bluuebunny/crossref_metadata_2025 huggingface dataset:
Technical and electrophysiological aspects of multisite cardiac stimulation through the access of the middle cardiac vein
Authors: Rosa Filho A , Rosa AAM , Rosa AW , Souza Neto JC , Cavalcanti LB , Gomes LHA , Suque HB , Silva LA , Silva JF , Moura D , Santiago G , Barreto V , Russo M , Xavier Junior EF
Published: May 2021

Funding Acknowledgements

Type of funding sources: None. Main funding source(s): Alfredo Aurélio Marinho Rosa and Alfredo Aurélio Marinho Rosa Filho

Background

Heart failure (HF) is a serious, progressive disease, caused by ventricular dysfunction, leading to a worsening in quality and a reduction in life expectancy. Cardiac resynchronization therapy through multisite stimulation has become an important tool in the treatment of advanced HF, however, due to anatomical variations and even the absence of appropriate veins for the insertion of the left ventricular electrode, the access of the middle cardiac vein can be an option for biventricular cardiac stimulation. Objective: To present the technique used to access the middle cardiac vein (MCV) for the implantation of the left ventricular electrode and the results of this multisite stimulation. Material and Method: Between March 2006 and May 2016, 388 patients (PT) underwent biventricular stimulation (BIV) at our service. 276 PT (71.1%), were associated with the cardioverter-defibrillator (ICD), 226 PT (58.2%) were male and their age ranged from 28 to 84 years with an average of 64 years. In this group, in 63 PT (16.2%) the left ventricular electrode was implanted through CMV. The technique initially consists of introducing a deflectable catheter for marking the coronary sinus (SC) via the femoral approach, then the SC approach is performed by puncturing the left subclavian vein, introducing an 8F sheath up to the proximal 1/3, where the VCM venogram is performed by introducing a 0.014 "guide wire and the 5 F bipolar or quadripolar electrode, then defining the best electrode position from the smallest stimulated QRS. Results: In this group of 63 PT, 52 PT (82.5%) responded to cardiac resynchronization therapy. The most frequent cardiopathies involved were ischemic (38%), chagasic (25%), hypertensive (12%) and others (25%). The thresholds varied from 3.5 to 0.5 V, impedance from 600 to 1200 ohms and sensitivity between 10 and 20 mV. There were no complications in the trans or post implant and in 5 PT (7.9%), there was phrenic stimulation. The procedure time varied from 50 to 180 minutes. Conclusion: Multisite stimulation through the access of the middle cardiac vein proved to be a possible alternative, easy to perform and with a high PT index responsive to cardiac resynchronization therapy.
Electrocardiographic characteristics of patients with coronavirus disease 2019 (COVID-2019) related pneumonia at first presentation
Authors: Nguyen U , Strik M , Abu-Arib S , Bruekers A , Nguyen T , Massud A , Willems R , Dekker S , Spaetgens B , Engels E , Crijns HGJM , Koopmans R , Henry R , Stehouwer CDA
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Purpose

To evaluate electrocardiographic (ECG) characteristics at first presentation in patients with possible coronavirus disease (COVID-19) pneumonia.

Methods and results

356 patients presenting at the emergency room with possible COVID-19 pneumonia based on clinical presentation and computed tomography findings were included and subdivided into a COVID-19 positive group ([COVID-19-positive], n = 231, 65%) and a COVID-19 negative group ([COVID-19-negative], n = 125, 35%) based on polymerase chain reaction tests.

The study population was predominantly middle aged-elderly (67 ± 14 year; n = 235, 66% male). Mortality rate was 24% after 1-month follow-up. There were no significant (NS) differences in sex, age, and mortality between the COVID-19-positive and COVID-19-negative group. 

Atrial fibrillation (AF) was common (9%), though its prevalence was NS (regression analyses adjusted for age and sex) different in the COVID-19-positive vs. the COVID-19-negative group. ECG characteristics reflecting atrial enlargement and repolarization abnormalities were frequently present (<38% and 14% respectively). No significant differences were found between the COVID-19-positive vs. the COVID-19-negative group for the majority of morphological ECG characteristics (Figure 1 for more detailed data). 

Conclusion

AF and ECG characteristics reflecting atrial enlargement and repolarization abnormalities are commonly present in COVID-19 patients. The prevalence of these ECG characteristics however do NS differ from their COVID-19-negative counterparts. Abstract Figure.
Result of electrophysiological study in patients with undocumented suspected paroxysmal supraventricular tachycardia: the BELIEVE-SVT registry
Authors: Ramos Jimenez J , Marco Del Castillo A , Lozano Granero VC , Ramos Fernandez P , Jimenez Sanchez D , Gunturiz Beltran C , Alonso Fernandez P , Ayala HD , Dallaglio P , Salgado R , Lazaro Rivera C , Rodriguez Manero M , Borrego Bernabe L , Arribas Ynsaurriaga F , Rodriguez Munoz DA
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Paroxysmal supraventricular tachycardias (PSVT) are common arrhythmias and catheter ablation is considered its first-line treatment. However, the duration of the episodes frequently precludes ECG documentation. Thus, patients may not be referred for ablation until the tachycardia is documented, leading to recurrences, emergency room visits and often unnecessary tests or treatments. Our objective was to evaluate the results of electrophysiological study (EPS) followed or not by ablation in patients with suspected but not documented PSVT.

Methods

Multicenter, retrospective, observational registry of consecutive patients undergoing EPS due to clinical suspicion of PSVT, but with no prior ECG documentation. Collection of clinical and EPS data, along with data regarding ablation, when performed.

Results

427 patients of 12 centers were included. Mean age was 46.3 ±16.1 and 297 (69.6%) were females. Most frequent symptoms consisted on sudden onset (n = 360; 84.9%) and abrupt end (n = 304; 72.0%), with median episode duration of 10 minutes (interquartile range 5-20 min).

Sustained arrhythmias were induced in most patients (n = 255; 59.7%). Specific types are summarized in Table 1. Ablation was performed in 274 (64.2%) patients. A total of 10 complications (2.3% of procedures) were reported: 3 transient AV block, 2 PR interval prolongation, 2 puncture-related hematoma, 2 painful site of puncture and 1 catheter entrapment in mitral chordae.

Conclusions

Electrophysiological study in patients with palpitations highly suggestive of PSVT is an effective and safe diagnostic and therapeutic tool that may be considered as a first-choice even in the absence of documented tachycardia. Results of EP study Results of electrophysiological study Typical AVNRT 183 (42.9%) Orthodromic AVRT 38 (8.9%) Dual AV nodal physiology 30 (7.0%) 1 nodal echo beat 21 (4.9%) Atrial tachycardia 19 (4.5%) >1 nodal echo beat 17 (4.0%) Atrial fibrillation 7 (1.6%) Atypical AVNRT 7 (1.6%) Atrial flutter 1 (0.2%) No abnormal findings 104 (24.4%) AVNRT atrioventricular nodal reentran tachycardia AVRT atrioventricular reentrant tachycardia
Recurrence of palpitations following electrophysiological study and ablation in suspected but undocumented paroxysmal supraventricular tachycardias: follow-up results of the BELIEVE-SVT registry
Authors: Marco Del Castillo A , Ramos Jimenez J , Lozano Granero VC , Rodriguez Manero M , Ramos Fernandez P , Lazaro Rivera C , Jimenez Sanchez D , Ayala HD , Dallaglio P , Alonso Fernandez P , Salgado R , Gunturiz Beltran C , Fontenla Cerezuela AR , Arribas Ynsaurriaga F , Rodriguez Munoz DA
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

ECG documentation of paroxysmal supraventricular tachycardias (PSVT) may be challenging due to their short duration and usually abrupt end.  As ablation represents first-line treatment of this pathologies, it is not uncommon that physicians refer patients to electrophysiological study (EPS) when symptoms are suggestive of PSVT even though no ECG documentation has been obtained. Our objective was to evaluate the results of ablation performed in patients with induced arrhythmias in EPS but no previous ECG documentation.

Methods

Retrospective and observational multicenter registry of consecutive patients undergoing EPS, followed or not by ablation, referred because of undocumented clinical suspicion of PSVT. We collected clinical, EPS and clinical follow-up data, along with data regarding ablation, when performed. Descriptive statistical analysis was carried out using Stata.

Results

427 patients of 12 centers were included. Mean age was 46.3 ± 16.1 and 297 (69.6%) were females. Sustained arrhythmias were induced in most patients (n = 255; 59.7%) and ablation was performed in 274 (64.2%). 10 complications (2.3% of procedures) were reported: 3 transient AV block, 2 PR interval prolongation, 2 puncture-related hematoma, 2 painful sites of puncture and 1 catheter entrapment in mitral chordae.

During a mean follow-up of 3.1 ± 2.0 years, 111 patients experienced recurrence of palpitations, mostly (n = 77; 69.4%) without ECG documentation. Clinical recurrence was more frequent in subjects who had not been ablated (41.8% vs 17.2% in ablated patients; risk ratio 2.44 (CI 95% 1.77-3.36); p < 0.001). Table 1 shows types of clinical recurrences.

Conclusions

EPS in patients with high clinical suspicion of PSVT, followed by ablation when tachycardia is induced is effective in preventing future recurrences of palpitations. Early referral for EPS can, therefore, reduce visits to the emergency room, admissions and healthcare burden due to other low-yield, unnecessary tests. Type of recurrence ECG documentation 34(8.0%) ·Sinus rhythm 12(2.8%) ·Atrial tachycardia 6(1.4%) ·Typical atrioventricular nodal reentrant tachycardia 5(1.2%) ·Atrial fibrillation 5(1.2%) ·Premature ventricular beats 3(0.7%) ·Orthodromic atriventricular tachycardia 2(0.5%) Non documented recurrence 77(18.0%)
Management and perinatal outcomes of cardiac arrhythmias in pregnancy
Authors: Abdrakhmanov A , Ainabekova B , Nuralinov O , Bakytzhanuly A , Smagulova A
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Arrhythmias in pregnancy are common and can cause significant complications. The decision to use drug therapy or invasive treatment in pregnancy must have absolutely reasons. Data on perinatal outcomes in pregnant women with arrhythmias is limited.

Objective

The aim of our study is to observe the characteristics and prognosis of cardiac arrhythmias in pregnant women.

Methods

72 pregnant women with arrhythmias have been included (single-center, prospectively study). Mean age of patients: 28,34 ± 5,25years, mean gestation age 22,37 ± 6,77 weeks. Clinical characteristics of patients, obstetric and neonatal outcomes were documented.

Results

The most common reported arrhythmias were supraventricular tachycardia (n = 32; 44%). This was followed by premature contractions (n = 29; 40%). Advanced heart block (n = 7; 10%) and ventricular tachycardia (n = 4; 6%) were exceedingly rare during pregnancy. Arrhythmias was benign in 12 patients (17%) and did not require drug therapy. Administration of antiarrhythmic treatment was justified when symptoms were very frequent and cause haemodynamic instability (n = 52; 65,7%). In patients with drug refractory and dangerous rhythm disturbances (n = 22; 31%) were performed catheter ablation by using 3D navigation system without fluoroscopy. Permanent pacemaker was implanted in 7 cases (10%) of third-degree atrioventricular block. Interventions were effective in all cases without adverse outcome. In the majority of cases were spontaneus vaginal (n = 48; 66,7%) or vaginal-assisted (n = 6; 8,3%) delivery. Eighteen pregnancies (25%) were delivered by cesarean section. Intrapartum hemorrhage was 350,4 ± 238,2 ml. Maternal cardiac events and obstetric complications were none declared. There were 72 live births (in all pregnancies). Fetal birth weight was 3407,39 ± 785,61 grams, 5 minute Apgar was 8,47 ± 1,6. There were no maternal and fetal mortality.

Conclusions

supraventricular tachycardia and premature beats are common in pregnancy. Spontaneous vaginal delivery is more likely in this patients. Major maternal and fetal adverse outcomes are infrequent in pregnant women with arrhythmias.
Voltage bridge mapping in atrioventricular nodal reentry tachycardia ablation in adult population: results from a multicenter registry
Authors: Costa A , Rauhe W , Martignani C , Igniatiuk B , Sabbatani P , Nangah R , Marinelli A , Molon G
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The presence of Low Voltage Bridge (LVB) in Atrioventricular Nodal Reentry Tachycardia (AVNRT) ablation has been described in children populations. Slow pathway ablations visualizing and targeting the LVB has been described to be safe and effective. However, the incidence of LVB in AVNRT ablation has not been widely explored in adult population.

Purpose

We aim to investigate the presence of LVB in adult patients (pts) undergoing AVNRT ablation, and the relationship between the LVB and the successful ablation site. We have also investigated the correlations between the Koch’s triangle (KT) anatomy and biophysical pts data.

Methods

The observational registry prospectively collected data of 165 pts. undergoing AVNRT ablation guided by 3D electroanatomical mapping system (EnSite - Abott, St Paul, MN) in 6 EP centers. Gender: 90F – 75M (55% - 45%) - Age: 57 ± 17 ys (min 15 – max 87) - Weight: 73 ± 15 kgs (min 42 - max 150)  Prior of ablation a voltage map of KT was created using diagnostic and ablation catheters.

We define as Type I LVB a clear, long area of low voltage within the KT between the CS ostium and the AV node with the base on the edge of the tricuspid annulus and Type II LVB a narrow low voltage channel between normal-voltage regions with the base on the edge of the tricuspid annulus.

The relationship between LVB and successful site was evaluated at the end of the procedure. KT anatomical data were correlated to gender, age and weight.

Results

The LVB was identified in 134 pts (81%) with a prevalence of type I (91 - 68%) over type II (33 - 25%). In 10 pts (7%) the LVB did not match type I nor type II. When an LVB was identified, the correspondence between the LVB and the successful ablation site was verified in 117 pts (87%). In addition, a shorter RF time was applied when an LVB was found (396s vs 298s; p = 0.03). Strong correlations between KT anatomy and biophysical pts data were not identified. The distance between His electrograms and the successful ablation site weakly correlated (ρ = -0.24, p < 0.01) with pts age suggesting a shortening in the distance with age progression.

Conclusion

The visualization of the Low Voltage Bridge may be a helpful tool to guide AVNRT ablation in a large cohort of pts; furthermore it is associated with reduced RF applications time. The KT characteristics are difficult to be predicted a priori according to patient gender, age or weight.
Workflows and clinical utilization of dynamic mapping data in radiofrequency catheter ablation of cardiac arrhythmias
Authors: Di Cori A , Rillo M , Sultan A , Ramanna H , Deisenhofer I , Richter S , Mccready J , Muller D , Senatore G , Tao C , Zedda AM
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Previous publications suggest that the use of high-density (HD) mapping leads to better substrate visualization and may lead to improved procedural outcomes. A novel dynamic mapping software, utilizes the HD grid mapping catheter (HD Grid) to display beat-to-beat, dynamic regional mapping data (LiveView). Incorporation of real-time dynamic mapping data into routine mapping/ablation workflows may further enhance the clinical benefits of HD mapping during radiofrequency (RF) catheter ablation procedures.

Purpose

 To examine the clinical utility and common workflows when dynamic mapping data was used during RF ablation procedures among operators with various experience levels.

Methods

Observational procedural data including procedure time, total RF time, and workflow preference were prospectively collected in catheter ablation cases utilizing LiveView from May to September 2020. Mapping and ablation strategies were determined at the operator’s discretion. Total percentage exceed 100% when multiple usage were reported.

Results

A total of 428 cases were collected from over 25 operators in 11 European countries. LiveView was used in a variety of cases including atrial fibrillation (paroxysmal and persistent), atrial flutter (typical and atypical), and VT (ischemic, non-ischemic, and idiopathic). Visualization of real-time mapping data from the current location of the HD Grid was commonly used after creation of traditional full-chamber maps (319/428, 74.5%). While operators in over 55% of the cases indicated that the use of dynamic display during mapping helped identify areas that were under ablated (238/428, 55.6%), using LiveView did not affect the lesion delivery strategies in those regions. LiveView was also used as a primary method for confirmation of pulmonary vein isolation (PVI) in 213 cases (49.8%). The most common reported usage of LiveView among the 428 cases analyzed was PVI confirmation/gap identification (75.2%), ablation line gap identification (41.1)%, and identification of breakthrough activation (23.6%)

Conclusions

This initial analysis demonstrated the diverse clinical utilization of LiveView dynamic display during RF catheter ablation procedures, including atrial and ventricular arrhythmias. Without causing significant changes to normal workflow, dynamic display of regional signals allows for rapid identification of ablation targets. When used during RF delivery, real-time assessment of regional activation patterns helped improve outcomes by rapidly identifying critical ablation location and ensuring successful lesion delivery. A further study that examines the impact of dynamic display on procedure efficacy may be warranted.
HeartMate 3- Challenges in Ventricular Tachycardia Ablation
Authors: Sabbag A , Peichl P , Stojadinovic P , Arceluz M , Maury P , Katz M , Tedrow UB , John RM , Stevenson WG , Beinart R , Grupper A , Sternik L , Sacher F , Kautzner J , Nof E
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

HeartMate3TM (HM3) is a relatively new left ventricular assist device (LVAD) system. Its design and magnetically levitated pump may impact VTA.

Objectives

To describe clinical characteristics, procedural details, specific challenges and outcomes in patients with HM3 referred for ventricular tachycardia ablation (VTA).

Methods

Data was collected from patients implanted with an HM3 system who underwent VTA in 7 tertiary centers. Data included baseline patient characteristics, procedural data, mortality, and arrhythmia-free survival.

Results

 The study cohort included 19 patients (18 male, aged 65 ± 7.8 years) with low left ventricular ejection fraction (LVEF, 17 ± 5%), presenting with VT (53% with storm VT).  VTs were induced in 89% of patients and a total of 41 VTs were observed.  Severe electromagnetic interference was present in the surface ECG (Figure A) but not on endocardial electrograms (Figure B). Hence, VT localization required analysis of intra-cardiac signals or the use of filter in the 40-20 Hz range. A total of 32 VTs were mapped and were successfully ablated (31% to the anterior wall, 38% to the septum, and only 9% to the inflow cannula region).  Notably, the large pump housing tends to obscure clear visualization of the apical region in fluoroscopy particularly in the LAO view (Figure C,D). Therefore, three-dimensional electro-anatomical mapping was aided by ICE or CARTOSound in 71% cases (Figure E). Non-inducibility of any VT was reached in 11 patients (58%). Over a follow up of 429 (IQR 101-692) days, 5 (26%) patients underwent a redo VT ablation due to recurrent VTA and 2 (11%) patients died.

Conclusions

VT ablation in patients with HM3 is feasible and safe when done in the appropriate setup. Long-term arrhythmia free survival is acceptable but not well predicted by non-inducibility at the end of the procedure. Abstract Figure. HeartMate3 ablation Challenges
Cognitive outcomes post-catheter ablation for atrial fibrillation: a systematic review and meta-analysis
Authors: Kerley R , Dolphin H , Cronin H , Murphy R , O"lionaird R , O"regan N , Pope G , Fahy G
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is a known risk factor for cognitive impairment and dementia. Recent data suggests that successful restoration of sinus rhythm by catheter ablation improves cognitive outcomes. Purpose: Our aim was to perform a systematic review and meta-analysis of the available data regarding the effectiveness of AF catheter ablation on neurocognitive outcomes. Methods: A comprehensive literature search was performed through December 1, 2020, for all eligible studies comparing neurocognitive outcomes in AF patients with or without AF catheter ablation. Clinical outcomes included rate of dementia, cognitive function by Montreal Cognitive Assessment (MOCA) and Mini-Mental State Examination (MMSE) scores. Additional outcomes included the impact of time in sinus rhythm on neurocognitive outcomes. Results: We identified 11 studies which evaluated the effect of AF catheter ablation on dementia rate, MMSE and MOCA score. Meta-analysis of observational results indicates a decreased risk of dementia (risk ratio 0.51; 95% CI: 0.43 to 0.60; p <0.001) and an improvement in MOCA scores (2.92 points, p < 0.001) but not MMSE scores in patients undergoing AF catheter ablation compared to medical therapy. In addition, the maintenance of sinus rhythm was identified as a significant factor in dementia rate and improvement of MMSE and MOCA scores observed post catheter ablation therapy. Conclusion: AF catheter ablation may reduce the incidence of dementia and improve cognitive function. A large-scale randomized control trial is warranted before recommendations can be made regarding AF ablation and cognitive outcomes. Abstract Figure.
Catheter ablation of difficult accessory pathways guided by three-dimensional electroanatomic mapping: first experience
Authors: Vecchio N , Bochoeyer A , Lopez Diez JC , Schnetzer N , Dorado J , Basile F , Militello C
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation of paraseptal accessory pathways (PAP)  is associated with longer fluoroscopy and procedure times, more radiofrequency lesions, as well as a higher rate of recurrence and complications. In anteroseptal or midseptal PAP, recurrence and risk of AV block is even higher.

Guided ablations with a three-dimensional  electroanatomic mapping system  (3D) report greater efficacy and safety.

Purpose

To assess the acute success rate and complications of PAP 3D catheter ablation. Report the recurrence rate at one year of follow-up.

Methods

Descriptive analysis that included patients with difficult PAP 3D catheter ablation between 2017 and 2019. Acute success was defined as the disappearance of ventricular pre-excitation 15 seconds after starting the application and the absence of retrograde conduction (Figure). In all cases, a one-year follow-up was performed with ECG and 24-hour Holter.

Results

25 patients were included during the mentioned period. The average age was 23 years, 60% (15 p) were men and 56% (14 p) were symptomatic due to palpitations. 1 patient had previous heart disease (ebstein"s anomaly). 36% (9 p) had a previous procedure: 5 patients with previous failed radiofrequency ablation, 1 patient with failed anteroseptal cryoablation and 3 patients with suspended ablation due to risk of AV block.

The most frequent location was the posteroseptal. (Table)

The primary success rate was 92% (23 of 25 p). Ablation was unsuccessful in two patients, one with Ebstein"s disease and the other with a left posteroseptal PAP. None of the patients presented complications associated with the procedure.

During the one-year follow-up, one patient was registered with asymptomatic recurrence (1 of 23; 4.35%: right posteroseptal location), demonstrated by manifest preexcitation on the control ECG.

Conclusion

In our first experience, catheter ablation of difficult accessory pathways guided by three-dimensional electroanatomic mapping showed a high primary success rate without associated complications.

Recurrence during follow-up was similar to that reported in the literature. Accessory Pathway locationPatientsRight Posteroseptal11 (44%)Left Posteroseptal5 (20%)Anteroseptal5 (20%)Midseptal4 (16%)Abstract Figure
A new electrophysiological triad for atrial flutter critical isthmus identification and localization
Authors: Adragao P , Nascimento Matos D , Galvao Santos P , Moscoso Costa F , Rodrigues G , Carmo J , Carmo P , Cavaco D , Morgado F , Mendes M
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

In a previous retrospective study it was demonstrated that an electrophysiological triad was able to identify critical isthmus in atrial flutter (AFL) patients.  This triad is based in the Carto® electroanatomical mapping (EAM) version 7, which displays a histogram of the local activation times (LAT) of the tachycardia cycle length (TCL), in addition to the activation and voltage maps. This study aimed to prospectively assess the ability of an electrophysiological triad to identify and localize the AFL’s critical isthmus.

Methods

Prospective analysis of a unicentric registry of individuals who underwent left AFL ablation with Carto® EAM. All patients with non-left AFL, lack of high-density EAM, less than 2000 collected points or lack of mapping in any of the left atrium walls or structures were excluded. Ablation sites of arrhythmia termination were compared to an electrophysiological triad constituted by: areas of low-voltage (0.05 to 0.3mV), sites of deep histogram valleys (LAT-Valleys) with less than 20% density points relative to the highest density zone and a prolonged LAT-Valley duration that included 10% or more of the TCL. The longest LAT-Valley was designated as the primary valley, while additional valleys were named as secondary.

Results

A total of 12 patients (9 men, median age 72 IQR 67-75 years) were included. All patients presented with left AFL and 67% had a previous atrial fibrillation and/or flutter ablation. The median TCL and number collected points were 250 (230─290) milliseconds and 3150 (IQR 2340─3870) points, respectively. All AFL presented with at least 1 LAT-Valley in the analysed histograms, which corresponded to heterogeneous low-voltage areas (0.05 to 0.3mV) and encompassed more than 10% of TCL. Eleven of the 12 patients presented with at least 1 secondary LAT-Valley. All arrhythmias were effectively terminated after undergoing radiofrequency ablation in the primary or the secondary LAT-Valley location.

Conclusion

In a prospective analysis, an electrophysiological triad was able to identify the AFL critical isthmus in all patients. Further studies are needed to assess the usefulness of this algorithm to improve catheter ablation outcomes.
Effect of anti-coagulation in elderly patients with atrial fibrillation
Authors: Chung I
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation has been shown to associate with greater cognitive decline and increased dementia risk independent of ischaemic stroke. Anti-coagulation was associated with a lower risk of ischemic stroke and positive net clinical benefit in elderly patients in Asian populations.  We hypothesise that elderly patients (>75 years old) with atrial fibrillation on oral anti-coagulants have lower incidence of dementia compared with patients on anti-platelet agents or no anti-thrombotic treatment.

Method

A retrospective study of 747 patients, male 37%, mean age 84.29 ± 5.99 years old with mean follow up of  13.54  ± 3.38  years. 94 % hypertension, 40% diabetes mellitus, 38% ischaemic heart disease, 33% heart failure, 39% previous stroke, mean CHA2DS2-VASc score of 5.23 ± 1.59. 27% patients on oral anti-coagulants, 64% anti-platelet agent and 9% not on any anti-thrombotic medication.

Results

265 patients were diagnosed with dementia, 17 patients were on oral anti-coagulants, 222 patients were on anti-platelet agent. Oral anti-coagulants were associated with lower incidence of dementia compared with anti-platelet agents (p < 0.0001). 26 patients developed dementia were not on any anti-thrombotic agent. 261 patients were readmitted with stroke (2.58%/100 patient year) 182 patients were on anti-platelet agent while 12 were on anti-coagulant (P < 0.0001).

Conclusions

Oral anti-coagulants were associated with lower incidence of dementia and stroke compared with anti-platelet agents in elderly patients with atrial fibrillation.
Electrical cardioversion to assess the association between self-reported symptoms and rhythm status in patients with persistent atrial fibrillation
Authors: Hermans ANL , Pluymaekers NAHA , Lankveld TAR , Van Mourik MJW , Zeemering S , Dinh T , Den Uijl DW , Luermans JGLM , Vernooy K , Crijns HJGM , Schotten U , Linz D
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background. Knowledge about the association between symptoms and rhythm status (symptom-rhythm correlation) has potential clinical implications as it may identify patients with atrial fibrillation (AF) who profit from rhythm control in regard to reduction in symptom burden and improvement in quality of life. However, standardized strategies to assess symptom-rhythm correlation in AF patients are currently not available.

Purpose. This study aimed to assess symptom-rhythm correlation in patients with persistent AF using electrical cardioversion (ECV) as a diagnostic probe.

Methods. We used ECV to examine symptom-rhythm correlation in 81 patients with persistent AF. The presence of self-reported symptoms before ECV and at the first outpatient AF clinic follow-up visit (within 1-month) was assessed to determine the prevalence of a symptom-rhythm correlation (defined as self-reported symptoms present during AF and absent in sinus rhythm or absent in AF and yet relief during sinus rhythm). The symptom-rhythm correlation was absent in patients with symptoms before ECV who remained symptomatic during sinus or in patients with symptoms prior to ECV and without symptoms in AF after ECV. Asymptomatic patients before ECV with or without symptoms in AF or sinus rhythm afterwards had no symptom-rhythm correlation as well. The symptom-rhythm correlation was unevaluable in patients who were symptomatic in AF before ECV and at the first outpatient AF clinic follow-up visit. In addition, predominant self-reported symptoms (symptoms with highest self-reported symptom burden) were assessed to evaluate the symptom patterns around ECV. Intra-individually variable symptom patterns were defined as changes in predominant self-reported symptoms within patients around ECV.

Results. Symptom-rhythm correlation was assessed in all patients. Only in 18 patients (22%), a symptom-rhythm correlation could be documented. Twenty-eight patients (35%) did not show any symptom-rhythm correlation and 35 patients (43%) had an unevaluable symptom-rhythm correlation as these patients were in symptomatic AF both at baseline and at the first outpatient AF clinic follow-up visit. Importantly, self-reported symptom patterns around ECV were intra-individually variable in 10 patients (12%) without symptom-rhythm correlation (of which 9 patients (11%) had AF recurrence) and in 2 patients (2%) with an unevaluable symptom-rhythm correlation.

Conclusions. In patients with persistent AF, the prevalence of a symptom-rhythm correlation around ECV is low, but ECV often changes symptom pattern. Further studies are warranted to identify more optimal strategies to assess symptom-rhythm correlation in patients with persistent AF. Abstract Figure. Symptom-rhythm correlation and patterns
Outcomes of heart failure with preserved ejection fraction after radiofrequency catheter ablation for atrial fibrillation
Authors: Zolotarova T , Brynza M , Bilchenko O
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction. Recent randomized controlled trials have shown that in heart failure (HF) patients with reduced left ventricle ejection fraction (HFrEF) atrial fibrillation (AF) ablation reduces hospitalization and mortality due to HF compared to medical therapy (MT). However, only few studies have examined outcomes of catheter ablation (CA) for AF in HF patients with preserved left ventricle ejection fraction (HFpEF). 

Purpose. To compare the effect of catheter ablation on the outcomes of atrial fibrillation with chronic heart failure with preserved ejection fraction.

Methods. Our prospective study included the main group (136 patients with the HFpEF who underwent a single procedure of the CA for symptomatic AF) and control group (58 patients with the HFpEF patients with paroxysmal or persistent AF on MT for rhythm and rate control strategy). To be eligible for inclusion for both groups, left ventricular diastolic dysfunction had to be present and/or relevant structural heart disease according to the current guidelines had to be fulfilled within 6 months prior to AF ablation. Outpatient follow-up were performed at 6, 12, 24 months intervals thereafter baseline. 

Results. At the follow-up the composite primary end point (all-cause death or worsening of HF that led to an unplanned hospitalization) appeared in significantly fewer patients in the CA group than in the MT group (18 (13,2%) patients vs. 16 (27,5%) patients; p =0,005). The secondary analyses showed there was 5 deaths in the CA group and 2 deaths in MT group, with rate of 3,7%  and 3,4% respectively that were equal in comparable groups (p = 0,362). The incidences of HF hospitalization and cardiovascular hospitalization were also significantly higher in MT group than in CA group (14 (24,1%) vs. 13 (9,6%), p = 0,005) vs. 21 (15,4%), p = 0,016, respectively). Cardiovascular death and cerebrovascular accident were equal in comparable groups. The Kaplan–Meier curve for primary end-point demonstrated significant higher survival and freedom from hospitalizations due to HF in the CA group compared to MT group (p = 0,005); the freedom from hospitalization for worsening HF and the freedom from the cardiovascular hospitalization were having higher probability in the СA group (p = 0,003 and p= 0,016 ).

Conclusion. Comparing catheter ablation with medical therapy for rhythm or rate control strategy in patients with heart failure with preserved left ventricle ejection fraction and atrial fibrillation, we found that catheter ablation was associated with lower rate of deaths and hospitalization due to worsening of heart failure.
Sacubitril/valsartan therapy and supraventricular arrhythmias detected through remote monitoring in heart failure patients
Authors: Guerra F , Marchese P , Flori M , Pimpini L , Scarano M , Scappini L , Contadini D , Stronati G , Massara F , Gennaro F , Busacca P , Antonicelli R , Grossi P , Dello Russo A
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Sacubitril/valsartan (S/V) has demonstrated a significant benefit in decreasing mortality and morbidity in patients with heart failure with reduced ejection fraction (HFrEF) when compared to angiotensin inhibition. Recent studies demonstrated that the benefits of S/V encompass a positive cardiac remodeling, leading to a reduction of ventricular arrhythmias. The effect of S/V on the supraventricular arrhythmic burden is still unknown. 

Purpose

To evaluate the effect of sacubitril/valsartan on the supraventricular arrhythmic burden in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy-defibrillator (CRT-D) and remote monitoring. 

Methods

The SAVE THE RHYTHM is a multicentre, observational, prospective registry is enrolling all patients with HFrEF, ICD or CRT-D actively followed through remote monitoring and starting treatment with sacubitril/valsartan. All patients are followed-up at least one year after sacubitril/valsartan start. The primary endpoint is the number of sustained atrial tachycardia or AF (AT/AF). Secondary endpoints include incidence of AT/AF in the total population, total burden of AT/AF (defined as the percentage of time in AT/AF per day), mean number of premature ventricular contractions (PVC) per hour and percentage of biventricular pacing per day (in patients with CRT-D).  All primary and secondary endpoints are collected through remote monitoring.

Results

At the time of the second ad interim analysis, 188 patients (85.2% male, age 68 ± 10 years) were consecutively enrolled. In patients without permanent AF, treatment with S/V was associated with a reduced incidence of AT/AF episodes,  which changed from 32.6% (before treatment start) to 24.3%, 20.5% and 6.9% according to the sacubitril/valsartan dose (24/26 mg, 49/51 mg and 97/103 mg respectively; p= 0.041). A significant decrease in the median annual number of AT/AF episodes was also seen in these patients (16/year before treatment; 12/year at 24/26 mg; 6/year at 49/51 mg and 1/year at 97/103 mg; p = 0.046). No significant differences were reported in terms of PVC or biventricular pacing (all p = NS). Patients with permanent AF experienced no benefits from sacubitril/valsartan therapy in terms of arrhythmic burden reduction. No new diagnosis of clinical AF was made after starting treatment with sacubitrl/valsartan in all patients.

Conclusions

Preliminary data suggest that therapy with S/V could reduce the episodes of AT/AF in patients with HFrEF and remote monitoring, and the benefit seems related to the maximum tolerated dose of S/V. No positive effect has been noted in patients with permanent AF.
Association between thromboembolic and bleeding risk with adverse outcomes in contemporary European atrial fibrillation patients: final analysis from the ESC-EHRA EORP AF general long-term registry
Authors: Boriani G , Proietti M , Laroche C , Fauchier L , Marin F , Nabauer M , Potpara T , Dan GA , Kalarus Z , Tavazzi L , Maggioni AP , Lip GYH
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

The ESC-EHRA EORP AF General Long-Term Registry provides a contemporary snapshot of European atrial fibrillation (AF) patients’ characteristics and management. Aims: We present data about the final 2-years follow-up observation of AF patients enrolled in the ESC-EHRA EORP AF General Long-Term Registry.

Methods

A contemporary evaluation of residual risk of adverse outcomes in a cohort of largely anticoagulated AF patients according to the baseline thromboembolic and bleeding risk, defined according to CHA2DS2-VASc and HAS-BLED scores. We determined cardiovascular (CV) events, CV death and all-cause death as outcomes.

Results

Among the original 11069 patients enrolled, 8409 (76.0%) patients had available follow-up status at the end of the 2-years follow-up. Patients age, female sex and most comorbidities were progressively more prevalent across the spectrum of thromboembolic and bleeding risk. Data on adverse outcomes were available for 10087 (91.1%), over the 2-year observation period. Outcome rates were progressively higher across CHA2DS2-VASc and HAS-BLED scores (all p < 0.0001). A fully adjusted Cox multivariable regression analysis, adjusted for clinical covariates selected by a univariate procedure and not included in the scores, showed that increasing baseline CHA2DS2-VASc score was associated with an higher risk for CV events (hazard ratio [HR]: 1.25, 95% confidence interval [CI]: 1.21-1.30), CV death (HR: 1.31, 95%CI: 1.25-1.38) and all-cause death (HR: 1.30, 95%CI: 1.25-1.36). Similarly, increasing baseline HAS-BLED score was associated with an increased risk for all 3 outcomes (HR: 1.21, 95%CI: 1.13-1.28; HR: 1.24, 95%CI: 1.14-1.34; HR: 1.22, 95%CI: 1.14-1.31, respectively). An association with a progressively higher risk was found for all outcomes across the spectrum of thromboembolic and bleeding risk [Figure]. Both CHA2DS2-VASc and HAS-BLED scores showed a modest to good predictive ability for cardiovascular (CV) events, CV death and all-cause death, in terms of c-index and 95% CI[0.66 (0.64-0.68) and 0.62 (0.61-0.64), 0.70 (0.68-0.72) and 0.65 (0.63-0.67), 0.69 (0.68-0.71) and 0.64 (0.63-0.66) for CHA2DS2-VASc and HAS-BLED for each outcome respectively.

Conclusions

In this large contemporary European-wide cohort of AF patients, both baseline thromboembolic and bleeding risks were associated to an increased risk of major clinical outcomes. Both scores are reflective of high risk clinical states, and are predictive of major adverse outcomes even in a large cohort of largely anticoagulated patients with a lower residual risk of adverse outcomes. Abstract Figure.
Atrial fibrillation in the young: clinical characteristics, predictors of new onset and outcomes
Authors: Segev A , Maor E , Goldenfeld M , Grossman E , Beinart R , Klempfner R , Sabbag A
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial fibrillation (AF) onset in the young (≤45 years) is uncommon and not well studied.

Purpose

Identifying the determinants of AF in this population in order to help direct timely diagnosis, appropriate follow up and management.

Methods

We retrospectively evaluated all patients aged ≤45, admitted to the internal and cardiology wards between January 2009 and December 2019 at a large tertiary center. Clinical, electrocardiographic and echocardiographic data were collected and compared among patients with and without AF at baseline. A subgroup of patients with no AF at baseline and a subsequent hospital visit were followed for development of new onset AF (NOAF).

Results

A total of 16,432 patients (55.5% male, 33 ±8.3 years old) were analyzed. At baseline, patients with AF (n = 366) tended to be older, more often male, and had a higher proportion of comorbidities and ECG conduction disorders, compared with the patients without AF (n = 16,066). Male sex, increased age, obesity, heart failure (HF) and the presence of left or right bundle branch block (LBBB and RBBB, respectively) were all strongly and independently associated with young-onset AF. A total of 10,691 patients were followed for a median of 41.5 (16.6-78.6) months, during which 85 patients developed NOAF (equivalent to 0.5%/year). Increased age, hypertension, HF, RBBB and LBBB were independent predictors of NOAF. CHARGE-AF score outperformed CHA2DS2-VASc score in NOAF prediction [AUC of ROC 0.75 (0.7-0.8) vs. 0.56 (0.48-0.65)].

Conclusions

The annual risk of NOAF among young adults admitted to the hospital is noteworthy. NOAF may be predicted by clinical risk factors and the CHARGE-AF score. Characteristic No AF (N = 16066) AF (N = 366) Total (N = 16432) P value Age- yr. 33.06 ± 8.3 36.8 ± 7.3 33.1 ±8.3 <0.0001 Male gender 8914 (55.5) 240 (65.6) 9154 (55.7) <0.0001 BMI- kg/m2 25.5 ± 5.75 27.48 ± 6.36 25.2 ± 5.8 <0.0001 HTN 2679 (16.7) 73 (19.9) 2752 (16.7) 0.098 CHF 124 (0.8) 13 (3.6) 137 (0.8) <0.0001 PR interval > 200ms 117 (1.3) 15 (9.1) 132 (1.5) <0.0001 QRS interval > 120ms 220 (2.4) 25 (8.4) 245 (2.6) <0.001 LBBB 29 (0.2) 6 (1.6) 35 (0.2) <0.0001 LVEF < 40 323 (10.1) 35 (16.9) 358 (10.5) 0.002 CHA2DS2-VASc 0.75 ±0.75 0.73 ±0.84 0.74 ±0.76 0.647 CHARGE AF 6.3 ±1.1 6.8 ±0.9 6.32 ±1.06 <0.001
Prevalence of silent atrial fibrillation in high-risk patients - preliminary results from a European three-country handheld ECG-screening study
Authors: Lund I , Engdahl J , Rosenqvist M , Puererfellner H , Sieghartsleitner S , Hendrikx T , Lillqvist J , Pervez Sheikh A , Bech Jensen J , Dixen U
Published: May 2021

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Helsefonden Lilly and Herbert Hansens Foundation

Introduction

Patients with atrial fibrillation (AF) should in most cases be offered prophylactic anticoagulation treatment to prevent a stroke. However, the arrhythmia can appear without symptoms, so-called silent AF. Even without symptoms AF constitutes a risk for stroke.

Purpose

To screen high-risk patients with diabetes type 2 (DMII) or heart failure (CHF) for silent AF.

Methods

We included patients > 64 years with either DMII or CHF from out-patient clinics and local health centers. Exclusion criteria were known AF, anticoagulation treatment, recent stroke, or an implanted pacemaker or ICD. Patients were recruited from a total of eleven study centers in three countries. All underwent 14-days of intermittent ECG screening with a handheld ECG recording four times each day; the recordings were digitally stored. AF was diagnosed in cases of irregular heart rhythm and absence of P waves on at least one recording (thirty seconds) or on at least two recordings for a minimum of ten seconds.

Results

In total, 813 patients were included, 541 of these with DMII. The mean age was 73,4 years ± 5,8 SD, 40,7% of the patients were female.

In the DMII group thirteen patients (2.4%) were diagnosed with silent AF and offered anticoagulation. In the CHF group six (2.2%) patients had diagnosed silent AF on the handheld ECG. The prevalence of AF increased with increasing age, see Table 1. Thus, in the youngest group AF was diagnosed in 1.3% of the patients compared to 3.9 % in the age group 75 years or older.

Conclusions

Screening for silent AF in high-risk patients with DMII or CHF seems worthwhile, especially in patients 75 years or older. Abstract Figure. ECG with atrial fibrillation
Gender-related differences in patient selection for and outcomes after pace and ablate for refractory atrial fibrillation: insights from a large multicenter cohort
Authors: Baumgartner T , Kaelin-Friedrich M , Makowski K , Noti F , Schaer B , Haeberlin A , Badertscher P , Baldinger S , Seiler J , Osswald S , Kuehne M , Roten L , Tanner H , Sticherling C , Reichlin T
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

A pace & ablate strategy may be performed in cases of severe refractory atrial arrhythmias.

Purpose

We aimed to assess gender related differences in patient selection and clinical outcomes after pace & ablate.

Methods

In a retrospective multicenter study, patients undergoing AV-junction-ablation between 2011 and 2019 were studied. Gender-related differences in terms of baseline characteristics, device-related complications, heart failure (HF) hospitalisations and death were assessed.

Results

Overall, 513 patients underwent AV-junction-ablation (median age 75 years, 50% males). At baseline, male patients were younger (72 vs. 78 years, p < 0.001), more frequently had non-paroxysmal AF (82% vs. 72%, p = 0.006), a lower LVEF (35% vs. 55%, p < 0.001) and more often received biventricular stimulation (75% vs. 25%, p < 0.001). Interventional complications were rare in both gender (1.2% vs 1.6%, p = 0.72). Following AV-junction-ablation, improvement of EHRA-class by ≥1 and of LVEF by ≥5% occurred in 44% and 19% of patients respectively, without gender differences (p = 0.66 and p = 0.38). Patients were followed for a median of 42 months in survivors (IQR 22-62). Lead-related complications (11 patients, 2.1%), infections (1 patient, 0.2%) and upgrade to ICD or CRT (18 patients, 3.5%) were rare. In Kaplan Meier analysis, HF hospitalisations during 4 years of follow-up were more common in men (22% vs 11%, p = 0.02), as were death (28% vs 21%, p = 0.02) and the combination of death or HF hospitalisation (37% vs. 26%, p = 0.008, Figure). Gender remained an independent predictor of the combined endpoint of death or HF hospitalisation after adjustment for age, LVEF and type of stimulation.

Conclusion

A Pace & Ablate strategy is safe and results in improvement of EHRA class and LVEF in a substantial number of patients. We found significant gender differences in patient selection for pace & ablate. Female patients had a more favorable clinical course after AV-junction-ablation, which was independent of age, EF and type of stimulation. Abstract Figure. Comb. endpoint of death or heart failure