bluuebunny/crossref_metadata_2025 huggingface dataset:
Regular exercise is associated with a lower risk of developing dementia in patients with a new diagnosis of atrial fibrillation: a nationwide population-based study
Authors: Lim J.H , Lee S.R , Choi E.K , Yun J.P , Ahn H.J , Han K.D , Jung J.H , Lee E.J , Cha M.J , Oh S.I , Lip G.Y.H
Published: November 2020

Introduction

Regular exercise is known to decrease the risk of dementia. There is a paucity of information about the impact of the change of exercise habit on cardiovascular outcomes after a new diagnosis of atrial fibrillation (AF). We aimed to investigate whether regular exercise is associated with the risk of developing dementia in patients with AF.

Methods

Using the Korean National Health Insurance Service database, we enrolled patients with newly diagnosed AF who had undergone health screening between 2010 and 2016. The study population was divided into four groups based on the consistency of regular exercise before and after AF diagnosis: (1) persistent non-exerciser, (2) exercise starter, (3) exercise quitter, and (4) exercise maintainer. We investigated the association between exercise and the risk of dementia.

Results

A total of 126,555 patients were included (mean age 62.7 years, male 62.0%, and mean CHA2DS2-VASc Score 2.7). During a median follow-up duration of 3.0 years, 5,943 patients were newly diagnosed as dementia (1.57 per 100 person-years). Among patients with incident dementia, 4,410 patients had Alzheimer's dementia and 951 patients had vascular dementia (1.16 and 0.25 per 100 person-years, respectively). Persistent non-exerciser, exercise starter, quitter, and maintainer groups were 65.1%, 12.8%, 12.7%, and 9.4%, respectively. After multivariable adjustment, we found that exercise was associated with a lower risk of developing overall dementia. When compared to persistent non-exerciser, exercise starter and maintainer showed reduced risk of developing dementia (hazard ratio [HR] 0.80, 95% confidence interval [95% CI] 0.73–0.88 and HR 0.63, 95% CI 0.54–0.73, respectively, all p-value <0.0001), but exercise quitter showed no significant risk reduction (HR 0.95, 95% CI 0.88–1.03, Figure). Alzheimer's dementia showed consistent results: a 20% lower risk with exercise starter, and a 37% lower risk with exercise maintainer. Change of exercise habit, however, did not affect the risk of vascular dementia (all, p-value >0.05, Figure).

Conclusions

Regular exercise showed a lower risk of dementia in patients with new-onset AF. Starting exercise even after the diagnosis of AF was beneficial to patients who had little physical activity previously. These findings may support physicians to recommend that AF patients should start exercise or keep their physical activity to reduce the risk of dementia.

Funding Acknowledgement

Type of funding source: None
Assessing the atrial substrate: electrograms from the coronary sinus can predict left atrial fibrosis
Authors: Mohsen Y , Draheim J , Grossmann N , Turan C.H , Schoett M , Horlitz M , Stoeckigt F
Published: November 2020

Background

Left atrial fibrosis plays a key role regarding the success rate of pulmonary vein isolation for atrial fibrillation. It can be analyzed using LGE-MRI or invasive LA electroanatomical mapping. Assessing LA substrate prior to performing LA ablation procedures might help in optimizing the ablation approach.

Method

We analysed highdensity-electroanatomical maps of the left atrium derived by Carto 3 from 282 consecutive atrial fibrillation patients scheduled for RF pulmonary vein isolation (PVI). Maps were divided into 5 different anatomical areas and fibrosis was defined as local voltage <0.5mV. The extent of fibrosis was analyzed and compared with signal recordings from different positions of a diagnostic catheter positioned in the coronary sinus (CS) using Pearson correlation analysis.

Results

PVI was carried out in 282 patients (male 72%, mean age 63±10.8 years). A minimum of 1000 evenly distributed local electrograms were recorded in every patient. Significant LA fibrosis (>5%) was present in 54% of the patients with the maximum incidence of 100% at the anterior and 80% at the posterior wall. Signal amplituds in the proximal CS position significantly correlated with presence of LA fibrosis in the posterior LA (R 0.84, p<0.001), LA roof (R 0.65; p<0.001), left lateral (R 0.54; p<0.001), septal (R 0.47; p<0.001), and even LA anterior wall (R 0.56; p<0.001). Comparable results were found when using distal CS signals or a signal averaged over all individual CS signals. When used as a diagnostic tool, a CS amplitude <1.9mV could predict fibrosis at the posterior left atrial wall with a specificity of 97% and a sensitivity of 67% (PLR 24, AUC 0.91, 95% CI 0.87 - 0.95; p<0.001). A cut-off value of 1.9mV could be used to identify patients with only minimal LA fibrosis (<5%) with specificity of 88% and a sensitivity of 50% (PLR 4.2, AUC 0.81, 95% CI 0.71–0.89; p<0.001.

Conclusion

Voltage signals in the CS are significantly associated with presence of fibrosis in all left atrial areas. Moreover, CS voltage signals can be used to identify presence of significant left atrial extrapulmonary vein fibrosis and could help guiding left atrial ablation procedures and choice of ablation technique.

Funding Acknowledgement

Type of funding source: None
Dominant frequency predicts sinus rhythm maintenance after electrical cardioversion for persistent atrial fibrillation in men but not in women
Authors: Lankveld T , Zeemering S , Van Gelder I.C , Odening K.E , Crijns H.J , Schotten U
Published: November 2020

Background

Women are usually underrepresented in studies evaluating rhythm control strategies in patients with atrial fibrillation (AF). Subsequently, the same holds true for studies looking at predictors for success of a rhythm control strategy for AF.

Purpose

To study the predictive power of the non-invasively determined dominant frequency (DF) on the electrocardiogram (ECG) in men and women undergoing electrical cardioversion (ECV) for persistent AF.

Methods

We matched 105 female patients undergoing elective ECV for persistent AF and 105 male control patients based on age and cardiovascular comorbidity profile. We determined the DF on all 12 leads of a standard digital 10 seconds ECG recorded on the day of ECV. Recurrences of AF within the first year after ECV were documented.

Results

There were no differences in comorbidities, AF duration, left ventricular systolic function, indexed left atrial volume and anti-arrhythmic drugs between male and female patients. The dominant frequency was significantly lower in male patients without an AF recurrence on all leads. The best performing lead to identify patients with recurrences was lead III with an AUC 0.752. The optimal cut-off point was a DF <5.98 Hz with a sensitivity 84% and a specificity 67%. There was no significant difference in DF between female patients with and without an AF recurrence. The AUC in lead III was 0.47 (Figure 1).

Conclusion

The non-invasively measured dominant frequency is able to predict AF recurrence after electrical cardioversion in male patients with persistent AF but not in a matched female cohort. This difference might be explained by different pathophysiological mechanisms underlying AF in male and female patients. Therefore, future research is needed on pathophysiological differences between men and women that can explain and might overcome these challenges.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): European Network for Translational Research in Atrial Fibrillation (grant no. 261057), the Center for Translational Molecular Medicine (COHFAR),
A cool modality to restore sinus rhythm
Authors: Yasin O , Sugrue A , Van Zyl M , Ladejobi A , Tri J , Rynbrandt J , Seifert G , Sanders R , Pedersen J , Yngsdal L , Ladewig D , Taubel R , Ritrivi C , Asirvatham S , Friedman P
Published: November 2020

Background

Slowing electrical conduction by cooling the myocardium can be used for defibrillation. We previously demonstrated the efficacy of a small cold device placed in oblique sinus (OS) in terminating atrial fibrillation (AF). However, the parameters needed to achieve effective atrial defibrillation are unknown.

Purpose

Assess effect of the size of cooled myocardium on frequency of AF termination in acute canine animal models.

Methods

Sternotomy was performed under general anesthesia in 10 acute canine experiments. AF was induced using rapid atrial pacing and intra-myocardial epinephrine and acetylcholine injections. Once AF sustained for at least 30s, either a cool (7–9°C) or placebo (body temperature) device was placed in the OS. Four device sizes were tested; ½X½, ¾X¾, and 1X1 inch devices and two ¾X¾ inch devices placed side by side simultaneously. Time to AF termination was recorded. Chi-squared or Fisher's exact test were used to compare the frequency of arrhythmia termination with cooling versus placebo.

Results

A total of 166 applications were performed (89 cool vs 77 placebo) in 10 animal experiments. Overall, AF terminated in 82% of the cooling applications vs. 67.5% of placebo (P=0.03, Figure 1). For the ½X½ inch device 88% of cold applications restored sinus rhythm vs. 63.6% for placebo (P=0.05). The frequency of sinus restoration for cold ¾X¾, 1X1 and two ¾X¾ side by side devices was 86.7%, 83.3% and 70% respectively. Time to sinus restoration when achieved was within three minutes was also not significantly changed.

Conclusion

Placing a cool device in the oblique sinus can terminate AF and efficacy is not affected by the size of device.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): MediCool Technologies
Antazoline for pharmacological cardioversion of atrial fibrillation: the results of the high-volume multicenter CANT study
Authors: Wybraniec M , Maciag A , Miskowiec D , Ceynowa-Sielawko B , Balsam P , Wrobel W , Farkowski M , Cwiek-Rebowska E , Szolkiewicz M , Ozieranski K , Krzowski B , Kozinski M , Kasprzak J , Szwed H , Mizia-Stec K
Published: November 2020

Background

Antazoline mesylate represents a first generation antihistamine with quinidine-like antiarrhythmic properties, which allows for rapid and effective termination of atrial fibrillation (AF). Despite its widespread use in Polish emergency departments, paucity of data exists concerning safety and efficacy of antazoline in comparison to other antiarrhythmic agents.

Purpose

This study aimed to evaluate the pooled hitherto data on effectiveness and safety of pharmacological Cardioversion with intravenous ANTazoline (CANT Study) in short-duration atrial fibrillation.

Methods

This retrospective observational study was performed in 5 medical centers and comprised 1300 patients with paroxysmal or persistent AF who underwent emergent pharmacological cardioversion in the real-world setting of emergency or cardiology department. The choice of antiarrhythmic drug was left to the discretion of attending physician. The exclusion criteria involved permanent AF, other supraventricular arrhythmias, including atrial flutter, chronic antiarrhythmic therapy or preemptive electrical cardioversion. The primary endpoint was restoration of sinus rhythm up to 12 hours after antiarrhythmic drug infusion. The combined safety endpoint was bradycardia <45 bpm, hypotension, syncope or death.

Results

The mean age of study population was 67.7±11.6 years and the majority of patients were men (52.9%). The median AF episode duration was 10 (4; 24) hours, while median CHA2DS2-VASc score was 3 (2; 4) pts. Antazoline alone was administered in 45.6% of patients (n=593); amiodarone in 22.1% (n=287); propafenone in 11.5% (n=150); sotalol in 0.5% (n=6), while 20.3% (n=264) received overlapping antiarrhythmic therapy. Antazoline had the highest rhythm conversion rate (Figure), which was comparable to propafenone (78.2% vs 72.7%; RR 1.08; 95% CI:0.97–1.20; P=0.175) and superior to amiodarone (vs 66.9%; RR 1.17, 95% CI:1.07–1.28; P=0.0008) and collective amiodarone/propafenone/sotalol treatment (vs 68.6%; RR 1.14; 95% CI:1.06–1.23; P=0.0006). The rate of combined safety endpoint was comparable in patients treated with antazoline and other antiarrhythmic drugs (5.2% vs 3.9%; P=0.297). Among patients treated with antazoline, 29 exhibited bradycardia <45 bpm and 5 patients suffered from hypotension, but no case of syncope, nor in-hospital death was reported.

Conclusion

Antazoline appears to be an effective antiarrhythmic drug for cardioversion of atrial fibrillation, which is associated with low rate of relatively benign adverse events.

Figure 1

Funding Acknowledgement

Type of funding source: None
Ranolazine as you have never seen it before: an antiarrhythmic for atrial fibrillation
Authors: Sousa J.P , Puga L , Ribeiro J , Lopes J , Saleiro C , Gomes R , Campos D , Lourenco C , Goncalves L
Published: November 2020

Background

Currently available pharmacological options for rhythm control in atrial fibrillation (AF) are overshadowed by suboptimal efficacy and both frequent and potentially severe adverse events. Recent studies have added evidence to the hypothesis that ranolazine might exert antiarrhythmic effects, particularly in atrial tachyarrhythmias.

Purpose

To perform a systematic review with meta-analysis in order to ascertain the potential role of ranolazine in the management of AF.

Methods

We systematically searched MEDLINE, Embase and Scopus for randomized controlled trials (RCTs) and cohort studies addressing the association between ranolazine and AF outcomes, published up until December 1, 2019. The primary endpoint was incidence of AF, which was evaluated under a ranolazine versus placebo design. In this regard, patients in the setting of postcardiac surgery were further investigated separately. Secondary endpoints included AF cardioversion outcomes, which were addressed through comparison between ranolazine plus amiodarone and amiodarone alone for proportional efficacy and temporal requirements (time-to-cardioversion). The latter analysis was also undertaken in a dose-sensitive fashion (≤1000mg vs. 1500mg of ranolazine). Tertiary endpoints covered AF burden and episodes, in paroxysmal AF patients, and safety outcomes, namely death, QTc interval prolongation and hypotension. Study-specific odds ratios (ORs) were pooled using meta-analytic techniques with a random-effects model.

Results

A total of 10 RCTs comprising 8.109 participants and 3 cohort studies encompassing 37.112 patients were regarded as eligible for evaluation. Ranolazine was found to attenuate patients' odds of developing AF (OR 0.53, 95% CI: 0.41–0.69, p<0.001, i2=58%). This effect held true, with an even larger effect size, in the context of post-cardiac surgery (OR 0.34, 95% CI: 0.16–0.72, p=0.005, i2=64%). Ranolazine increased the chances of successful AF cardioversion when added to amiodarone over amiodarone alone (OR 6.67, 95% CI: 1.49–29.89, p=0.01, i2=76%), while significantly reducing time-to-cardioversion [SMD 9.54h, 95% CI: −13.3–5.75, p<0.001, i2=99%]. Interestingly, cardioversion was faster with ≤1000mg of ranolazine (SMD −13.16h, 95% CI: −15.07–11.25, p<0.001, i2=95%) than with 1500mg (SMD −3.57h, 95% CI: −5.06–2.08, p<0.001, i2=23%). In paroxysmal AF, ranolazine was also proved to significantly reduce both AF burden and episodes. There were no safety signals regarding mortality odds, QTc interval prolongation (mostly clinically insignificant) and hypotension (mostly transitory).

Conclusion

Current evidence suggests that ranolazine provides an effective and safe option for a chemical rhythm control strategy in AF management, a field in which medical breakthroughs are desperately needed.

Funding Acknowledgement

Type of funding source: None
Catheter ablation can improve survival with the reduction of heart failure in frail patients with atrial fibrillation
Authors: Joung B , Yang P.S , Sung J.H , Jang E , Yu H.T , Kim T.H , Uhm J.S , Kim J.Y , Pak H.N , Lee M.H
Published: November 2020

Background

It is unclear whether catheter ablation is beneficial in frail patients with AF.

Purpose

This study aimed to evaluate whether catheter ablation reduces death and other outcomes in real-world frail patients with atrial fibrillation (AF).

Methods

Out of 801,710 patients with AF in the Korean National Health Insurance Service database from 2006 to 2015, 1,411 frail patients underwent AF ablations. The Hospital Frailty Risk Score were calculated retrospectively. Inverse probability of treatment weighting (IPTW) was used to categorize ablation and non-ablation frail groups.

Results

After IPTW, the two cohorts had similar background characteristics. During a median follow-up of 4.7 years (interquartile range: 2.2–7.8), the risk of death in frail patients with ablations was reduced by 65% compared to frail patients without ablations (2.0 and 6.4 per 100 person-years, respectively; hazard ratio [HR] 0.35; 95% confidence interval [CI] 0.25–0.50; P<0.001). Ablations were related with a lower incidence and risk of heart failure admission (1.8 and 3.1 per 100 person-years, respectively; HR 0.66, 95% CI 0.44–0.98; P=0.042) and acute myocardial infarction (0.2 and 0.6 per 100 person-years, respectively; HR 0.30, 95% CI 0.15–0.62; P=0.001). However, the risk of stroke did not change after ablation.

Conclussion

Ablation may be associated with lower incidences of death, heart failure, and acute myocardial infarction in real-world frail patients with AF, supporting the role of AF ablation in these patients. The effect of frailty risk on the outcome of ablation should be evaluated in further studies.

Funding Acknowledgement

Type of funding source: None
Clinical outcome of non-use of touch-up focal ablation catheters strategy during cryoballoon atrial fibrillation ablation
Authors: Matsunaga Y , Egami Y , Yano M , Yamato M , Shutta R , Nishino M , Tanouchi J
Published: November 2020

Background

It has been reported that frequent use of touch-up focal ablation catheters was related to worse outcomes after cryoballoon (CB) atrial fibrillation (AF) ablation. It is unknown whether non-use of touch-up focal ablation catheters strategy affects the outcome of AF ablation. Therefore, this study aimed to assess whether non-use of touch-up focal ablation catheters strategy improve clinical outcome after AF ablation using CB.

Methods

A total of 151 consecutive patients who received CB ablation from February 2017 to August 2019 were enrolled. Non-use of a touch-up focal ablation catheters strategy was started from February 2018. Patients were divided into 2 groups according to the type of strategy. In the non-touch-up group, pulmonary veins were isolated without touch-up focal ablation catheters as much as possible and in conventional group, touch-up focal ablation catheters were used as required. The 1-year atrial tachyarrhythmia free survival without class 1 or 3 antiarrhythmic drugs after a 90-day blanking period was assessed between the 2 groups.

Results

The conventional group consisted of 76 patients and the non-touch-up group consisted of 75 patients. Baseline characteristics were comparable between 2 groups. Touch-up focal ablation catheters were used more in the conventional group (11 patients, 14%) than non-touch-up group (0 patients, 0%) (p<0.001). Pulmonary isolation was achieved in all patients of both groups. Atrial tachyarrhythmia recurrence occurred more frequently in the non-touch-up group (15/75 patients, 20%) than conventional group (7/76 patients, 9%) (p=0.045).

Conclusion

Non-use of a touch-up focal ablation catheters strategy may be related to worse outcome after CB AF ablation.

Funding Acknowledgement

Type of funding source: None
Who is too old for epicardial fat volume quantification?
Authors: Brizido C , Matos D , Ferreira A.M , Sousa J.A , Freitas P , Presume J , Rodrigues G.R , Carmo J , Costa F.M , Carmo P , Cavaco D , Morgado F.B , Adragao P , Mendes M
Published: November 2020

Introduction

Epicardial adipose tissue has been implicated in the pathophysiology of atrial fibrillation (AF) and was recently shown to be an independent predictor of AF relapse rate and severity after pulmonary vein isolation (PVI). However, its impact in older patients hasn't been analyzed. The aim of this study was to assess the relative importance of pericardial fat in an older population of patients undergoing pulmonary vein isolation (PVI).

Methods

Single-center retrospective study of symptomatic drug-resistant AF patients undergoing PVI from November/2015 to June/2019. Baseline demographics, clinical and imaging data including cardiac CT and clinical outcomes were collected and analyzed. Population was dichotomized according to age above or below 70 years of age and groups were compared. Epicardial fat volume was quantified by contrast-enhanced cardiac CT using a semi-automated method. The study endpoint was symptomatic and/or documented AF recurrence after a 3-month blanking period.

Results

We assessed 575 patients (354 males, mean age 61±11 years, 449 paroxysmal AF), 145 of which were 70 or older. Compared to the younger cohort, these patients had an higher prevalence of women, lower BMI (27 kg/m2 [IQR 24–30] vs 28 kg/m2 [IQR 25–30] kg/m2, p=0.012), higher CHA2DS2-VASc score (3 [IQR 2–4] vs 1 [IQR 1–2], p<0.001) and larger indexed left atrial volumes (61mL [IQR 52–84] vs 54mL [IQR 47–66], p<0.001).

Median epicardial fat volume was 2.96 cm3/m2 [IQR 2.99–4.00] in the overall population and was higher in older patients (HR 2.21 cm3/m2 [IQR 1.44–3.17] vs HR 1.87 cm3/m2 [IQR 1.24–2.90]; p=0.016).

During follow-up, 232 patients relapsed (40%), with similar recurrence rates between younger and older patients (40% vs 42%, p=0.63) according to Kaplan-Meier survival curve analysis (HR 1.10, 95% CI 0.82–1.48; log-rank p=0.519). Epicardial fat volume remained an independent predictor of AF relapse in the older subset of patients (HR 1.06 for every 1 cm3/m2 increase in epicardial fat volume [95% CI 1.28–2.00]; p<0.001), as did the presence of non-paroxysmal AF (HR 2.78 [95% CI 1.48–5.21]; p=0.001).

Conclusion

Patients over 70 years old with drug-refractory symptomatic AF presented with higher epicardial fat volume. Epicardial fat burden showed similar predictive power for AF relapse after PVI in this subset of patients, representing a useful tool for intervention decision across this age spectrum.

Funding Acknowledgement

Type of funding source: None
Mechanisms of long-term recurrence three years after catheter ablation of atrial fibrillation
Authors: Park J.W , Yu H.T , Kim T.H , Uhm J.S , Joung B.Y , Lee M.H , Pak H.N
Published: November 2020

Background

AF is a progressive disease, and the mechanism underlying long-term recurrence after AFCA is unclear.

Purpose

This study explored the potential mechanisms of long-term recurrence (LTR) of atrial fibrillation (AF) 3-years after AF catheter ablation (AFCA).

Methods

Among 2,209 consecutive patients who underwent AFCA, 1,325 (59±11 years, 72.5% male) who underwent regular rhythm follow-ups for >3-years were enrolled. Among them, 659 patients remained in sinus rhythm (SR), 327 recurred after 3–12 months (short-term recurrence; STR), 235 after 1–3 years (mid-term recurrence; MTR), and 104 after 3-years (long-term recurrence; LTR). Two hundred eighteen recurrent patients underwent repeat procedures: 112, 80, and 26 in the STR, MTR, and LTR groups, respectively.

Results

The pre-ablation left atrial (LA) dimensions were larger in the STR (p<0.001) and MTR groups (p<0.001), but not in the LTR group compared to the SR group. Low LA voltages were independently associated with an LTR (adjusted HR 0.57 [0.36–0.92], p=0.022). Upon the redo-mapping, the number of reconnected pulmonary veins (PVs) was 2.0 (IQR 0–3), 1.5 (IQR 0–3), and 1.0 (IQR 0–2) in the STR, MTR, and LTR groups, respectively (p=0.030). Post-ablation extra-PV triggers were more commonly found in the LTR than STR or MTR groups (LTR 40.9% to STR 19.2%, p=0.014) during the second procedure.

Conclusions

The LTR group had a similar baseline LA size and significantly lower LA voltage than the SR group. In the repeat procedures, the LTR group had fewer reconnected PVs, but extra-PV triggers were more common than in the STR and MTR groups.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Ministry of Health and Welfare, Ministry of Science, ICT & Future Planning (MSIP).
Electrocardiographic characteristics of 5-year atrial tachy-arrhythmia free patients after catheter ablation for atrial fibrillation
Authors: Park J.W , Yu H.T , Kim T.H , Uhm J.S , Kim J.Y , Joung B.Y , Lee M.H , Pak H.N
Published: November 2020

Background

Predictors are not well known for long-lasting sinus rhythm after atrial fibrillation catheter ablation (AFCA).

Purpose

We investigated the pre-procedural clinical factors associated with the patients with 5-year long-term atrial fibrillation (AF) free after AFCA.

Methods

Among 2,085 patients who underwent de novo AFCA, 934 patients (58±11 years, 73.1% male, 66.0% paroxysmal AF), who underwent guidelines-based rhythm follow-up longer than 5-years, were included in this study. We compared 340 patients who never showed AF recurrence for 5-years and 594 patients with AF/ atrial tachycardia (AT) recurrence at least a single episode. Cut-off values of pericardial fat volume and electrocardiogram (ECG) parameters were obtained by Youden index.

Results

1. The patients with AF-free for 5-years (AF-Free-5yrs) had higher proportion of paroxysmal AF (p<0.001), lower body mass index (p=0.020), and lower proportion of pre-existing congestive heart failure (p=0.035), and smaller LA size (p<0.001) than those who experienced recurrence. 2. The patients with AF-Free-5yrs showed lower pericardial fat volume (105.9±47.5 vs. 121.2±53.cm3, p<0.001) and shorter PR interval (181.5±29.6 vs. 190.5±33.1ms, p<0.001) and P wave duration in lead II (PWDII, 121.1±18.0 vs. 129.4±18.8ms, p<0.001) rather than those of counter-part. 3. Multivariate regression analysis revealed that paroxysmal AF at the procedure, lower pericardial fat volume (OR 0.995, 95% CI [0.991–0.998], p=0.004), short PR interval (OR 0.994, 95% CI [0.988–1.000], p=0.038), and PWDII (OR 0.986, 95% CI [0.978–0.995], p=0.002) were independently associated with the AF-Free-5yrs. 3. Among the patients with persistent AF, PWDII was significantly shorter in AF-Free-5yrs group. (123.7±22.6 vs. 133.5±19.5, p<0.001), and PWDII <127.1ms was independently associated with AF-Free-5yrs (OR 3.114, 95% CI [1.819–5.331], p<0.001).

Conclusions

Pericardial fat volume (<113.7cm3) and PR interval (<196 ms) in pre-procedural ECG was independently associated with an excellent 5-year rhythm outcome after AFCA, and PWDII (<127.1 ms) predicted super-responders especially after persistent AF ablation.

Funding Acknowledgement

Type of funding source: None
Extended Pulmonary Vein Isolation: is it sufficient to achieve long-term sinus rhythm in octogenarian women with atrial fibrillation?
Authors: Mohanty S , Trivedi C , Della Rocca D.G , Gianni C , Salwan A , Macdonald B , Mayedo A , Bassiouny M , Gallinghouse J.G , Burkhardt J.D , Horton R , Al-Ahmad A , Di Biase L , Natale A
Published: November 2020

Background

Atrial fibrillation (AF) is a disease of the elderly and women typically present with AF at an older age than men do. Moreover, they tend to experience more symptoms and post-ablation recurrences, have worse quality of life and increased risk of stroke and mortality.

Objective

We evaluated long-term efficacy of our standard ablation approach of extended pulmonary vein isolation (PVI) in octogenarian women undergoing their first AF ablation.

Methods

Consecutive female AF patients aged ≥80 years receiving their first catheter ablation at our center were included in the analysis. Our standard ablation approach at the first procedure includes PVI + empirical isolation of left atrial posterior wall (LAPW) and superior vena cava (SVC). Complete abolition of all potentials rather than decrease in amplitudes was the procedural end point. Patients were prospectively monitored at regular intervals for 3 years after the index procedure with event recorders, 12-lead ECG, cardiology evaluation at office visits and 7-day Holter monitoring.

Results

A total of 194 patients with mean age of 84.2±1.4 years were included in the analysis. Of the 194, 120 (61.8%) had non-paroxysmal AF. All received PVI+ isolation of LAPW and SVC. Acute procedural success was achieved in 100% of cases.

At 3 years of follow-up, 24 (12.4%) patients remained in sinus rhythm; 22 on- and 2 off-antiarrhythmic drugs (AAD). All of the 23 patients had paroxysmal AF as their initial diagnosis.

Of the 170 patients experiencing recurrence, 147 underwent repeat ablation. PV/PW/SVC reconnection was noted in only 6 (4.1%) patients at redo. Triggers originating from non-PV sites were targeted for ablation in all. At 1.5 years after the repeat procedure, 136 (92.5%) patients were in sinus rhythm; 131 off-AAD and 5 patients on-AAD.

Conclusion

Extended PVI including isolation of posterior wall and SVC was not sufficient to maintain long-term sinus rhythm in majority of octogenarian women, regardless of AF type. Moreover, non-PV triggers rather than PV reconnection was the major cause of recurrence in this subset of AF population.

Funding Acknowledgement

Type of funding source: None
Improving pulmonary vein isolation during cryoballoon ablation using the re-look angiography technique
Authors: Reichert W , Tomaiko E , Patel M , Zawaneh M , Weiss P , Su W
Published: November 2020

Background

Cryoballoon ablation for pulmonary vein (PV) antral isolation is contact-dependent. Currently, occlusion assessment using the cryoballoon is most commonly performed using contrast venogram prior to ablation. However, there is a known difference in balloon size/shape between the inflated and ablation state, due to significant increase in cryoballoon pressure, which can cause potential undetected leak and, thus, failure of PV isolation. This phenomenon is currently not detected using standard techniques and effectiveness of mitigation techniques have not been assessed.

Purpose

We hypothesize that repeat injection of contrast five seconds after the initiation of cryoballoon ablation can be used to assess changes in shape and confirm ongoing occlusion during ablation; the re-look angiography technique. The incidence of PVI leak and the ability for the relook angiography to remedy the leak is assessed.

Methods

A total of 125 patients (440 PVs) undergoing cryoballoon ablation (Medtronic Arctic Front Advance Balloon™) were assessed using the re-look angiography technique unless they required occlusion with a segmental approach. Fifteen patients were excluded from contrast use due to renal insufficiency.

Results

Successful single occlusion was seen in 330 (75%) PVs and the re-look angiography technique was employed in each of those events. In 180 of the 330 (55%) single PV occlusions, a new PV leak undetected during the initial PV angiogram was identified. This prompted repositioning of the balloon to achieve complete PV isolation in 85 of 180 of the PV cases, with 95 of the cases requiring additional segmental ablation to complete full PV isolation.

Conclusion

A significant amount of insufficient PV antral contact during cryo-ablation may not be detected with conventional single PV angiography and may explain inadequate PV isolation. The re-look angiography technique is a simple tool to confirm robust balloon contact and guide repositioning as well as identify the need for additional segmental ablation. Additional follow up is needed for translation to improved clinical outcomes.

Funding Acknowledgement

Type of funding source: None
Five year follow-up of symptoms and health-related quality of life in patients with atrial fibrillation treated with catheter ablation
Authors: Walfridsson U , Hassel Jonsson A , Karlsson L.O , Almroth H , Liuba I , Walfridsson H , Charitakis E
Published: November 2020

Background

In accordance with current guidelines the primary indication for catheter ablation (CA) of atrial fibrillation (AF) is to reduce symptoms and thereby improve health-related quality of life (HRQoL). Even though, there are data showing patients' symptom situation before treatment, long-term follow up data are sparse.

Purpose

To assess symptoms and HRQoL five years after CA with the validated arrhythmia-specific questionnaire ASTA, in a large cohort of patients treated with catheter ablation due to AF.

Methods

1323 consecutive patients who underwent CA of AF at one university hospital in Sweden filled out the ASTA questionnaire before the procedure, mostly electronically, and 418 patients at five years follow-up. If not responded within 1 month the patient got a reminder.

Results

Five years after CA and after 1.6 procedures/patient, half of the patients (50%) reported freedom of symptoms, 18% had a major reduction of symptoms (>50% symptom reduction compared to baseline assessments) and 14% had a minor reduction of symptoms (between 10% – 50% reduction) while only 9% of the patients reported no effect on symptoms after the CA and 9% experienced a worsening of their symptoms after the treatment. Factors predicting presence of symptoms at the five-year follow-up were female sex (HR: 1.8; 1.2–2.8), Body Mass Index >35 (HR: 3.9; 1.6–9.8) and having ischemic heart disease (IHD) (HR: 2.6; 1.2–5.9). At the five years follow-up the symptoms breathlessness during activity, weakness/fatigue and tiredness were still the most commonly reported as well as regarding HRQoL it was impaired physical ability and deteriorated life situation.

Conclusions

Catheter ablation has a long-lasting effect and change the natural course of AF, as more than 50% of patients did not experience any symptoms and 32% were improved, while 18% had no treatment effect or worsening of symptoms.

Factors predicting remaining symptoms five years after CA were female sex, presence of IHD and obesity, a reminder to encourage life style managements.

ASTA symptom scale

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Carldavid Jönsson Research Foundation and the County Council of Östergötland (FORSS).
Quantitative analysis of the isolation area after larger-size laser balloon ablation
Authors: Yamasaki T , Hattori T , Kakita K , Oota K , Miyai N , Nakamura R , Sawanishi T , Kinoshita N
Published: November 2020

Background

The visually guided laser balloon ablation is a balloon-based catheter ablation technology used for atrial fibrillation (AF) ablation in recent years. This balloon catheter consists of a compliant balloon that has the capability of real-time endoscopic visualization of the targeted pulmonary vein (PV). The sizeable balloon is usually inflated to obtain optimal PV occlusion. The isolation area after laser balloon (LB) ablation was reported to be smaller than that after cryoballoon ablation. However, when LB is inflated with its maximum pressure, it can visualize wide-area PV antrum. Thereby, we suspected that larger-size LB can create wider isolation area.

Purpose

The aim of this study is to quantitatively evaluate the isolation area after LB ablation at the size larger than appropriate size for ablation in the pulmonary vein carina region.

Methods

We assessed 66 patients with AF who underwent LB ablation at the larger inflation size in our hospital during the period from July 2018 to July 2019. After LB ablation, we created voltage maps with a circular mapping catheter and calculated isolation areas with CARTO system.

Results

Figure shows a larger LB with its maximum pressure. PV antrum isolation was extended to the posterior wall in all patients. The left- and right-sided pulmonary vein antrum isolation area were 15.1±3.9 and 19.4±4.3 cm2, respectively.

Conclusion

LB at the larger inflation size with its maximum pressure can isolate wider-area circumferential PV antrum than previously reported. This method may be a new way of pulmonary vein antrum isolation.

Left atrial voltage mapping after PVI.

Funding Acknowledgement

Type of funding source: None
Association of a history of falls or syncope with intracranial bleeding in patients with atrial fibrillation
Authors: Oqab Z , Alak A , McIntyre W.F , Liu Y.Y , Connolly S.J , Healey J.S
Published: November 2020

Background

In patients with atrial fibrillation (AF), anticoagulation effectively reduces the risk of ischemic stroke. However, up to 50% of patients are not receiving this treatment. A history of falls or syncope and an associated risk of intracranial hemorrhage are commonly reported reasons for undertreatment, though these have not been well studied.

Purpose

To investigate the association of a history of falls or syncope with the risk of intracranial hemorrhage in patients with AF.

Methods

Patients with a history of AF from the RE-LY, AVERROES and ACTIVE A and W trials were combined into a large cohort. “Critical injury” was defined as any injury that resulted in death, was deemed to be life-threatening or resulted in permanent disability. A “serious injury” was defined as an injury that required hospitalization. “Other injuries” were defined as those that did not meet criteria for critical or serious injury. We used logistic regression and propensity-matched Cox models to assess the association between falls or syncope and adverse outcomes.

Results

Among 37,973 patients, 11.9% (n=4503) had a history of falls, 17.5% (n=6655) had a history of syncope and 25.1% (n=9518) had a history of either falls or syncope. The mean age of the cohort was 71±9.3 years and 58% were male. The median CHADS2 score was 2. A history of falls or syncope was not associated with the risk of incident intracranial hemorrhage (HR 1.11, 95% CI 0.88–1.4). In propensity-matched multivariable models, a history of falls or syncope was associated with an increased risk of death (HR 1.14, 95% CI 1.07–1.22), stroke (HR 1.17, 95% CI 1.05–1.3), myocardial infarction (HR 1.28, 95% CI 1.09–1.52) and major bleeding (HR 1.27, 95% CI 1.16–1.4). Moreover, a history of falls or syncope was associated with increased risk of critical injury (OR 1.97, 95% CI 1.52–2.54), serious injury (OR 2.06, 95% CI 1.75–2.43) and “other injury” (OR 1.58, 95% CI 1.46–1.72).

Conclusions

A history of falls or syncope is common in patients with atrial fibrillation; however, neither history was associated with increased risk of intracranial hemorrhage. These patients were at an increased risk of death, stroke, myocardial infarction and major bleeding, suggesting that they should receive anticoagulation for stroke prevention.

Funding Acknowledgement

Type of funding source: None
Edoxaban in atrial fibrillation with PCI by ACS or stable CAD presentation: a pre-specified analysis of the ENTRUST-AF PCI trial
Authors: Vranckx P , Valgimigli M , Eckardt L , Lewalter T , Laeis P , Reimitz P.E , Smolnik R , Zierhut W , Tijssen J , Goette A
Published: November 2020

Aim

We aimed to compare the safety and efficacy of edoxaban in combination with P2Y12 inhibition in the setting of percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF) presenting with an acute coronary syndrome (ACS) or stable coronary artery disease (SCAD).

Methods and results

This is a pre-specified sub-analysis of the ENTRUST-AF PCI trial. Participants were randomly assigned 1:1 to an edoxaban or vitamin K antagonist (VKA) based strategy and randomisation was stratified by ACS (edoxaban n=388, vitamin K n=389) vs. SCAD (edoxaban n=363, vitamin K=366). Participants received edoxaban 60mg once daily plus a P2Y12 inhibitor for 12 months; or VKA in combination with a P2Y12 inhibitor and aspirin 100mg (for 1–12 months).

The primary bleeding endpoint, a composite of International Society on Thrombosis and Haemostasis (ISTH) major or clinical relevant non-major bleeding, at 12 months occurred in 59 (18.52%/year) vs 79 (26.21%/year) ACS patients (Hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.591–1.018, P=0.0631), and in 69 (23.11%/year) vs 73 (25.02%/year) SCAD patients (HR 0.94, 95% CI 0.676–1.305, P=0.7082) with edoxaban and VKA based therapies, respectively (P for interaction [P-int]=0.2741).

The main efficacy endpoint (composite of cardiovascular death, myocardial infarction, stroke, systemic embolism, or definite stent thrombosis) occurred in 33 (9.59%/year) vs 28 (8.21%/year) ACS-patients (HR 1.16, 95% CI 0.697–1.916) compared with 16 (4.84%/year) vs 18 (5.47%/year) SCAD-patients (HR 0.91, 95% CI 0.465–1.781) with edoxaban and VKA based therapy, respectively (P-int=0.5573).

Conclusions

An antithrombotic regimen consisting of edoxaban and a P2Y12-inhibitor without aspirin provides equal safety and similar efficacy for ischaemic events in patients with AF regardless of their clinical presentation with ACS or SCAD.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH
Regular reassessment of bleeding risk using the HAS-BLED score reduces bleeding outcomes in a prospective cohort: a report from the mAFA II clinical trial extension
Authors: Guo Y , Lane D , Chen Y , Lip G.Y.H
Published: November 2020

Background

The HAS-BLED score was introduced to draw attention to modifiable bleeding risk factors and to identify patients with atrial fibrillation (AF) at high-risk of bleeding for early review and follow-up. The mAFA-II randomised trial reported that a holistic management strategy using App-based mobile Health technology support reduced AF-related adverse outcomes, compared to usual care.

Objective

To assess whether regular reassessment of bleeding risk using the HAS-BLED score would improve bleeding outcomes and oral anticoagulation (OAC) uptake.

Methods

Data for this analysis was drawn from the mAF App intervention arm. Bleeding risk (HAS-BLED score) and stroke risk (CHA2DS2-VASc score) were monitored prospectively using mAFA, and calculated during 4 periods: 1–30 days, 31–60 days, 61–180 days, and 181–365 days. Clinical events and OAC changes in relation to the dynamic monitoring and reassessments were analysed.

Results

We studied 1793 patients with AF (mean age 64 years, 32.5% female). The average number of re-assessments of CHA2DS2-VASc and HAS-BLED scores were 6.8 (SD 4.0) and 6.8 (4.1), respectively.

Comparing baseline and 12 months, the proportion of AF patients with HAS-BLED ≥3 decreased (11.8% vs. 8.5%, p=0.008), with changes in use of concomitant NSAIDs/antiplatelets, renal dysfunction, and labile international normalized ratio (INR) contributing to the decreased proportion of patients with HAS-BLED ≥3 temporally (p<0.05). Use of non-vitamin K antagonist oral anticoagulants (NOAC), warfarin, and any antiplatelet drug was 47.1%, 13.8%, and 15.5%, respectively, at baseline.

Incident bleeding events decreased significantly from 1–30 days to 181–365 days (1.2% to 0.2%, respectively; Table 1). Warfarin and NOAC use increased significantly over this period (17.9% to 18.4% and 46.4% to 51.8%, respectively).

Conclusion

In this clinical trial cohort, dynamic risk monitoring and reassessment using the HAS-BLED score, together with holistic App-based management using mAFA II reduced bleeding events, addressed modifiable bleeding risks and increased uptake of OACs.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Natural Science Foundation of China (H2501), NIHR Global Health Research Group on Atrial Fibrillation management
Additive predictive power of the CHA2DS2-VASc and HAS-BLED scores for mortality in patients with atrial fibrillation
Authors: Morrone D , Kroep S , Ricci F , Renda G , Patti G , Kirchhof P , Chuang L.C , Van Hout B , De Caterina R
Published: November 2020

Background and objectives

In atrial fibrillation (AF), assessment of thromboembolic and bleeding risks are recommended to prescribe anticoagulation for stroke prevention. However, AF also increases mortality, and predictors of death are less characterized than predictors for stroke. We investigated the predictive power for mortality of the CHA2DS2-VASc, the HAS-BLED score and their combination.

Methods

Individual patient data were analyzed from the PREvention oF thromboembolic events-European Registry in Atrial Fibrillation (PREFER AF), a prospective real-world registry with a 12-month follow-up, with a total of 7243 patients enrolled from 461 hospitals and 7 European countries (Austria, France, Germany, Italy, Spain, Switzerland, and United Kingdom). Logistic regression was used to analyze the relationship of the CHA2DS2-VASc and HAS-BLED scores, and their combinations with outcome events, including mortality, at one year. The predictive ability of the scores was analyzed by comparing c-statistics.

Results

The study sample consisted of 5,209 AF patients with complete information on both scores. Mean age was 71.8±10.46 years; 3145 subjects (60.4%) were male. Events rate of stroke/SEE and major bleeding at one-year were 2.3% (122 patients) and 2.9% (149 patients), respectively. At one year, 3.1% of patients died (160 out of 5,209). Both scores had broadly similar c-statistics; for CHA2DS2-VASc: 0.637, 0.656 and 0.616 for models predicting mortality, SSE and major bleeding, respectively; for HAS-BLED: 0.620, 0.647, and 0.627, respectively. When including the individual components of both scores separately, c-statistics increased to 0.715, 0.694 and 0.636 with CHA2DS2-VASc, and to 0.681, 0.697 and 0.680 with HAS-BLED. The predictive power with both scores combined, removing overlapping components, was higher, with a c-statistic of 0.74, 0.73 and 0.70 for mortality (Table), SSE and major bleeding, respectively.

Conclusion

Both the CHA2DS2-VASc and the HAS-BLED score predict mortality similarly in AF, and a combination of the score components increases prediction significantly. Such combination may thus be clinically useful.

Funding Acknowledgement

Type of funding source: None