bluuebunny/crossref_metadata_2025 huggingface dataset:
The zero fluoroscopic approach to avnrt ablation significantly reduces radiation without compromising safety, efficacy or procedure time compared to a conventional or minimal fluoroscopic approach
Authors: Saidane L , Robaye B , Kasbari R , Dormal F , Ballant E , Collet B , Blommaert D , Xhaet O
Published: November 2023

Introduction

In 2020, we showed that ablation of AVNRT (induced under conventional fluroscopy) with a 3D electro-anatomical mapping system (EAMS) (minimal X-RAY group) significantly reduces radiation exposure without compromising safety, efficacy and procedure time compared to a procedure performed entirely under conventional fluoroscopy (X-RAY group).

Purpose

The objective of this study was to determine whether the direct use of EAMS in selected patients with a high probability of induction of AVNRT could reduce radiation exposure to near zero without compromising the safety, efficacy and duration of the procedure (EAMS group)

Methods

We compare the 136 patients in the X-RAY group, the 141 patients in the minimal X-RAY group with 39 patients included in the EAMS group (included between July 2020 and December 2022). All procedures were performed at a single centre in Belgium using the same 3D electroanatomical mapping system. In the EAMS group, fluoroscopy had to be used to guide catheter progression for only 5 patients. We compared radiation dose, acute success, complication rates and procedure duration.

Results

AVNRT induction was achieved in 38 of 39 patients in the EAMS group. Only one patient was not inducible, but the slow pathway ablation was performed on the basis of the arrythmic ECG recording which was highly suggestive of AVNRT; the success of the ablation could therefore not be validated acutely.

Radiation dose in the EAMS group was significantly lower compared to the minimal X-RAY group and X-RAY group (8,5 vs 1179 and 2686 mgray.cm2, p <0,0001) and fluroscopic time was obviously shorter (0,02 vs 2,5 and 8,6 minutes, p<0,0001). Procedural time (74,3 vs 70 and 69 mon, p = NS) and success rate (97,5% vs 99 and 98%, p = NS) were not significantly different in the three groups.

No serious complications were observed in any group. No minimal complication were reported in the zero-fluoroscopy group.

Conclusion

AVRNT catheter ablation using a zero-fluoroscopic approach with EAMS significantly reduces radiation exposure without compromising safety, efficacy or procedure time.
Catheter ablation for ventricular tachycardia after myocardial infarction: meta-analysis of randomised controlled trials
Authors: Reddy R K , Howard J P , Ahmad Y , Shun-Shin M J , Simader F A , Miyazawa A A , Saleh K , Samways J , Keene D , Linton N W F , Francis D P , Whinnett Z I , Luther V , Kanagaratnam P , Arnold A D
Published: November 2023

Background

The prognostic impact of ventricular tachycardia (VT) catheter ablation is an important outstanding research question.

Purpose

We undertook a reconstructed individual patient data meta-analysis of randomised controlled trials comparing ablation to medical therapy in patients developing VT after myocardial infarction (MI).

Methods

We systematically identified all trials comparing catheter ablation to medical therapy in patients with VT and prior MI. The pre-specified primary endpoint was all-cause mortality assessed using reconstructed individual patient data obtained by digitisation of published Kaplan-Meier curves and subsequent construction of Cox proportional hazards regression models. Pre-specified secondary endpoints included trial-level assessment by random effects meta-analysis of all-cause mortality, VT recurrence, defibrillator shocks and all-cause hospitalisations. Meta-regression was performed to evaluate the effect of VT mapping in addition to substrate modification. Sensitivity analyses were performed depending on the proportion of patients with prior MI included. (PROSPERO ID CRD42023390799)

Results

Eight trials, recruiting a total of 874 patients, were included. 430 patients were randomised to catheter ablation and 444 to medical therapy. Catheter ablation reduced all-cause mortality compared to medical therapy when synthesising reconstructed individual patient data (hazard ratio 0.57, 95% confidence interval (CI) 0.38 to 0.85, p=0.007), but not in trial-level analysis (relative risk 0.91, 95%CI 0.67 to 1.23, p=0.53, I2=0%). Catheter ablation significantly reduced VT recurrence, defibrillator shocks and hospitalisations compared to medical therapy. Sensitivity analyses were consistent with the primary analyses.

Conclusion

In patients with post-infarct ventricular tachycardia, catheter ablation reduces mortality.
Clinical and echocardiographic impact of physiological estimulation in patients with preserved ejection fraction: a randomized clinical trial
Authors: Rodriguez Queralto O , Gonzalez Matos C , Zaraket F , Jimenez Lopez J , Casteigt B , Moreno Coca J , Valles Gras E
Published: November 2023

Introduction

Right ventricular stimulation in the apex (RVAS) produce dysynchrony, leading to left ventricle systolic dysfunction (LVSD) in some cases. Circumstances that can worsen the LVSD are a high burden of RVAS, and the presence of previous LVSD and/or intraventricular conduction disease (IVCD). Direct activation of the specialized conduction system with physiological stimulation (PS) can preserve this physiological pattern and shorten de QRS when the impairment is proximal to the pacing site. Most of the studies with PS has been focused on patients with LVSD, with few and scarce evidences regarding pacients without LVSD.

Objectives and methods: This is a parallel, single blinded, unicentric, randomized trial of patients with preserved of mild reduced left ventricular ejection fraction (LVEF) submitted to a pacemaker implantation due to atrioventricular block (AVB), with previous IVCD (wide QRS) an anticipated high rate of ventricular pacing. Patients were randomized 1:1 to RVAS vs PS and followed for 6 months. Clinical, ECG, echocardiography and analytic parameters were compared. The primary endpoint was the change in the LVEF at 6 months in each group. The secondary endpoints were the changes in the left ventricular end-diastolic diameter (LVEDD), the QRS duration, the pro–B-type natriuretic peptide (NT-proBNP), the NYHA class, and the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) in each group.

Results

The study included 57 patients of 77±9,6 years. Of all patients, 53% were treated with RVAS and 47% with PS. There were 2 patients with crossover to RVAS for technical difficulties and 1 patient with crossover to PS due to apical scar. There were no differences in the basal QRS duration (142.08±20,2 ms), LVEF (58.87±7,2%), NT-proBNP (3336,03±7258,68 pg/ml), or MLWHFQ (22,19±14,68), between both groups (Table 1). Acutely significant differences were observed in the change of QRS duration among groups (+16±29 ms in the RVAS group vs -17±25 ms in the PS group, p<0,001). At 6 months follow-up LVEF showed a non-significant reduction of 0.8±1.1% in the PS group compared to a significant reduction of 5.1±1.7% in the RVAS group (difference 4,26% IC 0,1-8,43 p=0,022). No differences were observed regarding the values of the NT-ProBNP and the MLWHFQ between groups at 6 months (Table 2).

Conclusions

In patients with preserved LVEF requiring pacemaker implantation for AVB, PS shorten the QTS duration and preserves the LVEF compared to RVAS.Basal characteristics of groupsDifferences in outcomes between groups
Clinical outcome for heart failure hospitalizations in patients with leadless pacemaker
Authors: Nagashima M , Hiroshima K , Katsuki T , Ando K
Published: November 2023

Background

Leadless pacemaker has a low risk of complications such as infection, pneumothorax, and skin erosion, and it is good adaptation for elderly patients. While ventricular pacing induces ventricular desynchronization, and that is causes of heart failure. The aim of the present study, therefore, was to investigate the association between heart failure hospitalization and leadless pacemaker implantation.

Methods

Between September 2017 and January 2022, 929 consecutive patients were implanted pacemakers. The patients were divided according to types of pacemakers: leadless pacemaker (LPM group, n=368), and conventional pacemaker (PM group, n=561). The clinical outcome was heart failure hospitalization. Hospitalization was considered when patients presented with sign and symptoms consistent with heart failure and required intravenous therapy, and the indication of heart failure hospitalization was at the discretion of the physician. Follow-up visit was planned at 1, 3, 12, 24, and 36 months after pacemaker implantation. Clinical follow-up data were obtained from medical records and/or by telephone contact with the patients, families, or referring physicians.

Results

The median follow-up duration was 1.7 years (interquartile range 0.8-2.6 years). Hospitalization rate for heart failure in the LPM group was 9.3% at 1 year, 15.6% at 2 years, and 21.6% at 3 years, respectively. Adjusted heart failure hospitalization risk in the LPM group was significantly higher than the risk in the PM group (hazard ratio [HR] 1.70, 95% confidence interval [CI] 1.09-2.64, P=0.01). Patients with symptomatic bradycardia caused by sinus node dysfunction (SND) in the LPM group (n=150) were more admitted to the hospital for heart failure, compared with in the PM group (n=219) (HR 2.02, 95%CI 1.04-3.90, P=0.03), while no significant difference was observed between the two groups in the patients with bradycardia caused by atrial fibrillation (LPM group, n=71; PM group, n=18) or atrioventricular block (LPM group, n=147; PM group, n=324).

Conclusions

Hospitalization risk for heart failure was higher in patients with leadless pacemakers, compared with conventional pacemakers. The greater risk was mainly driven by older patients and patients with SND.
Clinical outcomes of cardiac devices in heart failure patients hospitalized with COVID-19: insights from the united states national inpatient database
Authors: Moras E , Gandhi K , Correa A , Mahmood K
Published: November 2023

Background

COVID-19 has caused global impact especially in patients with cardiac devices(CD). Moreover, since the onset of the COVID-19 pandemic, physicians have suspended nonurgent procedures. Scarce date is available with respect to CD implantations in patients with active COVID-19.

Purpose

We aimed to investigate the impact of COVID-19 on implantation rates and clinical outcomes in heart failure (HF) patients hospitalized for COVID-19.

Methods

Data from National Inpatient Sample database from 2020 was used to identify hospitalizations for COVID in HF patients. Clinical outcomes of CD implantations were compared using univariate and multivariate logistic regression analysis.

Results

From March-December 2020, a total of 20,426 CD were performed in HF patients in the United States, of which 0.9 % were among those with active COVID-19 infection. Patients with COVID were younger, more hispanic and black population, and had a higher prevalence of comordities such as ventricular fibrillation and complete heart block when compared to patients without COVID. CD implantation in patients with COVID had significantly increased in-hospital mortality, longer lengths of stay, higher hospitalization costs, and outcomes such as incidence of acute stroke, thromboembolism, and sepsis. Device related complications and the need for revisions were comparable in the two cohorts. After adjustment for baseline characteristics, COVID cohort had increased odds of in-hospital mortality.

Conclusion

Patients with active COVID-19 infection who underwent device implantation had increased in-hospital mortality, longer lengths of stay and higher hospitalization costs with comparable outcomes of device complications.Figure 1Figure 2
Clinical impact of permanent pacemaker implantation following surgical ablation of atrial fibrillation concomitant to mitral valve surgery: a multicenter study
Authors: Pyo W , Lee S H , Lee S
Published: November 2023

Background

Permanent pacemaker (PPM) implantation is a common adverse event following arrhythmia surgery. However, the epidemiology and clinical impact of PPM has been shown in only few studies in heterogeneous population, and the results are controversial.

Purpose

The present study aimed to investigate the clinical impact of PPM implantation following surgical ablation of atrial fibrillation (AF) concomitant to mitral valve (MV) surgery.

Methods

We identified 721 patients (aged 60.2±11.0 years, 437 females) who underwent surgical ablation of AF along with MV repair or replacement at five representative institutions in Korea between 2005 and 2017. Of these, 56 had PPM implanted (PPM group) and the remainder (n=665) did not receive a PPM (No-PPM group). The clinical outcomes were compared between the groups, and multivariable Cox proportional hazard analysis with time-varying covariate was conducted to determine the impact of PPM implantation on mortality and stroke.

Results

The patients in the PPM group were older, and had a higher CHAD2S2-VASc score than those in the No-PPM group (Table). During follow-up of 68.3 months (interquartile range 44.5-105.4 months), no significant survival difference was evident between the groups, however, the PPM group presented a significantly higher incidence of stroke than No-PPM group (p<0.001) (Figure). On time-varying multivariable analysis, the PPM was not a risk factor for mortality (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.18-1.08; p=0.072), however, old age (HR, 1.10; 95% CI, 1.07-1.13; p<0.001), chronic kidney disease (HR, 1.61; 95% CI, 1.01-2.58; p=0.046) and previous cardiac surgery (HR, 1.86; 95% CI, 1.01-3.21; p=0.027) were independent predictors of mortality in this subset of patients. The only significant risk factor for stroke was CHAD2S2-VASc score (HR, 1.27; 95% CI, 1.01-1.61; p=0.044), and PPM was not associated with risk of stroke (HR, 1.87; 95% CI, 0.71-4.90; p=0.202).

Conclusion

PPM implantation following surgical ablation of AF concomitant to MV surgery was not associated with an increased risk of mortality or stroke. This study result provides a supporting evidence for an active attempt in surgical ablation despite of inherent risk of PPM implantation.
ABC (Atrial fibrillation Better Care) pathway in asian patients: an analysis from the prospective Asia-Pacific Heart Rhythm Society Atrial Fibrillation Registry
Authors: Bucci T , Shantsila A , Romiti G F , Teo W S , Park H W , Shimizu W , Tse H F , Proietti M , Lip G Y H , Chao T F
Published: November 2023

Introduction

The "Atrial fibrillation Better Care" (ABC) has been proposed as an integrated approach to improve management in patients with atrial fibrillation (AF) based on 3 pillars: "A" Avoid stroke with Anticoagulation; "B" Better symptom optimisation through rate or rhythm control; "C" Cardiovascular risk factor management. There are limited prospective data on the clinical outcomes associated with ABC pathway adherence from Asian countries.

Purpose

To investigate the beneficial effect of ABC pathway adherence in the prospective multi-country Asia-Pacific Heart Rhythm Society (APHRS) Atrial Fibrillation registry.

Method

We investigated 4013 AF patients prospectively enrolled in the APHRS registry. Cox-regression analyses were performed to investigate the association between ABC adherence and clinical outcomes. Primary outcome was a composite of all-cause death, any thromboembolic events, acute coronary syndrome or percutaneous interventional procedures and new/worsening heart failure. Secondary outcomes were each component of the composite outcome and major bleeding.

Results

In the whole population, 1549 (38.6%) patients were ABC adherent (mean age 66±12 years; 33% female). After 1-year of follow-up, ABC pathway adherent patients had a lower incidence of composite outcome (4.0% vs 8.5%, p<0.001), all-cause death (1.4% vs 4.0%, p<0.001), cardiovascular death (0.3% vs 0.9%, p=0.013) and new/worsening heart failure (1.7% vs 2.7%, p=0.010), when compared to those ABC non-adherent. On multivariable Cox regression ABC pathway adherence was associated with a lower risk for composite outcome (Hazard Ratio 0.72, 95% Confidence Interval 0.53-0.97) and the reduction of the risk increased progressively with the number of the ABC criteria fulfilled. There was no statistically significant interaction in the clinical benefit seen between the different participating countries in the APHRS registry (pint=0.217).

Conclusion

In a large contemporary cohort of Asian AF patients, ABC pathway adherence was associated with a reduction of the risk for the composite outcome of all-cause death and cardiovascular events. This benefit was seen irrespective of enrolling country.
Evaluation of risk factors for long-term atrial fibrillation development in patients undergoing typical atrial flutter ablation: a multi-center pilot study
Authors: Yumurtas A C , Pay L , Tezen O , Cetin T , Yucedag F F , Arter E , Kadioglu H , Akgun H , Ozkan E , Uslu A , Kup A , Saylik F , Cinar T , Hayiroglu M I
Published: November 2023

Background/Introduction

Atrial flutter (AFL) and atrial fibrillation (AF) are the most commonly detected supraventricular arrhythmia and share similar pathophysiological mechanisms (1). After the successful ablation of AFL, AF frequently occurs in such patients in the long-term follow up (2). As emphasized in some studies, some mechanisms seem to predispose to the development of AF in AFL patients and approximately 20% of such kind of patients have accompanying AFL (3).

Purpose

We aim to analyze independent risk factors that predict the development of AF in patients who underwent typical AFL ablation.

Methods

Our study was designed as multi-center, cross-sectional and retrospective. A total of 442 patients who underwent typical AFL ablation at 3 different centers between January 1, 2018 and January 1, 2022 were included retrospectively. The patients after the ablation procedure were divided into those who developed AF and those who did not. The patients were followed up for an average of 12 (4-20) months. In the post-procedure period, atrial arrhythmias were investigated with 24-hour Holter and ECG at 1st month, 6th month, 12th month and at 6-month intervals thereafter.

Results

AF developed in 206 (46.6%) patients in the long-term follow-up. Age, hypertension (HT), obstructive sleep apnea syndrome (OSAS), previous cerebrovascular accident (CVA), left atrium antero-posterior diameter, severe mitral regurgitation, hemoglobin, blood glucose and HbA1c values were found to be significant in univariable analysis. According to multivariable analysis, HT (p=0.014; HR: 1.483 (1.084 – 2.030)), OSAS (p=0.008; HR: 1.520 (1.117 – 2.068)) and previous CVA (p=0.038; HR: 1.749) (1,031 – 2,968)) were independently associated with the development of AF in AFL patients who underwent ablation procedure.

Conclusion

In the present study, we found that HT, OSAS and previous CVA were independently correlated with the development of AF in the long-term follow-up of patients who underwent typical AFL ablation. We consider that AFL patients with such risk factors should be followed-up closely following cavo-tricuspid isthmus ablation for the development of AF.

Univariable and Multivariable Analyzes Kaplan - Meier Curves
Integrated epigenomic and network analysis identifies novel DNA methylation signature in atrial fibrillation
Authors: Infante T , Pepin M E , Ruocco A , Mauro C , Napoli C
Published: November 2023

Background

CD4+ T cells are associated with atrial fibrillation (AF) pathogenesis but mechanistic insights as well as epigenetic phenomena underlying the onset and progression of AF are not fully understood.

Purpose

To identify differential methylation signature in circulating CD4+ T lymphocytes isolated from AF patients and HS enrolled in the DIANA clinical trial through epigenome and network medicine approaches.

Methods

DNA was extracted from CD4+ T lymphocytes obtained from patients diagnosed with AF (n = 10) vs patients with no known arrhythmias (n = 11). DNA was then used for paired-end reduced representation bisulfite sequencing to quantify differentially methylated regions (DMRs). NetworkAnalyst tool was interrogated in order to build a specific protein-protein interaction network and identify hub differentially methylated genes (DMGs) in AF. We considered the centrality degree as main network topological measure and defined hubs those DMGs with a centrality degree > 10.

Results

The analysis provided 7,846 DMRs (P<0.05), associated with 5,373 annotated genes, among which 7,075 hyper-methylated and 771 hypo-methylated regions were uncovered (Figure 1A). Among the identified DMRs, 3,601 were located within gene promoters of which 3,513 were hypermethylated while 88 hypomethylated. Network analysis including the 50 top hyper- and hypomethylated DMGs, according to the differential methylation values, provided a heart specific subnetwork with 56 nodes and 611 edges and 51 seeds (Figure 1B). Although the DNA methylation trend showed a predominant hypermethylation pattern in CD4+ T cells from AF patients (Figure 1A), network analysis demonstrated that hypomethylation was prevalent in the top 15 hub DMGs. In particular, GSTK1, WWP1, PSMD6, TFRC, CDK5R1, HSPG2, WDFY3, WT1, USP49, ACOT7, LAMB2, ITGB7, SHARPIN, and PLXNB2 emerged as hypomethylated hub DMGs, while AIFM1, PFDN1, LMO3, CDK5RAP2, COL4A1, SEPT8, and CYTH4 resulted hypermethylated hub DMGs. Interestingly, several genes are involved in pathological mechanisms of AF in cardiac tissues such as inflammation, fibrosis and cardiac remodeling.

Conclusions

Our preliminary data represent the first global methylation analysis in circulating CD4+ T cells in AF. The validation of specific genomic regions and the detection of molecular pathways characterized by aberrant DNA methylation changes may help to clarify pathological mechanisms underlying AF, thus providing an important translational impact for novel diagnostic biomarker discovery and therapeutic target identification.Figure 1
Local changes in conduction velocity in the left atrium of atrial fibrillation patients undergoing pulmonary vein isolation
Authors: Meijer I , Keshtar S K , Kong X , Jiang C , Chang-Sheng M , Camara O , Marquering H A , Arrarte Terreros N , De Groot J R
Published: November 2023

Background

Electro-anatomical maps are standardly used to visualize anatomy and electrophysiological properties of the left atrium (LA) during pulmonary vein isolation (PVI) in atrial fibrillation (AF) patients.

Purpose

We sought to describe local differences in atrial conduction velocities (CVs), as a proof-of-principle, to study its association with tissue heterogeneity. We hypothesize that the variation and heterogeneity in these velocities throughout the LA carry important prognostic and diagnostic information, reflect the extent of remodeling and, in the future, might discern different subtypes of AF and treatment outcome.

Methods

We included AF patients who underwent PVI for the first time during 2021-2022. Electro-anatomical maps (EAMs) during sinus rhythm were acquired during the procedure and single data-points were projected on the patient-specific EAM-derived mesh of the LA. Patients were classified as persistent (AF lasting longer than 7 days and usually requiring electrical cardioversion) and paroxysmal (self-terminating AF episodes, lasting shorter than 7 days, mostly shorter than 24 hours) and were followed-up for 6 to 12-months. We determined unipolar voltages, activation times and computed local CVs for these patients. The CVs were normalized for each patients and reported as the median CV for each region containing enough points.

Results

We included 12 patients: 6 with paroxysmal and 6 with persistent AF. Patients in the paroxysmal group had larger median activation times and median CVs compared to the persistent group. The variability in voltage, activation time and CV was twice as large in the paroxysmal group (Table 1). Figure 1 displays an example of an electro-anatomical reconstruction of the LA of a paroxysmal AF patient showing the local median conduction velocity from an anterior and posterior view (Figure 1A and 1B) and the variance and distribution of median CV (Figure 1C). In this patient, we observed large local CV differences, which might reflect tissue heterogeneity (e.g. fibrosis).

Conclusion

We provided a proof-of-principle demonstrating that, with the use of conventional electro-anatomical maps, important information on heterogeneity and variance in local CVs can be quantified. We found a large variability in CV within and between patients. This can help discern different AF subtypes and might contribute to understanding different arrhythmogenic substrates and treatment outcome differences.
Elucidating the role of leukocyte telomere length in the risk of atrial fibrillation
Authors: Ardissino M , Von Ende A , Murgia F , Casadei B , Van Duijn C , Hopewell J C
Published: November 2023

Background

Atrial fibrillation (AF) is strongly associated with older age. However, it is unclear whether, in addition to chronological age, more advanced biological ageing confers AF risk. Previous studies suggest AF and peripheral leukocyte telomere length (LTL, a measure of biological ageing) are associated, but this relationship and the causal relevance remains controversial.

Purpose

This study aims to explore the role of LTL in risk of AF through observational analyses and Mendelian randomisation (MR).

Methods

UK Biobank (UKB) is a large prospective study of individuals 40 to 69 years of age in which 393,018 participants have measured LTL and genetic data available. Observational associations between LTL and incident AF (ascertained in hospital admission data) were estimated using Cox proportional hazards models adjusted for potential confounders (age at LTL measurement, body mass index, physical activity, smoking status, alcohol intake, ethnicity, Townsend deprivation index, and sex). MR analyses included 195 SNPS previously shown to have conditionally independent genome-wide significant associations with measured LTL. In UKB, causal effects of genetically-predicted LTL for AF risk were estimated using the inverse-variance weighted approach. Validation was undertaken in independent data from the AFGen Consortium (Nielsen et al. 2015). Sensitivity analyses to consider the potential effects of pleiotropy were also conducted (weighted median MR, MR-Egger and Radial MR).

Results

Among 385,851 participants with available LTL measurements and without AF at baseline, 26,639 (6.9%) developed AF during follow-up. Longer measured LTL was associated with lower risk of AF (HR=0.98, 95%CI=0.97-0.99, p=0.002), with the cumulative incidence of AF by LTL quartile shown in Figure 1. However, MR analyses did not support a causal association between genetically-predicted LTL and AF (OR=1.04, 95%CI=0.96-1.14, p=0.36). Sensitivity analyses were consistent with the primary MR results, and did not suggest unbalanced pleiotropy (MR Egger intercept, p=0.54). Radial MR identified 4 outlier SNPs (associated with height, adiposity, and blood cell traits) but results remained consistent after exclusion of these variants (OR 1.00, 95%CI 0.93-1.08, p=0.90). Validation analyses in independent data were consistent with the non-significant association observed in UKB (OR=1.08, 95%CI=0.99-1.18, p=0.07; Figure 2).

Conclusion

This study combines conventional and genetic epidemiological approaches to explore the role of LTL in risk of AF. Large-scale observational analyses in UKB suggest an inverse association between LTL and AF. However, despite previous studies reporting associations between genetically-determined LTL and AF risk factors, our validated MR results do not support a causal relationship between LTL and AF, and potentially suggest observational associations are due to residual confounding.Figure 1Figure 2
Predicting post-operative atrial fibrillation after heart surgery: clinical profile and biomarkers
Authors: Iglesias D , Rodriguez-Manero M R M , Fu X F , Martinez-Cereijo J M C , Agra-Bermejo R A B , Veiras-Del Rio S V D R , Taboada-Muniz M T M , Fernandez-Gonzalez A F G , Rivera-Caravaca J M R C , Lahoz A L , Arribas J M A , Canovas S C , Marin F M , Gonzalez-Juanatey J R G J , Eiras-Penas S E P
Published: November 2023

Objective

Post-operative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery, increasing the morbidity and mortality of this specific patient population. We investigated the association of clinical, biochemical and molecular markers on several tissues with the occurrence of POAF in patients undergoing coronary and/or valve surgery.

Methods

Between August 2020 and September 2022, patients undergoing cardiac surgery without previous history of AF were studied. Clinical variables were collected before the surgery, plasmatic samples and biological tissues (epicardial and subcutaneous fat) were obtained the day of surgery. We observed the development of POAF during the post-operative period. Logistic regression analyses were carried out in order to identify the predictors with better performance. Patients were followed-up until hospital discharge.

Results

Out of 123 consecutive patients without prior history of AF, 43 developed POAF during hospitalization. Significant clinical differences were associated with POAF, such higher EuroSCORE II, left atrial dimension and longer cardiopulmonary bypass times. Logistic regression analysis also showed orosomucoid (a biomarker associated with the inflammatory pathway) as the best predictor for POAF [odds ratio (OR) 7.175 (95% confidence interval (CI), 2.172-23.701), p=0,001].

Conclusions

In patients referred for open heart surgery, orosomucoid at the moment of surgery is an independent risk factor for the development of POAF and its addition to EuroSCORE II increased the predictive ability.
Episode-level characteristics of atrial fibrillation are associated with symptomatic events
Authors: Ahluwalia N , Schilling R J , Majumder S , Koehler J , Landman S , Sarkar S
Published: November 2023

Background

Symptoms related to Atrial Fibrillation (AF) can be debilitating are the main driver to seek hospital attention. However, many patients do not experience any symptoms and intra-subject variation is also seen. The reasons for this variability are unclear and a better understanding of the features associated with symptomatic AF episodes may improve stratification and personalisation of care.

Purpose

To evaluate the features associated with symptomatic versus asymptomatic AF episodes recorded using an insertable cardiac monitor (ICM).

Methods

We linked a deidentified database of aggregated electronic health records from 2007-2021 to a manufacturer’s device data warehouse with continuous diagnostic monitoring data. ICM-detected AF episodes of a minimum of one hour duration were retrospectively analysed. Symptomatic AF was defined as episodes temporally correlated with patient activation of a handheld symptom activator device. Episode- level comparison of mean heart rate at detection and during the entire AF episode, AF episode duration, activity index and AF evidence score (a linear scale based on episode irregularity) between symptomatic and asymptomatic patients was performed. Data was reported as mean ± standard deviation or median (inter-quartile range) if non-normally distributed. Wilcoxon Signed-Rank test was used for per-subject paired analysis. Multi-variate logistic regression model with binomial distribution and exchangeable correlation structure was used to identify factors associated with symptomatic episodes. A Generalized Estimating Equations model was used to account for multiple AF episodes within a subject.

Results

417,432 unique episodes were recorded in 11,436 patients. 6,190 (1.48%) episodes from 1776 patients were marked as symptomatic. These were longer (5.5 (12.1) hours vs 3.7 (9.3) hours), had a higher mean HR at onset (105.7±29.3bpm vs 89.1+-24.6bpm) and a greater AF evidence score (97.6+-26.9 vs 82.1+-24.4). On multi- variate logistic regression, AF evidence score, and mean HR was independently associated with symptomatic AF (table 1). Per subject analysis of 1589 patients with both symptomatic and asymptomatic episodes also suggested significantly higher AF evidence scores. (-3.64±22.0).

Discussion: This is the largest episode-level characterisation of AF episodes in patients with an ICM. The AF evidence score, a marker of ventricular rate variability, may be useful for the remote stratification of AF episodes. Prospective study of stratification based on this parameter would be of value.Regression model of symptomatic AF
Stroke, mortality, and major bleeding among patients with atrial fibrillation and chronic kidney disease; insights from a contemporary large-scale population study
Authors: Ben Baruch Golan Y , Tsaban G , Eisen A , Loewenberg Weisband Y , Iakobishvili Z , Henkin Y , Arnson Y , Haim M
Published: November 2023

Introduction

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, sharing a complex interplay. Although both conditions are prothrombotic, the prognostic role of CKD in AF remains uncertain, and anticoagulation effect on clinical outcomes is unclear.

Methods

A historical population-based study based on the "Clalit" health organization computerized database, including patients >21 years first diagnosed with AF between January 1st, 2010, and January 1st, 2020. The study population was stratified according to the estimated glomerular filtration rate (eGFR) at baseline to: No or mild CKD (eGFR≥60mL/min/1.73m2), moderate-CKD (eGFR above 30 and below 60 mL/min/1.73m2) and advanced-CKD (eGFR≤30 mL/min/1.73m2). Multivariable Cox-regression analyses were performed to evaluate the association between CKD stages and the 5-year risk of death, stroke, intracranial hemorrhage (ICH), and gastrointestinal bleeding (GIB). The association of anticoagulation treatments and possible interaction with CKD with the risk for the study outcomes were also examined.

Results

We identified 87,804 patients with incident AF. Of them, 3.2% had advanced CKD, and 25% had moderate CKD. 39,421 patients (45%) received anticoagulation. In multivariable models, moderate and advanced CKD were associated with increased risk for death in an incremental manner (moderate CKD: adjusted-hazard ratio (aHR) 1.17; 95% CI 1.14-1.20, p<0.001) (advanced CKD: aHR 1.85; 95% CI 1.76 -1.96; p<0.001). Both moderate CKD (aHR 1.1; 95% CI 1.00-1.20, p<0.05) and advanced CKD (aHR 1.37; 95% CI 1.13-1.67; p=0.001) were associated with increased risk of stroke. Renal function was not associated with increased risk for ICH, yet it was associated with increased risk of GIB. DOAC therapy reduced the risk of stroke (aHR 0.7; 95% CI 0.57-0.86, p=0.001) and death (aHR 0.83; 95% CI 0.77-0.78, p<0.001) while warfarin treatment did not. The association of anticoagulation treatment with reduced risk for stroke was consistent across CKD strata (p-for-interaction=0.19).

Conclusions

In this contemporary registry of AF patients, worse CKD was incrementally and independently associated with an increased risk of death, stroke and gastrointestinal bleeding among patients with AF. DOAC therapy was associated with a reduced risk for stroke and death without evident increase in ICH or GI bleeding. The inverse association between DOACs and stroke was consistent across all CKD categories. If confirmed by others, CKD ought to be added to stroke risk scores in AF.5 year stroke risk5 year death risk
Association of atrial fibrillation burden with rhythm control and stroke prevention interventions among patients with cardiac implantable electronic devices
Authors: Peigh G , Zhou J , Roberts A I , Rosemas S C , Longacre C , Schwab G , Soderlund D , Passman R S
Published: November 2023

Background

Prior analyses have demonstrated that persistent atrial fibrillation (PeAF) is associated with higher healthcare costs than paroxysmal AF (pAF) or permanent AF (PermAF). While clinical classification of AF is often inaccurate, assessing AF burden from cardiac implantable electronic devices (CIEDs) provides an opportunity to more accurately assess the mechanisms of cost differentials by type of AF.

Objective

To assess the rates of AF-specific healthcare interventions among patients with device detected pAF, PeAF and PermAF.

Methods

Using the de-identified Optum Clinformatics U.S. claims database (2015 to 2020) linked with the Medtronic CareLink database, we identified patients with newly implanted CIEDs that transmitted data 6 months post-implant (baseline period). Device monitoring data during baseline was utilized to stratify patients by AF burden category: pAF (at least one day with >5m AF but <7d with >23h AF), PeAF (at least 7 consecutive days with >23h AF) or PermAF (all days with >23h AF or >95% AF burden). Annualized rates of AF-specific interventions (cardioversions, ablations, hospitalizations for antiarrhythmic drug [AAD] loads, oral anticoagulation [OAC] prescription and AAD prescription) during follow-up were analyzed from insurance claims. Analyses were adjusted for geographical region, insurance type, CHA2DS2-VASc Score, and implant year.

Results

Of the 21,391 patients (72.9±10.9 yrs; 56.3% male) analyzed, 7,798 (36.5%) had device-detected AF. Among these, 5,966 (76.5%) were pAF (avg burden 2.9±8.6%), 1,145 (14.7%) were PeAF (avg burden 47.2±29.9%), and 687 (8.8%) were PermAF (avg burden 99.3±0.7%). Compared to patients with pAF, those with PeAF had a higher adjusted ratio of cardioversions, hospitalizations for new AAD initiation, OAC prescription and AAD prescription. Patients with PeAF also had higher adjusted rates of ablations, cardioversions, hospitalizations for new AAD initiation, and AAD prescriptions than those with PermAF. Compared to patients with pAF, those with PermAF had a lower adjusted rate of ablation, hospitalization for new AAD load and AAD prescription, but a higher rate of OAC prescription (fig).

Conclusion

In a real-world cohort, patients with CIED-detected PeAF had higher rates of cardioversions, hospitalizations for AAD initiation, and AAD prescriptions than those with CIED-detected pAF and PermAF. The higher intensity of observed physician-driven interventions may be a potential driver of the increased cost associated with PeAF.Figure
Clinical impact of type 1 and type 2 diabetes mellitus in atrial fibrillation and the effect of severe hypoglycaemia: a nationwide cohort study
Authors: Fauchier L , Bentounes S , Bisson A , Fauchier G , Bodin A , Vigny P , Pierre B , Angoulvant D , Ducluzeau P H , Lip G Y H
Published: November 2023

Background

Both atrial fibrillation (AF) and diabetes mellitus (DM) are common chronic conditions associated with a significant disease burden. Diabetes increases the risk of AF and the presence of both diseases is associated with higher risk of all-cause mortality and complications. We aimed to compare prognosis individuals with type 1 (T1DM) and type 2 (T2DM) diabetes, against those without DM, in a nationwide cohort of patients with AF and second, to study the outcomes in cases of severe hypoglycaemia amongst those with DM.

Methods

Based on the France nationwide administrative hospital-discharge database, we collected information for all AF patients seen in French hospitals between 2014 and 2022. Among 3,311,634 patients identified with AF, 694,610 (21.0%) had diabetes: 37,218 (1.1%) with T1DM and 657,392 (19.9%) with T2DM. History of severe hypoglycaemia was defined as a primary or secondary hospital ICD-10 diagnosis of E16.0, E16.1, E16.2, E10.0, E11.0, E12.0, E13.0, or E14.0 and was identified in 22,717 patients (3.1% of those with T1DM and 3.3% of those with T2DM). Adverse outcomes were investigated during follow-up until 31 December 2022. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox model and were adjusted for age, sex and comorbidities (hypertension, obesity, smoking, alcohol abuse, coronary artery disease, heart failure, valve disease, presence of pacemaker or implantable cardioverter defibrillator, peripheral artery disease, stroke, chronic lung disease, chronic kidney disease, dementia and history of cancer).

Results

Using individuals without diabetes as reference, the adjusted HRs indicated an increased risk in patients T1DM and in those with T2DM for all-cause death, cardiovascular death, HF, MI, ischemic stroke, dementia, VT/VF and cardiac arrest (HRs ranging from 1.19 to 1.69 in T1DM and from 1.10 to 1.41 in T2DM, all p <0.0001, see Table 1).

Among patients with diabetes, those with a history of severe hypoglycaemia had increased risks of all-cause death, dementia and cardiac arrest in case of T1DM and an increased risk of all-cause death, cardiovascular death, HF, MI, dementia and cardiac arrest in case of T2DM (see Table 2).

Conclusion

Presence of diabetes (regardless of type) is associated with an increased risk of premature death, cardiovascular events and dementia in patients with AF. This increase seems more pronounced in T1DM than in T2DM. A history of severe hypoglycaemia is associated with a much worse prognosis in patients with T1DM or T2DM.
Cigarette smoking and structural brain deficits in patients with atrial fibrillation
Authors: Peter R , Aeschbacher S , Coslovsky M , Krisai P , Rodondi N , Mueller A , Haller M , Stauber A , Sinnecker T , Bonati L , Burkard T , Conen D , Osswald S , Kuehne M , Meyer-Zuern C
Published: November 2023

Background

Brain lesions are common in patients with atrial fibrillation (AF). Whether cigarette smoking is associated with an increased risk of brain lesions and reduced brain volume in patients with AF is currently unknown.

Purpose

In this analysis, we aimed to investigate the association of cigarette smoking habits with cerebral small vessel disease and overall brain volume.

Methods

For this cross-sectional analysis, we included AF patients from a multicentre cohort study. Smoking habits were defined by smoking status categories (never, former, current), duration (tertiles of years), cigarettes per day (CPD as obtained at baseline), packyears (PKY, tertiles) and time since smoking cessation (≤5 years, 6-10 years, 11-15 and ≥16 years). A standardized brain magnetic resonance imaging was done to assess the prevalence of small vessel disease white matter lesions (WML, graded according to the Fazekas scale) and small non-cortical infarcts (SNCI). Additionally, MRI was used to quantify the volumes of WML and SNCI; as well as to measure grey matter (GM) and white matter (WM) brain volumes. Multivariable adjusted logistic and linear regression analyses were applied.

Results

1746 patients were enrolled (mean age 72.6 years, 27.5% females). 131 (7.5%) were current smokers, 846 (48.5%) former and 769 (44%) never smokers. Patients with a longer smoking duration, higher amount of CPD and PKY had reduced GM brain volume (p for linear trend 0.05, 0.005 and 0.02, respectively). Patient with higher CPD also had a reduced WM brain volume (p for linear trend 0.04). Compared to patients with a smoking duration in the lowest tertile (≤18 years), patients who had smoked for 19-34 years (second tertile) and more than 35 years (third tertile) had a higher risk for WML Fazekas ≥2 with an OR (95% CI) of 1.85 (1.29; 2.66, p=0.001) and 1.46 (1.01; 2.09, p=0.04) (Figure 1). Additionally, increasing smoking duration tertiles exhibited larger WML volumes, with a significant linear trend (p=0.05). AF patients who quit smoking ≥16 years ago had a lower odds for SNCI (OR 0.47 (0.24; 0.94, p= 0.03), less WML volume (β: -0.451 (-0.8; -0.11, p=0.01), and a higher WM brain volume (β: 16.9 (0.3; 33.6, p= 0.05) compared to patients who quit 5 years prior to the study enrolment (Figure 2). We found no significant difference in any structural brain deficit between current and former smokers compared to never smokers.

Conclusion

In a large AF population, we found that smoking duration and amount were associated with the loss of brain volumes. Smoking duration and time since smoking cessation were associated with small vessel disease.
AF in the AFternoon: The circadian pattern of incident atrial fibrillation in a loop recorder population
Authors: Chousou P A , Chattopadhyay R , Tsampasian V , Pugh P , Vassiliou V
Published: November 2023

Introduction

Loop recorders have provided the opportunity to systematically screen individuals for arrhythmias, and in doing so provide new appreciated mechanistic insights to arrhythmia pathophysiology. Atrial fibrillation (AF) is a complex arrhythmia with a multitude of precipitants and substrates. Previous studies looking at the circadian rhythm of AF, have required patient symptoms to define onset. All studies on the circadian rhythm of AF suggest that AF does not occur randomly. It has been suggested that the circadian variation in autonomic function may provide an underlying substrate for AF initiation.

This is the largest study to utilise loop recorder detected AF to explore the circadian pattern of AF.

Purpose

We sought to ascertain how the detection of incident AF varied throughout the day, in patients monitored with a loop recorder

Methods

This was a single-centre retrospective observational study. Consecutive adult patients referred for ILR implantation between March 2009 and November 2019, without prevalent AF or atrial flutter, were included. Demographic and anthropometric data was identified from the individuals medical notes. The time of incident AF episodes was identified from loop recorder reports.

Results

A total of 1168 AF episodes of any duration were identified by the ILR, of which onset time was available for 1118 episodes. Onset of AF episodes in our data for the entire population demonstrated a monophasic distribution (figure 1a). The OR for developing AF between 13.00-14.59 compared to 03.00-04.59 was 4.89 (95% CI 3.47-6.90).

Amongst the ESUS population time of onset distribution showed multiple daytime peaks (figure 1b). The OR for developing AF between 10.00-11.59 compared to 03.00-04.59 was 4.39 (95% CI 2.68-7.20).

Amongst the non- ESUS population time of onset distribution (figure 1c) shows a monophasic pattern with the peak at time blocks 12.00-14.59. The OR for developing AF between 13.00-14.59 compared to 02.00-03.59 was 6.75 (95% CI 4.17-10.93).

Conclusion(s)

Our study demonstrated that there is a diurnal variation for incident AF detection using a loop recorder. There is a general propensity for episodes to occur in the afternoon, with a nadir at night. This is in contrast to previous reports which have suggested that the nocturnal and morning peaks are more apparent. Moreover, different cohorts appear to show different temporal patterns, with ESUS patients having multiple time peaks, whereas the non-stroke cohort had a solitary peak period.

Understanding the diurnal variation of AF may help to shed more light on the complex pathogenesis of AF, and whether different AF phenotypes are associated with stroke risk. Moreover, the finding of a day-time propensity for AF, adds weight to the utilisation of consumer facing non-invasive monitoring tools during the day for AF identification in high-risk populations.