a poor prognosis, defined as death or transfer to Intensive Care Unit, were severe course of COVID (p=0.01) and the need for high- flow oxygen therapy (p=0.042).

Conclusions

It is noticed that the presence of AF is associated with a poor prognosis in COVID. Further analysis is still needed to prove this statement.

Funding Acknowledgement

Type of funding sources: None.
Prognostic implications of valvular heart disease in patients with non-valvular atrial fibrillation
Authors: Samaras A , Vrana E , Kartas A , Rampidis G , Doundoulakis I , Fotos G , Efthimiadis G , Karvounis H , Tzikas A , Giannakoulas G ,   MISOAC-AF
Published: October 2021

Background

Atrial fibrillation (AF) and valvular heart disease (VHD) are frequently encountered in clinical practice, and often coexist, especially in the elderly population. Both conditions are associated with increased mortality and morbidity. Recent guidelines suggest careful evaluation of patients with AF and VHD due to the puzzling nature of their coexistence.

Purpose

To evaluate the prognostic effect of significant valvular heart disease (sVHD) among patients with non-valvular AF.

Methods

This is a post-hoc analysis of the MISOAC-AF trial (NCT02941978). Consecutive inpatients with non-valvular AF who underwent echocardiography were included. sVHD was defined as the presence of at least moderate aortic stenosis (AS) or aortic/mitral/tricuspid regurgitation (AR/MR/TR). Cox regression analyses with covariate adjustments were used for outcome prediction.

Results

In total, 983 patients with non-valvular AF (median age 76 years) were analyzed over a median follow-up period of 32 months. sVHD was diagnosed in 575 (58.5%) AF patients. sVHD was associated with all-cause mortality (21.6%/yr vs. 1.6%/yr; adjusted HR [aHR] 1.55, 95% confidence interval [CI] 1.17–2.06; p=0.02), cardiovascular mortality (16%/yr vs. 4%/yr; aHR1.70, 95% CI 1.09–2.66; p=0.02) and heart failure-hospitalization (5.8%/yr vs. 1.8%/yr; aHR 2.53, 95% CI 1.35–4.63; p=0.02). The prognostic effect of sVHD was particularly evident in patients aged <80 years and in those without history of heart failure (p for interaction <0.05, in both subgroups) [Figure 1]. After multivariable adjustment, moderate/severe AS and TR were associated with mortality, while AS and MR with heart failure-hospitalization [Figure 2]. AS was the only independent predictor of valve intervention during follow-up (aHR 10.78, 95% CI 4.80–24.22; p<0.001). Mixed aortic valve disease (AS+AR) had superior prognostic power across patterns of combined VHD.

Conclusions

Among patients with non-valvular AF, sVHD was highly prevalent, and beared high prognostic value across a wide spectrum of clinical outcomes. AS, MR, TR and mixed aortic valve disease were associated with worse prognosis.

Funding Acknowledgement

Type of funding sources: None. Subgroup analyses by VHD statusPrognostic impact of valve lesions
Effect of pulmonary vein isolation on left atrial remodeling and muscle sympathetic nerve activity in patients with atrial fibrillation
Authors: Mukai Y , Murai H , Hirai T , Sugimoto H , Hamaoka T , Tokuhisa H , Takamura M
Published: October 2021

Background

Catheter ablation (CA) for atrial fibrillation (AF) improves left ventricular function and induces left atrium reverse remodeling (LARR). CA is also associated with the modulation of ganglionated plexi in the left atrium (LA), including stretch-sensitive sympathetic and parasympathetic nerve mechanoreceptors. Increased filling pressure and enlargement of LA stimulate stretch-sensitive sympathetic nerve mechanoreceptors in heart failure, which contribute augmented sympathetic nerve activity. However, little is known about an effect of CA on the interaction between the changes of LARR and sympathetic nerve activity.

Purpose

To test the hypothesis that CA induce the reduction in sympathetic nerve activity in accordance with LARR in patients with atrial fibrillation.

Methods

This study was conducted as a retrospective, observational study. Twenty-eight AF patients (65.4±12.1 years old) were included in this study. We measured mean blood pressure (BP), heart rate (HR), brain natriuretic peptide (BNP), and direct recording of muscle sympathetic nerve activity (MSNA) using microneurography technique before and 12 weeks after CA. Echocardiogram was also performed to assess LARR and left ventricular function. To evaluate the interaction between LARR and MSNA, AF patients were divided into two groups by presence (LARR group; n=18) and absence (no LARR group; n=10) of LARR according to left atrium volume index (LAVi) following CA.

Results

No significant differences were observed at baseline in BP, MSNA and LAVi between two groups. BP did not change significantly after CA in both groups. HR significantly increased in the LARR group (63.1±5.7 vs 69.9±7.8, p<0.01) compared to no LARR group. CA significantly reduced MSNA in the LARR group (37.8±10.1 vs 24.9±8.8 bursts/min, p<0.01), but there was no significant change in the no LARR group. The septal E/e' ratio (11.3±3.8 vs 9.8±2.9, p<0.05), left ventricular end-systolic volume index (LVESVi) (24.4±11.9 vs 19.6±7.8 ml/m2, p<0.05) and Ln BNP (4.0±1.2 vs 3.3±1.0 log/pg/ml, p<0.05) were also significantly improved in the LARR group. On the other hand, in the no LARR group, there were no significancy in the changes of the septal E/e' ratio, LVESVi and Ln BNP. LVEF was not significantly changed in both two groups.

Conclusion

Our study shows CA reduced MSNA accompanied by LARR in AF patients. The reduction in MSNA, septal E/e' ratio, LVESVi and Ln BNP were all more pronounced in the LARR group compared to the no LARR group. These findings suggest that LARR is associated with the reduction in MSNA in AF patients, which was attributed to CA-induced modulation of stretch-sensitive sympathetic nerve mechanoreceptors.

Funding Acknowledgement

Type of funding sources: None.
Most remote monitoring alerts about atrial fibrillation are not relevant to identify clinically significant events: proposal of a new approach
Authors: Rosier A , Gentils M , Lazarus A , Moubarak G , Klaes S , Durand J , Danoun K
Published: October 2021

Background

Cardiac Implantable Electronic Devices (CIEDs) are an important tool for detecting Atrial Fibrillation (AF) in implanted patients.

However AF burden values and notifications emitted by the manufacturer's platforms are not directly related to the standard classification of AF types (paroxysmal, persistent or permanent) that are used in daily practice. Moreover, AF alerts represent the most frequent notifications for implanted patients resulting in a time-consuming review for healthcare professionals.

Purpose

This study intends to compare the manufacturers' atrial burden related notifications in remotely monitored (RM) patients to the detection of clinically significant events with a new proprietary algorithm.

Methods

From 2017 to 2020, all RM patients from 57 centers with daily atrial burden measurements available for at least 30 days and at least one atrial burden related alert were enrolled.

All atrial burden related alerts emitted by the manufacturers' platforms were compared to the following clinically significant events (based on the standard classification) detected by a new proprietary algorithm: “1st recorded AT/AF episode”, “paroxysmal AF”, “increasing paroxysmal AF”, “persistent AF”, and “end of persistent AF”.

Results

This multicentric retrospective study analyzed, between 01/2017 and 10/2020, 2 463 RM patients with a Biotronik, Boston Scientific or Medtronic CIED (implantable defibrillator, pacemaker or implantable loop recorder), with a mean follow-up of 490 days [33–1386].

A total of 22 345 manufacturers' atrial burden related alerts were emitted while only 4 826 clinically significant events were detected by the algorithm: 1770 “1st recorded AT/AF episode”, 620 “Paroxysmal AF”, 252 “Increasing paroxysmal AF”, 1373 “Persistent AF”, and 811 “End of persistent AF”.

These clinically significant events represent only 22% of the total number of atrial burden related alerts emitted by the manufacturers' platforms.

Conclusion

A new AF alert algorithm could have the potential to identify clinically significant AF status change in remotely monitored implanted patients while reducing the total number of alerts generated and thus the review burden for healthcare professionals.

Funding Acknowledgement

Type of funding sources: None.
Clinical application of the novel 4S-AF scheme for the characterisation of patients with atrial fibrillation: a report from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) registry
Authors: Ding W.Y , Proietti M , Boriani G , Marin F , Blomstrom-Lundqvist C , Fauchier L , Potpara T.S , Lip G.Y.H
Published: October 2021

Background

Current classification systems recommended by major international guidelines are based on a single domain of atrial fibrillation (AF): temporal pattern, symptom severity or underlying comorbidity. Lack of integration between these various elements limits our approach to patients with AF and acts as a barrier against the delivery of better holistic care. The 4S-AF classification scheme was recently introduced as a means for the characterisation of patients with AF. It comprises of 4 domains: stroke risk (St), symptoms (Sy), severity of AF burden (Sb) and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and effects of individual domains on outcomes in AF.

Methods

Patients with AF from 250 centres across 27 participating European countries were included. All patients were over 18 years old and had electrocardiographic confirmation of AF within 12 months prior to enrolment. Data on demographics and comorbidities were collected at baseline. Individual domains of the 4S-AF scheme were assessed using the CHA2DS2-VASc score (St), European Heart Rhythm Association classification (Sy), temporal classification of AF (Sb), and cardiovascular risk factors and the degree of left atrial enlargement (Su). Each of these domains were used during multivariable cox regression analysis.

Results

A total of 6321 patients were included in the present analysis, corresponding to 57.0% of the original cohort of 11096 patients. The median age of patients was 70 (interquartile range [IQR] 62–77) years with 2615 (41.4%) females. Among these patients, 528 (8.4%) had low stroke risk (St=0), 3002 (47.5%) no or mild symptoms (Sy=0), 2558 (40.5%) newly diagnosed or paroxysmal AF (Sb=0), and 322 (5.1%) no cardiovascular risk factors or left atrial enlargement (Su=0).

Median follow-up was 24 months. Using multivariable cox regression analysis, independent predictors of all-cause mortality were (St) (adjusted hazard ratio [aHR] 8.21 [95% CI, 2.60–25.9]), (Sb) (aHR 1.21 [95% CI, 1.08–1.35]) and (Su) (aHR 1.27 [95% CI, 1.14–1.41]). For cardiovascular mortality and any thromboembolic event, only (Su) (aHR 1.73 [95% CI, 1.45–2.06]) and (Sy) (aHR 1.29 [95% CI, 1.00–1.66]) were statistically important, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding.

Conclusion

Overall, we demonstrated that the 4S-AF scheme may be used to provide clinical characterisation of patients with AF using routinely collected data, and each of the domains within the 4S-AF scheme were independently associated with adverse long-term outcomes of all-cause mortality, cardiovascular mortality and/or any thromboembolic event.

Funding Acknowledgement

Type of funding sources: None.
The significance of the level of triiodothyronium in the diagnosis of the syndrome of “low triiodothyronine” in heart failure
Authors: Pyvovar S , Rudik I.S , Medentseva O.O
Published: October 2021

Heart failure (HF) is an important issue in cardiology. Some patients with HF have the low T3 syndrome (LT3S). There is no consensus regarding the criteria for determining LT3S.

The purpose is to study the features of LT3S determination in HF and its relationship with the disease course.

Materials and methods

A total of 157-patients with HF and postinfarction cardiosclerosis were examined. At the I stage, all patients were divided into 2 groups: I – 122 patients with normal level of free T3f, T4f and thyroid-stimulating hormone (TSH); II – 35 patients with LT3S (T3f≤2.5 pmol/l and normal levels of T4f and TSH). At the II stage, 129 patients without LT3S were included into group I and 28 patients with LT3S (T3f ≤2.07 pmol/l) – into group II. Serum levels of TSH, T3f, T4f, reverse T3 (T3r) were determined. Echocardiography was performed. HF course was studied during 2 years.

Results

The frequency of LT3S (T3f <2.5 pmol/l) among patients with HF is 22.3%. The risk of rehospitalization of patients according to ROC-analysis increases at the intersection of the point T3f ≤2.07 pmol/l (P=0.0017). At T3f ≤2.07 pmol/l the frequency of LT3S is 17.8%. Patients with LT3S (T3f ≤2.07 pmol/l) are younger (2.5 years younger; P=0.039), have larger end-diastolic size (by 4.8%; P=0.010) and volume (by 10.2%; P=0.012), end-systolic size (by 8.8%; P=0.003) and volume (by 20.1%; P=0.006), lower left ventricle (LV) ejection fraction (by 9.5%; P=0.033), than the patients without LT3S. The relative risk of rehospitalization in patients with LT3S (T3f ≤2.07 pmol/l) is 2.224 (P<0.05).

Conclusions

The frequency of LT3S (T3f <2.5 pmol/l) among patients with HF is 22.3% at level of T3f ≤2.07 pmol/l – 17.8%. The risk of rehospitalization in patients with HF increases at intersection of the point T3f ≤2.07 pmol/l. Patients with LT3S (T3f ≤2.07 pmol/l) are younger, have larger LV dilatation and lower ejection fraction, higher frequency of coronary intervention and rehospitalization risk than the patients without LT3S.

Funding Acknowledgement

Type of funding sources: None.
The Impact of HbA1c level on heart failure with recovered rjection fraction in patients with Type 2 Diabetes
Authors: Yang C.D , Wang X.Q
Published: October 2021

Background

Heart failure (HF) with improved or recovered ejection fraction (EF, HFrecEF) has been recognized as a new type of HF with different underlying clinical phenotype, pathophysiology and prognosis. However, few studies have analyzed the relationship between type 2 diabetes and HFrecEF, and the impact of glycemic level on myocardial function recovery.

Purpose

In the present study, we sought to investigate the relation between HbA1c level and HFrecEF in patients with type 2 diabetes.

Methods

A total of 796 HF patients with reduced left-ventricular ejection fraction (LVEF, <40%) and type 2 diabetes were consecutively enrolled from August 2012 to July 2020. During follow-up for up to 24 months, patients were classified into HFrecEF for whom developed recovered LVEF (≥40% and absolute increase ≥5%) and HFrEF for whose LVEF was persistently reduced (<40%). The relation between HbA1c and the recovery of LV function was analyzed.

Results

HF patients with type 2 diabetes had significantly lower rates of LVEF recovery when having higher versus lower HbA1c levels in the baseline (the lowest tertile: 62.4%, intermediate tertile: 50.4%, the highest tertile: 46.8%; P<0.001). There were stepwise decreases in changes of LVEF (P<0.001) and increases in changes of LV end-systolic diameter (LVESD; P=0.093) with increasing tertiles of LVEF during follow-up. In the subgroup analysis, the impact of HbA1c on LVEF recovery was more prominent in patients with ischemic heart disease (P<0.001) than those with dilated cardiomyopathy (P=0.536). A significant interaction term was present between HbA1c and etiology of heart failure with regard to LVEF recovery (P=0.012). After multivariate adjustment of conventional confounding factors, high HbA1c level remained to be an independent risk factor lower incidence of HFrecEF in patients type 2 diabetes.

Conclusions

Our study suggests that optimal glycemic control is an independent predictor for incidence of HFrecEF in patients with type 2 diabetes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Natural Science Foundation of China, Shanghai Municipal Commission of Health and Family Planning
Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients after Anterior MI
Authors: Atici A , Asoglu R , Ali Barman H , Faruk Baycan Ö
Published: October 2021

Background

The presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction. Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential.

Purpose

We aimed to compare the Two-Dimensional Echocardiography (2DE), contrast-2DE and Real-time Three-Dimensional Echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior.

Methods

The study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (<40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and Magnetic Resonance Imaging (MRI) were performed to all patients within one month after anterior MI.

Results

Transthoracic 2DE detected thrombi in 29 patients, contrast 2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast 2DE and RT-3DE, respectively.

Conclusion

We found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT.

Funding Acknowledgement

Type of funding sources: None.
Clinical effects of the enhanced external counterpulsation therapy in patients with ischemic chronic heart failure exacerbation COVID-19
Authors: Shashenkov I , Gabrusenko S.A , Babak S.L , Maliavin A.G
Published: October 2021

Objectives

The aim of the study was to assess the effects of the enhanced external counterpulsation (EECP) therapy as a rehabilitation method in patients with ischemic chronic heart failure (CHF) after COVID-19.

Methods

54 (n=54) stable symptomatic CHF (NYHA, functional class I-II; 35%≤LVEF≤50%) subjects (44 male and 10 female; mean age 61±9,8) with prior anamnesis of CAD, at least one myocardial infarction got the exacerbation of CHF after COVID-19 episode. They were randomized in a 2:1 manner into either 35 1-hour 250–300 mm Hg sessions of EECP (n=36; 30 male, 6 female) or Sham-EECP (n=18; 14 male, 4 female). All subjects had been received optimal CHF and CAD drug therapy. At baseline, a month and half a year after EECP course every subject was examined with echocardiography and 6-minute walk test.

Results

All 36 active EECP treatment group subjects improved by at least 1 NYHA class, 66% of them had no heart failure symptoms post treatment (p<0.01). 84% of treatment group pts. had sustained NYHA class improvement at half a year follow-up (p<0.01), compared with baseline. There was significant difference between LVEF 44±6,5% at baseline vs post-EECP LVEF 50±4,6% (p<0.01) in active EECP treatment group subjects. At the same time there were no significant changes of NYHA class and LVEF in Sham-EECP subjects. No one subject dies after half a year of follow up.

Conclusions

Enhanced external counterpulsation (EECP) therapy sustainably improves NYHA functional class and LVEF in patients with ischemic CHF exacerbation after COVID-19.

Funding Acknowledgement

Type of funding sources: None.
Trends, risk factors and mortality of unplanned 30-day readmission after heart transplantation
Authors: Alvarez P , Malik A , Briasoulis A
Published: October 2021

Introduction

Outcomes after heart transplantation have improved, but the burden of readmissions is understudied. We sought to examine the incidence, risk factors, and associated mortality of unplanned 30-day readmissions following heart transplantation.

Methods

This cohort study examined patient data from the United States population-based Nationwide Readmissions Database. All adults (age ≥18 years) who underwent isolated heart transplantation in US hospitals between January to November of 2012 to 2018 were included. The primary outcomes were 30-day readmission rates and readmission mortality.

Results

A total of 14,784 patients who underwent heart transplantation from 2012 to 2018 were included in our analysis. A total of 3299 (22.3%) patients were readmitted within 30 days after discharge. The median time from discharge to readmission was 9 days, and approximately 70% of the readmissions occurred within 15 days. After multivariable analysis, only CKD (Hazard ratio (HR): 1.11 95% CI 1.00–1.23) and length of stay (HR: 1.002; 95% CI 1.001–1.003; p<0.001) were associated with increased 30-day post-heart transplantation readmission. Readmissions diagnoses were heart transplantation complications, heart transplant rejection, postoperative infection, acute kidney injury, heart failure, pulmonary embolism, pneumonia, and pericardial effusion. The overall incidence of infection as a cause of readmission was 24.9%, with an associated mortality of 2.6% and a Median LOS of 7 days (4–14). The overall incidence of rejection was 38.0%, with a mortality of 1.2% and a median LOS of 5 days (3–8).

Conclusion

Approximately 1 in 5 patients will be readmitted within 30 days after heart transplantation, and most of those readmissions will occur during the first two weeks after discharge. Readmissions were associated with a low mortality rate.

Funding Acknowledgement

Type of funding sources: None.