bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of ABC pathway adherence in high-risk patients with atrial fibrillation: an analysis from the ESC-EHRA EORP-AF long-term general registry
Authors: Ding W Y , Proietti M , Romiti G F , Vitolo M , Fawzy A M , Boriani G , Marin F , Blomstrom-Lundqvist C , Potpara T S , Fauchier L , Lip G Y H
Published: October 2022

Background

The impact of Atrial Fibrillation Better Care (ABC) pathway adherence among high-risk subgroups of patients with atrial fibrillation (AF), ie. those with chronic kidney disease (CKD), advanced age and/or prior thromboembolism remains unknown. We evaluated the impact of ABC pathway adherence on clinical outcomes in these high-risk AF patients.

Methods

The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. High-risk patients were defined as those with either CKD (eGFR <60 mL/min/1.73 m2), older age (≥75 years) and/or prior thromboembolism. The primary outcome was a composite event of all-cause death, any thromboembolism and acute coronary syndrome, evaluated according to ABC pathway adherence.

Results

A total of 6646 patients with AF were included (median age was 70 [IQR 61–77] years; 40.2% females). There were 3304 (54.2%) `high risk' patients with either CKD (n=1750), older age (n=2236) or prior thromboembolism (n=728). Among these there were 924 (28.0%) managed as adherent to ABC.

At 2-year follow-up, a total of 966 (14.5%) patients reported the primary outcome. The incidence of the primary outcome was significantly lower in high-risk patients managed as adherent to ABC pathway (IRR 0.53 [95% CI, 0.43–0.64]). Consistent results were obtained in the individual subgroups [Table]. Using multivariable Cox proportional hazards analysis, ABC adherence in the high-risk cohort was independently associated with a lower risk of primary outcome (aHR 0.64 [95% CI, 0.51–0.80]), as well as in the CKD (aHR 0.51 [95% CI, 0.37–0.70]) and elderly subgroups (aHR 0.69 [95% CI, 0.53–0.90]). Overall, there was greater reduction in the risk of primary outcome as more ABC criteria were fulfilled, both in the overall high-risk patients, as well as in the individual subgroups [Figure].

Conclusion

In a large, contemporary European AF cohort there was a significant proportion of high-risk patients. Among these, a low prevalence of integrated care, as assessed by adherence to ABC pathway, was found. Nonetheless, a clinical management adherent to the ABC pathway was associated with a significant reduction in the risk of adverse outcomes, the benefits of which were more significant with increasing number of ABC criteria adherent.

Funding Acknowledgement

Type of funding sources: None.
Atrioventricular nodal ablation with pacemaker implant is associated with improved safety outcomes compared to pulmonary vein isolation of atrial fibrillation with heart failure
Authors: Olarte N , Vincent L , Ebner B , Grant J , Maning J , Hernandez R , Rivera-Rodriguez B , Giraldo M , Mendoza I
Published: October 2022

Background

Pulmonary vein isolation (PVI) and atrioventricular nodal ablation (AVNA) with pacemaker implant have both been advocated for patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). Direct comparisons between the two are limited.

Purpose

We sought to compare outcomes and complications following PVI versus AVNA with implant of a cardiac implantable electronic device (CIED) among patients with AF and HFrEF.

Methods

We queried the National Inpatient Sample from 2011 to 2019, using relevant ICD-9 and -10 diagnostic and procedural codes for AF, HFrEF, ablation, and CIED implant to identify our study cohort. Exclusion criteria included presence of a pre-existing CIED, ventricular arrhythmias, non-AF supraventricular arrhythmias, and surgical AF ablation. Baseline characteristics included age, sex, race, and comorbidities related to AF and cardiovascular disease. Severity of comorbidities was assessed via Deyo-Charlson Comorbidity Index (Deyo-CCI). Outcomes investigated include all-cause mortality, major adverse cardiovascular events (MACE), extra-cardiac procedural complications, length of stay, and total hospital charges. Outcomes associations were analyzed using multivariate logistic regression adjusted for baseline characteristics that were significantly different (P<0.05) between cohorts expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI). SPSS v28.0 (IBM, Armonk, NY) was used to carry out all calculations.

Results

We identified 3,565 encounters for PVI and 1,355 for AVNA with CIED implant among hospitalized patients with AF and HFrEF. Patients who underwent AVNA were more often older (73.8 vs 66.2 years), with more severe comorbidities (mean Deyo-CCI score 2.9 vs 2.6) and were more likely to have an emergent procedure performed (81.3% vs 69.7%; p<0.001 for all). However, the AVNA cohort had less mortality (0.5% vs 1.2%, p=0.03), MACE (6.1% vs 7.8%, p=0.04), and total complications (12.7% vs 16.3%, p=0.002), but longer hospital stay (8.0 vs 6.5 days) and higher total charges ($201,100 vs $159,382; p<0.001 for both). After adjusting for confounders, AVNA remained independently associated with decreased odds of mortality (aOR: 0.370; 95% CI [0.159–0.862], p=0.02), MACE (aOR: 0.552; 95% CI [0.420–0.726], p<0.001), and total complications (aOR: 0.708; 95% CI [0.589–0.852], p<0.001).

Conclusion

Despite older age with more severe comorbidities and less elective procedures, hospitalized patients with AF and HFrEF who underwent AVNA with CIED implant had improved safety outcomes compared to PVI. Further studies comparing the intermediate and long-term outcomes and efficacy between therapies are needed to better delineate which would best serve this population.

Funding Acknowledgement

Type of funding sources: None.
Long-term risk of replacement of cardiovascular implantable electronic devices following external cardioversion
Authors: Elgaard A F , Dinesen P T , Riahi S , Hansen J , Lundbye-Christensen S , Johansen J B , Nielsen J C , Larsen J M
Published: October 2022

Introduction

External cardioversion (ECV) with transthoracic shock is a recommended and important part of the rhythm control strategy regardless of cardiovascular implantable electronic devices (CIED). Studies and case reports have demonstrated rare, but serious CIED malfunctions related to the ECV procedure. However, follow-up data on contemporary CIEDs undergoing ECV procedures are limited. The aim of this study is to investigate the long-term risk of generator replacements following an ECV procedure.

Methods

All CIED implants and surgical re-interventions in Denmark were identified in the Danish Pacemaker and ICD Register from January 2005 to April 2021. The ECV procedures were identified in the Danish National Patient Registry from January 2010 to February 2019. For each patient undergoing ECV, five matched (age, sex, and type of CIED) controls without previous ECV were identified. Time to generator replacement was estimated using competing risk analyses, with death, extraction and up-/down-grade being competing events. Risks were estimated by the pseudo-observation method.

Results

We identified in total 3,924 ECV-events in 2,610 CIED patients with 74.4% male. Mean age of patients at first ECV-procedure were 68.6±11.7 years, and median implant time was 1.5 year. The type of CIED included 50% of pacemakers, 28% of Implantable Cardioverter Defibrillators, and 22% of Cardiac Resynchronization Therapy-systems. During the first 5 years of follow-up, 451 (17.3%) of the shock-exposed devices were replaced vs. 2,000 (15.2%) of the unexposed devices. The relative risks (RR) of device replacement were 1.43 (95% CI: 0.5; 2.4) after 12 months, 1.44 (95% CI: 0.1; 2.8) after 24 months, and −0.53 (95% CI: −2.8; 1.7) after 5 years. The cumulated incidence of first endpoint: Replacement, death, extraction, and up-/down-grade are illustrated in Figure 1. A larger proportion of patients died in the shock-exposed group with n=427 (16.4%) compared to n=1,588 (12.2%) in the unexposed group during 5-years of follow-up with RR=3.2 (95% CI: 1.2; 5.3) of dead before other events.

Conclusion

Contemporary CIEDs do not indicate different risk of generator replacement following external cardioversion with transthoracic shocks. Shock-exposed device patients were more prone for extraction and death.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This is work was financed by Department of Cardiology, Aalborg University Hospital and supported by Karl G. Andersen foundation.
Effect of dronedarone versus placebo on atrial fibrillation progression: a post-hoc analysis from ATHENA trial
Authors: Blomstrom-Lundqvist C , Naccarelli G V , McKindley D S , Bigot G , Wieloch M , Hohnloser S H
Published: October 2022

Background

Atrial fibrillation (AF) may progress over time, leading to greater AF burden. Data suggest that patients receiving rhythm control drugs are less likely to progress to more severe forms of AF vs those receiving a rate control strategy only. ATHENA (NCT00174785) demonstrated that dronedarone significantly decreased cardiovascular (CV) hospitalization and death [1], but it is unclear whether dronedarone affects progression of AF and atrial flutter (AFL).

Purpose

This post hoc analysis of ATHENA assessed (1) the effect of dronedarone on estimated AF/AFL burden, and (2) AF progression to presumed permanent AF/AFL or AF regression to sinus rhythm (SR).

Methods

AF/AFL burden was estimated using a modified Rosendaal method [2] based on status of all ECG assessments at each visit. Cumulative incidence of presumed permanent AF/AFL (defined as ≥6 months of AF/AFL until end of study) or preserved SR (≥6 months of SR until end of study) were calculated using the complement of Kaplan-Meier estimates. Log-rank test was used to assess statistical significance.

Results

Demographic characteristics in 2231 patients on placebo and 2208 on dronedarone were well balanced between groups. Overall, 304 (13.8%) dronedarone-treated patients progressed to presumed permanent AF/AFL compared with 455 (20.4%) treated with placebo. Patients progressing to presumed permanent AF/AFL tended to have larger left atrial diameters and lower left ventricular ejection fractions irrespective of treatment group. The cumulative incidence of presumed permanent AF/AFL was significantly lower in dronedarone-treated patients over time (log-rank p<0.0001; Figure 1). Estimated AF/AFL burden was lower in dronedarone-treated patients over time (Figure 2). Overall, 1149 (52.0%) dronedarone-treated patients had preserved SR compared with 1021 (45.8%) placebo-treated patients, and cumulative incidence of preserved SR was significantly higher in the dronedarone arm compared with the placebo arm (log-rank p<0.0001). Treatment-emergent adverse events were consistent with the findings in the main ATHENA analysis.

Conclusions

Dronedarone use was associated with fewer patients progressing to presumed permanent AF/AFL, more patients with AF/AFL regressing to preserved SR, and a lower estimated AF/AFL burden, suggesting a protective benefit against AF disease progression.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sanofi
Dronedarone versus sotalol in patients with atrial fibrillation: a systematic literature review and network meta-analysis
Authors: Kreidieh B , Singh J P , Blomstrom-Lundqvist C , Turakhia M P , Camm A J , Fazeli M S , Crotty C , Kowey P R
Published: October 2022

Background

There are limited comparative data on safety and efficacy within Vaughn Williams class III anti-arrhythmic drugs (AADs) for maintenance of sinus rhythm in adults with atrial fibrillation (AF).

Purpose

We sought to compare the safety and efficacy of dronedarone and sotalol, two commonly prescribed Vaughn Williams class III AADs with class II rate-controlling properties in patients with non-permanent AF.

Methods

A systematic literature review was conducted by searching MEDLINE®, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) up to June 15, 2021. Clinical trials and observational studies that evaluated safety and efficacy of dronedarone or sotalol in adults with AF were included. Where feasible, Bayesian random-effects network meta-analysis (NMA) was conducted to estimate comparative safety and efficacy. Where possible, sensitivity analyses were conducted by including only randomized controlled trials (RCTs).

Results

Of 3,581 records identified through database searches, 37 unique studies (23 RCTs, 13 observational studies, and 1 non-randomized trial) were included in the NMA. Dronedarone was associated with a statistically significantly lower risk of all-cause death versus sotalol in the all-studies NMA (hazard ratio [HR]: 0.38; 95% credible interval [CrI]: 0.19, 0.74; 22 studies); sensitivity analysis followed the same trend numerically (HR: 0.46; 95% CrI: 0.21, 1.02; 16 RCTs). Risk ratios of AF recurrence were not significantly different between dronedarone and sotalol in both all-studies and sensitivity analyses.

Conclusion

Dronedarone, compared with sotalol, was associated with significantly lowered risk of all-cause death in the analysis combining RCTs and observational studies, with no differences in AF recurrence observed between the two therapies. This meta-analysis provides a comprehensive assessment of safety and efficacy evidence useful in evaluating treatment options in AF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sanofi
Long-term results of catheter ablation of atrial fibrillation in patients with a reduced left ventricular ejection fraction
Authors: Baimbetov A , Tursunkhanov Z H , Jukenova A , Bizhanov K , Yakupova I , Bigeldiyev N
Published: October 2022

Objective

This study aims to evaluate long-term results after catheter ablation of atrial fibrillation (AF) in patients with reduced left ventricular ejection fraction (LVEF) and to evaluate sinus rhythm (SR) maintenance, clinical status, and echocardiographic parameters in the long-term follow-up period.

Material and methods

The study included 112 patients (75.5% men, age 59.5±11.5 years) with LV EF <50% underwent radiofrequency catheter ablation for paroxysmal (24%) or persistent (76%) AF. Patients after ablation were followed up for 38.4 (17.7–54.5) months for AF recurrence, functional class, and echocardiographic parameters.

Results

All patients underwent complete antral isolation of the pulmonary veins, and 95 (84.8%) underwent additional linear ablations in the left atrium. During the follow-up period, 48 (42.8%) patients experienced arrhythmia recurrence in the form of AF, atrial flutter, or ectopic atrial tachycardia. Repeated ablations were required in 35 (31.2%) patients. After ablation, antiarrhythmic drugs continued to be taken in 75 (66.9%) patients. During follow-up, NYHA class improved at least one class more often among patients in stable sinus rhythm than patients with recurrences (77.5% vs 51.2%, p=0.003). LV EF improved in patients maintaining sinus rhythm (36.6% vs 19.4%; P=0.016), and the degree of mitral regurgitation was significantly reduced (P<0.001) only in these patients. On multivariate analysis, maintenance of sinus rhythm was an independent predictor (odds ratio 4.56, 95% CI 1.69–9.94, P=0.002) of long-term clinical improvement (reduction in NYHA class ≥1 and relative improvement in LVEF ≥10%).

Conclusions

In patients with reduced LV EF, maintenance of sinus rhythm after ablation is associated with more significant clinical improvement. In the long-term period, the effectiveness of AF ablation in patients with reduced LVEF, as an improvement in the NYHA class and an increase in LVEF, is affected by a high rate of long-term recurrences.

Funding Acknowledgement

Type of funding sources: None.
Evaluating the value of the timing of recurrence during blanking period after atrial fibrillation ablation
Authors: Lopes Da Cunha G J , Bem G , Durazzo A , Matos D , Rodrigues G , Carmo J , Carvalho M S , Carmo P , Santos P G , Costa F M , Cavaco D , Morgado F B , Mendes M , Adragao P
Published: October 2022

Introduction

In the first weeks after atrial fibrillation (AF) ablation, the arrythmia may recur theoretically due to transient local inflammation and not due to treatment failure. This is defined as the blanking period, with a proposed duration of 3 months. Recently, this time period has been brought into question. The aim of this work was to evaluate the correlation between the timing of blanking recurrence and late AF recurrence.

Methods

This was a single-centre retrospective study including patients without structural heart disease that underwent first AF ablation and were subsequently enrolled in the post ablation structured program between 2018 and 2021. Patients were excluded if they had <6 months follow-up. Appointment with ECG and Holter monitoring was performed at 1, 3, 6 and 12 months after ablation.

Results

We included a total of 193 patients (56% male, mean age 63±12 years). Of these, 79% had paroxysmal AF and mean left atrial volume index was 58±18 mL/m2. During the 3-month blanking period, there were 39 (21%) recurrences, 18 (9%) of which in the first month. After blanking period, at 6 months, 25 (13%) patients had AF recurrence, 56% of which had already recurred during blanking period. AF recurrence in the 2nd and 3rd month of blanking increased the odd of recurrence at 6-month by more than 5-fold (odds ratio (OR) 8,944; CI 95% 2,817–28,400, p<0.001 and OR 5,591; 95% CI 1,173–26,651; p=0.031). On the other hand, recurrence of AF during the 1st month of blanking was not associated with increased chance of 6-month AF recurrence (OR 2,095, 95% CI 0,630–6,964, p=0.227) (figure 1). There were no significant differences in clinical variables, including LA volume, between patients with 1-month recurrence and patients without recurrences. However, patients with AF recurrence in the 2nd and 3rd month of blanking had significantly increased LA volume.

Conclusion

Our study suggests that patients with AF recurrence in the 2nd and 3rd month of blanking have structurally different atria and are at a significantly higher risk of post blanking AF recurrence, in contrast with patients with AF recurrence in the 1st month of blanking, thus questioning the appropriate duration of the blanking period.

Funding Acknowledgement

Type of funding sources: None.
Regional variations in patient selection and procedural characteristics for cryoballoon ablation of atrial fibrillation
Authors: Scazzuso F , Ptaszynski P , Kaczmarek K , Chun K R J , Khelae S K , Foldesi C , Obidigbo V , Kaplon R , On Y K , Al-Kandari F , Okumura K
Published: October 2022

Background

Cryoballoon ablation is a well-established anatomical approach for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Although widely adopted, regional variations in standards of care have not been well characterized.

Purpose

To evaluate regional variations in patient selection and procedural characteristics for PVI with cryoablation in the Cryo Global Registry (NCT02752737).

Methods

Patients with AF were enrolled from May 2016 to October 2021 at 128 sites in 37 countries. Patients were treated with cryoballoon ablation according to local clinical practice. Baseline subject and procedural characteristics were summarized for 8 regions (Central Asia and Russia, East Asia, Europe, Middle East, North America, South Africa, South America, and Southeast Asia). Procedure-related serious adverse events (SAEs) were evaluated in a subset of patients with ≥7 days of follow-up.

Results

A total of 3680 patients undergoing initial PVI for AF were included. Cryoballoon ablation was more commonly performed in patients with paroxysmal vs. persistent AF in all regions, and in males vs. females in all regions except Central Asia and Russia. Mean age ranged from 47±12 in the Middle East to 64±11 in East Asia. Regional variations were observed in the proportion of patients with common AF comorbidities undergoing cryoablation (Table 1). Median procedure time ranged from 61 (49–68) minutes in Central Asia and Russia to 95 (76–120) minutes in Southeast Asia. Median fluoroscopy time was ≤20 minutes in all regions. The use of 3D mapping was relatively uncommon except in North America (63.3%). Large variation was observed in the use of esophageal monitoring, whereas phrenic nerve monitoring was used in ≥97.7% of cases in all regions (Table 2). Same-day discharge was uncommon except in North and South America (37.8% and 26.5% of cases, respectively). Average freeze duration ranged from 153±41 seconds in Southeast Asia to 230±29 seconds in Central Asia and Russia. Mean number of applications per vein ranged from 1.2±0.4 in Central Asia and Russia to 2.1±1.0 in North America. Acute procedural success was ≥94.7% in all geographies and focal radiofrequency touch-up was required in ≤13.0% of cases. In 3126 subjects with ≥7 days of follow-up, 122 procedure-related SAEs were reported in 111 patients (3.6%), and 1 procedure-related death was reported during data collection.

Conclusion(s)

Despite regional variations in patient selection and procedural characteristics, PVI using cryoballoon ablation is performed with high acute success and short procedural times around the world.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic, Inc.
High density catheter approach with liveview dynamic display improves procedural efficiency of atrial fibrillation ablation
Authors: Di Cori A , Giannotti Santoro M , Parollo M , Della Volpe S , Mazzocchetti L , Barletta V , Segreti L , Viani S , De Lucia R , Canu A , Grifoni G , Soldati E , Bongiorni M G , Zucchelli G
Published: October 2022

Introduction

PVI isolation confirmation after RF ablation is often time-consuming, especially in case of a single transeptal catheter approach into the left atrium. A novel Live View (LV) dynamic display mapping software, utilized in combination with the High Density (HD) Grid mapping catheter, allows to display beat-to-beat, dynamic regional mapping data.

Purpose

We evaluated the feasibility and the procedural impact of a procedural left atrial workflow with a single transeptal-single HD catheter analysis, incorporating the LV Mapping Software for the assessment of PVI after ablation.

Methods

Paroxysmal and persistent AF patients scheduled for AF ablation were prospectively enrolled. All patients underwent only PVI under LSI guidance (LSI between 5.5 and 6 anteriorly; LSI between 4.5 and 5 posteriorly) with a point by point strategy and an inter-lesion distance <6 mm. According to the HD mapping strategy used to confirm entrance block after first pass PVI, patients were divided in two groups. The HD-LV Group included patients mapped with the HD-LV software and the HD-standard mapping (SM) group included patients which received a conventional PVI validation with a static voltage/activation map. Left PVI was evaluated during distal coronary sinus pacing and right PVI during sinus rhythm. Exit block was also evaluated to confirm bidirectional block. Procedural efficiency parameters were compared between groups.

Results

Forty-six patients with AF (58% paroxysmal) were prospectively enrolled. Twenty-five patients were included in the HD-LV Group and 21 in the HD-SM Group. PVI was successful in all patients. LV dynamic display analysis was feasible in all patients and allowed a simple and fast validation of right and left PVI, without the necessity of introducing a second catheter into the left atrium. The split screen modality, with a dynamic activation map on the left and a dynamic voltage map on the right, allowed to switch from CS pacing to sinus rhythm without the necessity of a remap. The overall mapping time (27±10 vs 37±14 min, p=0.006), total procedure time (138±33 vs 178±50 min, p=0.006) and fluoroscopy time (14±5.3 vs 23±11 min, p=0.006) were significantly lower in the HD-LV Group. No complication was seen in either group.

Conclusions

A simplified clinical utilization of LiveView dynamic display with a single transeptal-single HD catheter approach is feasible and efficient after PVI, potentially simplifying the procedural workflow. A real-time dynamic mapping in daily practice may further enhance the clinical benefits of HD mapping during radiofrequency (RF) catheter ablation procedures.

Funding Acknowledgement

Type of funding sources: None.
Predictors of AF recurrence in patients with paroxysmal AF undergoing catheter ablation: new predictors coming?
Authors: Ribeiro Silva M , Ribeiro Queiros P , Santos Silva G , Teixeira R , Fernandes S , Almeida J , Fonseca P , Oliveira M , Goncalves H , Rodrigues A , Primo J , Fontes-Carvalho R
Published: October 2022

Introduction

Recurrence of atrial fibrillation (AF) after catheter ablation (CA) is estimated to be between 20% and 45% and the prediction of recurrence AF in patients (pts) with paroxysmal AF undergoing CA remains challenging.

Purpose

To determine the clinical and procedural predictors of recurrence AF after CA in pts with paroxysmal AF.

Methods

Single-centre retrospective study that included all pts with paroxysmal AF who underwent AF CA between 2017 and 2019. Ablation procedures included radiofrequency and second-generation cryoballoon CA. All pts underwent cardiac computed tomography prior the procedure. AF recurrence was defined as any recurrence of AF, atrial flutter or atrial tachycardia >30 seconds (recorded in 12-lead electrocardiogram or Holter) after 90 days of CA. The independent association between clinical and procedural variables and AF recurrence was evaluated with Cox regression analysis.

Results

We included 351 pts, 63,5% male and with a mean age of 57,1±11,4 years. CHADSVASCscore ≥2 points were present in 43,7% of the pts, median duration of AF prior the intervention was 3 years (IQR 1–6) and most pts were treated with some antiarrhythmic drug at the time of CA (56,9%). Overall, median follow-up was 27 months (IQR 19–39).

AF recurrence was present in 96 pts (27,4%), on average, 15,2±10,4 months after CA.

Univariate logistic regression identified female gender, thyroid disease, left atrium (LA) enlargement (defined as LA indexed volume >34 mL/m2 or LA diameter >38mm for female or >40mm for male), coronary calcium score >100, epicardial adipose tissue volume, number of previous electric cardioversions, treatment with antiarrhythmic drugs prior CA and the extent of CA (only pulmonary vein isolation (PVI) or PVI and ablation of other lesions) as predictors of recurrence AF after CA in pts with paroxysmal AF (p<0,05 for all).

Cox regression analysis identified female gender (OR 1,615, 95% CI 1,005–2,597; p=0,008), LA enlargement (OR 2,084, 95% CI 1,207–3,596; p=0,008) and coronary calcium score >100 (OR 1,958, 95% CI 1,133–3,385; p=0,016) as independent predictors of AF recurrence.

Conclusions

In our cohort, AF recurrence was significantly higher in pts with LA enlargement, with coronary calcium score >100 and female gender pts.

Funding Acknowledgement

Type of funding sources: None.
Significant procedure length reduction when utilizing active esophageal cooling – a six-year single center study
Authors: Joseph C , Willms D , Francisco G , Ruppert A , Athill C
Published: October 2022

Background

A number of factors can influence procedure duration of left atrial ablation for the treatment of atrial fibrillation (AF). In addition to ablation techniques, the use of auxiliary tools such as intraoperative fluoroscopy and luminal esophageal temperature (LET) monitoring may impact procedure duration. However, unlike recent trends toward zero-fluoroscopy procedures, there has not been a widespread transition to alternative means of esophageal protection. Multi sensor LET monitoring leads to frequent pauses during ablations when dangerous esophageal temperatures have been reached. Although an increased risk of esophageal injury when utilizing LET monitoring as compared to active esophageal cooling has been suggested in recent studies, the degree to which LET monitoring impacts procedure duration has not been well documented. Consequently, we aimed to compare procedure duration in a large single center before and after active esophageal cooling was implemented in place of LET monitoring.

Objective

Review procedural timing data at a single large hospital before and after the implementation of active esophageal cooling in place of LET monitoring, and compare differences in procedure duration.

Methods

Using an existing hospital registry of ablation procedures, we obtained procedure durations for left atrial ablations for AF before and after the implementation of active esophageal cooling into the hospital protocol. Data was collected with IRB approval from a single hospital from January 2015 through November 2021. Prior to September 2018, multi-sensor LET monitoring was utilized in all patients, whereas all patients afterwards were treated with active esophageal cooling.

Results

Data was analyzed from a total of 412 patients. LET monitoring was utilized with 176 patients, while active esophageal cooling was utilized with 236 patients. In the LET monitored group the median procedure length was 191 minutes with an interquartile range (IQR) of 91 minutes. In the actively cooled group, the median procedure length was 147 minutes with an IQR of 61 minutes. This represents a median difference of 44 minutes, or 23% of total procedure time (p<0.001).

Conclusion

When compared to LET monitoring, the use of active esophageal cooling is associated with a significant time savings in PVI procedures.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Attune Medical
Prediction of recurrence after catheter ablation for atrial fibrillation using left atrial morphology on preprocedural computed tomography: application of radiomics
Authors: Hirota N , Suzuki S , Arita T , Yagi N , Otsuka T , Yamashita T
Published: October 2022

Background

Radiomics is a comprehensive analysis methodology of medical image and involves the extraction of numerous features from standard imaging. Its usefulness has been reported mainly in the field of cancer for diagnosis and prediction of prognosis. In the territory of cardiac imaging, several reports have investigated the utility of radiomics for classifying the risk of prognosis in coronary artery disease, and few practical applications have been reported for patients with atrial fibrillation (AF) who underwent pulmonary vein isolation (PVI). Although the left atrial morphology can affect the clinical course after the PVI procedure, it is unclear whether the radiomics feature values of the left atrial morphology on cardiac computed tomography (CT) is useful for predicting the AF recurrence after PVI.

Purpose

To predict the recurrence of AF after PVI using the radiomics feature values of the left atrial morphology on cardiac computed tomography (CT).

Methods

We analyzed 525 consecutive three-dimensional cardiac CT in patients with atrial fibrillation who underwent PVI from 2018 to 2019 in our institute. After marking the region of interest on left atrium (including the root of pulmonary veins) semiautomatically, 107 radiomics feature values were obtained by Python program. After excluding the parameters having collinearity or with low predictive capability for the recurrence of AF after PVI, 42 parameters were applied to the final prediction model. Two prediction models were constructed by multivariate Cox regression analysis and machine learning model by support vector machine algorithm.

Results

The area under the curve (AUC) for predicting the recurrence of AF was 0.815 for the multivariate Cox regression model and 0.826 for the machine learning model by support vector machine.

Conclusion

The radiomics feature values on preprocedural cardiac CT could be helpful for predicting the recurrence of AF after PVI. Since radiomics feature analysis yields a huge number of numerical values representing the left atrial morphology in a reproducible manner, it would provide a new direction to construct a good prediction model using machine learning including artificial intelligence out of a routine cardiac CT scan.

Funding Acknowledgement

Type of funding sources: None.
Ablation of residual potentials along the circumferential line reduces acute reconnection in patients undergoing pulmonary vein isolation
Authors: Tzeis S , Kojic D , Manola S , Brusich S , Pernat A , Asvestas D , Xenos T , Tomovic M , Cubranic Z , Rauber M , Pavlovic N
Published: October 2022

Introduction

Acute pulmonary vein (PV) reconnection is frequently encountered in patients with atrial fibrillation (AF) subjected to PV isolation (PVI).

Purpose

In this prospective, multicenter, randomized study, we investigated whether the identification and ablation of sites along the circumferential line with specific electrogram criteria indicative of nontrasmurality, after initial achievement of PVI, reduces acute PV reconnection rate.

Methods

Patients referred for AF ablation at five European centers were enrolled. PVI with antral circumferential isolation of ipsilateral PVs was performed using a contact force sensing ablation catheter delivering 35–40W at the anterior/superior and 30W at the posterior wall with target ablation index of 550 at the anterior wall/roof and 400 at the posterior/inferior segments. Following PVI, mapping with the ablation catheter was performed to identify residual potentials (RP) along the ablation line, defined as bipolar amplitude ≥0.2 mV or 0.1–0.19 mV combined with negative component of the unipolar electrogram as recorded by the 3D mapping system. Ipsilateral PV sets with RPs were randomized to either no further ablation (Group B) or to additional ablation of RPs (Group C). The primary study endpoint was defined as spontaneous or adenosine-mediated recovery of conduction after 30-minute waiting period which was also evaluated in ipsilateral PV sets without residual potentials (Group A).

Results

In total, 109 patients (59.3±10.6 years, 47% hypertension, 9.3% diabetes, left atrial diameter 39.1±4.6mm) were enrolled in the study. After initial isolation of 194 PV pairs, 98 PV pairs had no RPs (Group A) while the remaining 96 with RPs were randomized to either Group B or C (48 PV pairs each). The number of sites with RPs did not differ between groups B and C (4.1±2.5 vs 4.7±3.2, p=0.27). The occurrence of the primary endpoint in Group A was 7.1%. Ablation of residual potentials resulted in significant reduction of spontaneous or adenosine mediated reconnection (14.6% vs 47.9%, p<0.001).

Conclusion

Following initial PVI achievement, ablation of RPs along the antral circumferential line reduces spontaneous or adenosine-mediated acute PV reconnection rate in patients undergoing first-time AF ablation. Therefore, scanning of the PVI line in search of weak links with specific electrogram criteria indicative of nontrasmurality, and subsequent deployment of bonus lesions, could represent a convenient and practical way to reduce acute PV reconnection. Further studies are required to assess long term effects on AF recurrence rates.

Funding Acknowledgement

Type of funding sources: None.
Spatiotemporal signatures of response to atrial fibrillation ablation
Authors: Ganesan P , Rogers A J , Deb B , Feng R , Rodrigo M , Ruiperez-Campillo S , Tjong F V , Bhatia N , Clopton P , Rappel W J , Narayan S M
Published: October 2022

Background

Atrial fibrillation (AF) can have organized regions, in the form of consistent dominant frequency sites, focal or reentrant sites, but it is unclear how these overlap with or differ from focal atrial tachycardias (AT) or potential drivers. We set out to develop an intuitive method based on fundamental electrogram shape and timing to separate types of AF.

Objective

To test the hypothesis that spatial regions of electrogram (EGM) in AF that show similar shapes over time based on cross-correlation analysis may separate patients with differing response to ablation.

Methods

We recruited N=133 patients (63.8±12.1 Y, 32% women), (i) N=10 had AT, (ii) N=122 AF that was or was not terminated by ablation, and (iii) N=1 pacing. All patients had left atrial mapping by 64 pole baskets. We applied repetitive activity (REACT) mapping that correlates EGMs in contiguous 2x2 regions (Fig. 1A) over 4sec. To calibrate REACT, we introduced simulated variations in shape (gaussian noise) and timing (gaussian delay) to pacing EGMs and computed nomograph over 100 random trials (Fig. 1C).

Results

Fig. 1B shows that REACT in a 71-year-old man with AT is more organized than in a 65 YO man with AF (100% vs 40% mapped field). Overall, REACT was higher in AT than AF (0.63±0.15 vs 0.36±0.22, p<0.001). There were 24 cases in which global REACT between AF and AT groups had the overlapping range of values, indicating organized “islands” in AF analogous to AT. From nomograph in Fig. 1C we identified that this overlap reflects 15 ms variation in cycle length and 20% variation in EGM shape (labelled “x” in Fig. 1C).

Conclusion

Basic electrogram properties in AF of similar shapes in spatial areas over time can separate response to ablation and may represent “islands” of AT. Future studies should investigate the mechanisms for such islands and whether they may be targeted for therapy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Institutes of Health
High epicardial fat volume is associated with atrial fibrillation recurrences after catheter ablation
Authors: Herman R , Hlivak P , Bernat V , Svetlosak M , Demolder A , Palus T , Urban L , Hatala R
Published: October 2022

Background

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation therapy for atrial fibrillation (AF). However, even with important technological improvements, AF recurrences are common in long-term follow-up. Recently, epicardial fat tissue (EFT) has been proposed as a potential AF modulator promoting and sustaining atrial arrhythmogenic milieu.

Aim

In this retrospective single-centre study, we sought to evaluate the association between CT-quantified EFT volume and long-term primary PVI outcome assed by means of continuous ECG monitoring with implantable loop recorders (ILR) in paroxysmal AF patients.

Methods

A cohort of 92 patients (median age 60.2 [IQR 51.9–64.0]; 74% male) with paroxysmal AF (a single persistent AF episode was accepted) undergoing catheter ablation targeted at PVI was analysed. Prior to CA all patients underwent cardiac CT imaging with subsequent implantation of implantable loop recorder (ILR). Radiofrequency CA ablation with electro-anatomical mapping for PVI was used in 79 patients, balloon cryoablation was used in 13 patients. Verified complete PVI was defined as procedural endpoint. EFT volume was semi-automatically segmented and quantified on contrast enhanced CT studies. AF recurrence, defined as AF burden >0.1% after the blanking period (90 days), was continuously assessed by ILR. Kaplan-Meier analysis of AF recurrence-free survival at 1-year, 2-year and 3-year follow-up periods compared patients stratified into EFT volume tertiles.

Results

During a median follow-up of 52.6 months [IQR 43–64], AF recurrence was detected in 58 (63%) patients, 29 (50%) of them underwent a repeat ablation. Patients in high, mid, and low total EFT volume tertiles had a median time to late AF recurrence of 154, 373, and 284 days (Fig. 1A). At a 1-year follow-up, patients in the high EFT volume tertile had the worst AF ablation outcome (p=0.023). However, this difference gradually faded-out and became non-significant at 2 and 3 years. ROC analysis revealed an EFT of 95 ml as an optimal cut-off (p=0.002) for expected arrhythmia recurrence post acutely successful PVI (Fig. 1B).

Conclusion

EFT volume quantification in a relatively homogenous, continuously monitored cohort of patients undergoing catheter ablation for paroxysmal AF revealed a significant association between AF recurrence at 1 year post ablation and volume of epicardial fat. These results suggest a possible role of epicardial adipose tissue as an adverse pro-fibrillatory factor. Identified EFT volume cut-offs have to be validated prospectively on a larger and balanced patient population.

Funding Acknowledgement

Type of funding sources: None.
Electrophysiological insights into left atrial conduction times and regional velocities in atrial fibrillation patients with and without fibrotic atrial cardiomyopathy
Authors: Heil E , Gerds-Li J H , Keznickl-Pulst J , Furundzija V , Hohendanner F , Pieske B , Schoeppenthau D
Published: October 2022

Background

Although considerable progress has been made in understanding the process of arrhythmogenesis in atrial fibrillation (AF) patients and the role of atrial substrate, little is known about atrial conduction characteristics in different grades of fibrotic atrial cardiomyopathy (FACM) and specific left atrial (LA) regions.

Purpose

The aim of this study was to evaluate left atrial conduction times (LACT) and -velocities (CV) in electroanatomical high density maps during sinus rhythm in AF patients with and without signs of atrial fibrosis.

Methods

Before radiofrequency catheter ablation electroanatomical high density mapping was performed in 41 AF patients (n=38 persistent, n=3 paroxysmal) using a 10-polar circular mapping catheter and the CARTO3 V7 navigation system (Biosense Webster, Diamond Bar, CA). We evaluated the size of low voltage areas (LVA ≤0.5mV), LACTs and local CVs at the anterior and posterior wall in low voltage areas and normal voltage areas (NVA ≥1.5mV). The latter were specifically calculated in the direction of wave-front propagation (coherent algorithm) by using 3-dimensional coordinates and local activation times of triads of sites.

Results

20 FACM and 21 non-FACM maps were analysed (1823±1031 points, n=16 low grade FACM I+II, n=4 high grade FACM III+IV, EF 57.24±6,18%, LAVI 43.01±15,63 ml/m2). The mean total size of LVA in FACM patients was 12.06 cm2 (anterior wall 9.51 cm2, posterior wall 2.55 cm2). LACT was 109.15±25.30 ms in our AF population, whereby LACT was shown to be longer (118.79ms, +18%) in FACM patients compared to patients without substrate (100.40 ms, p=0.01), particularly pronounced in high grade FACM (III–IV) (146 ms, +46%, p=0.001). The extension of LVA fairly strong correlated with LACT duration (Spearman ρ= 0.76). Conduction velocities in LVA revealed significantly lower (−55%) than those in NVA (0.61±0.11m/s vs. 1.34±0.30m/s, p=0.000). When comparing the anterior to the posterior wall, anterior conduction appeared slower than posterior conduction, which was significant in NVA (−12%, 1.02 vs. 1.16 m/s, p=0.0053) and failed to reach statistical significance in LVA (−11.6%, 0.61 vs. 0.069 m/s, p=0.39). See Figure 1 and Table 1 for more clinical and electrophysiological characteristics in FACM vs. non FACM patients.

Conclusion

Total LACT is significantly prolonged in FACM patients and seems to correlate with LVA size. Compared to areas with a normal bipolar voltage (≥1.5mV) LVAs (≤0.5mV) show a 55% CV reduction. Furthermore, regional CVs were shown to differ between the anterior and the posterior LA wall. Those findings might have an impact on developing substrate-based ablation strategies in catheter ablation of FACM patients.

Funding Acknowledgement

Type of funding sources: None.
Predictors of long-term atrial fibrillation recurrence after catheter ablation: non-linear analytical approach for individualized prognostic stratification
Authors: Herman R , Hlivak P , Bernat V , Svetlosak M , Demolder A , Palus T , Urban L , Hatala R
Published: October 2022

Background

Recurrences are common in patients with atrial fibrillation (AF) during long-term follow-up after catheter ablation (CA) for pulmonary vein isolation (PVI). Recently, machine learning (ML) models identifying non-linear relationships among various patient parameters have been applied for prognostic stratification in different cardiac diseases.

Aim

This is a retrospective study aimed to determine whether ML-based models can identify non-linear relationships in individual clinical baseline characteristics and CT-quantified volumetric parameters of epicardial fat tissue (EFT) to aid in prognosing outcome of catheter ablation for PVI in patients with paroxysmal AF.

Methods

A cohort of 92 patients (median age 60.2 [51.9–64.0]; 74% male) with paroxysmal AF (a single persistent AF episode was accepted) undergoing catheter ablation targeting PVI was analysed. All patients underwent cardiac CT imaging and were fitted with implantable loop recorder (ILR) prior to CA. For PVI, radiofrequency CA with electro-anatomical mapping was used in 79 patients, cryoballoon ablation in 13 patients. AF recurrence, defined as AF burden >0.1% after the blanking period (90 days), was continuously assessed by ILR. Feature selection on 23 baseline parameters was performed using random forest models (XGBoostRegressor). Mean absolute Shapley values (|mSHAP| – Shapley Additive expLanations) were used to quantify the relative discriminative power of analysed parameters.

Results

During a follow-up of 3-years, AF recurrence was detected in 58 (63%) patients, 29 (50%) of them underwent a repeat ablation. Five most important predictors of AF recurrence during 3-year follow-up were upper epicardial fat volume, BMI, baseline AF burden, age and pericardial volume (lower segment) (Fig. 1). Upper EFT volume was twice as important for males than females (0.44 and 0.21 |mSHAP| respectively). For a patient with no AF recurrence, low age (41 years) and low upper EFT volume (13.2 ml) were the most important drivers predicting positive ablation outcome (Fig. 2A). In contrast, in a patient with AF recurrence post CA, an above-average EFT volume of 55.5 ml and a high BMI had the most significant net contribution for predicting his failed CA outcome (Fig. 2B).

Conclusion

Non-linear ML analysis applied to our limited cohort of patients with paroxysmal AF undergoing CA suggests: i) a significant association of high EFT volume with ILR determined AF recurrence during a 3-year follow-up; ii) potential role of such analyses for a more granular and highly individualized prediction of outcome of planned CA. However, these results need further testing, and validation in prospective trials.

Funding Acknowledgement

Type of funding sources: None.