bluuebunny/crossref_metadata_2025 huggingface dataset:
Prediction of late atrial fibrillation recurrence after catheter ablation using machine learning
Authors: Budzianowski J , Kaczmarek-Majer K , Rzezniczak J , Slomczynski M , Wichrowski F , Hiczkiewicz J , Burchardt P
Published: November 2023

Background

Late recurrence of atrial fibrillation (LRAF) occurring 3 up to 12 months following catheter ablation is considered a relevant clinical problem (rate of occurrence estimated at 20%-45%). Hence, it is significant to define LRAF predictors which would allow for a more suitable selection of patients susceptible to AF recurrence and which could increase the effectiveness of the ablation procedure.

Purpose

The aim of the present study is to develop a machine-learning model of arrhythmic recurrence within one year from catheter ablation.

Methods

This study group comprised 201 patients with paroxysmal, persistent and long standing persistent AF who underwent pulmonary vein isolation performed by cryoballoon ablation and radiofrequency ablation using the CARTO-mapping (122 cryoablation and 79 radiofrequency) in a single center study between May 2016 and March 2018. The biomarker concentrations were measured at baseline and after ablation in a 24-h follow-up. First, five different supervised machine-learning models (decision tree, logistic regression, random forest, XGBoost, support vector machines) were developed for predicting AF recurrence within one year following catheter ablation. Next, SHapley Additive exPlanations (SHAP) were derived to explain the predictions using 82 parameters from clinical, laboratory and procedural variables collected from each patient. The models were trained and validated using stratified 5-fold cross-validation and a feature selection was performed with the permutation importance.

Results

During the 1-year follow-up LRAF occurred in 57 patients (28.3%). The respective receiver operating characteristic (ROC) curves for this model calculated for the Validation set are presented in Figure 1. It is observed that the XGBoost model with the 12 variables achieves the highest AUC of 0.75 (95% confidence interval: 0.7395, 0.7653). The high values of the top 2 features (early recurrence of atrial fibrillation (ERAF) and TSH) contribute to predicting LRAF most, while low values of the top 3 features (RBC, hs-Troponin T, HDL cholesterol) contribute positively to this class (Figure 2).

Conclusion

The machine learning model predicting the 1-year risk of atrial fibrillation recurrence after catheter ablation has achieved good predictive ability. The above model based on the easily available clinical and laboratory data will support the clinical decision-making for selecting good responders to the ablation procedure.
Comparison of additional ablation of spatio-temporal dispersion electrograms and low voltage area beyond pulmonary vein isolation in patients with persistent atrial fibrillation
Authors: Naruse Y , Kaneko Y , Narumi T , Sano M , Maekawa Y
Published: November 2023

Backgrounds

Although strategies beyond extensive pulmonary vein isolation (EPVI) including low voltage zone (LVZ) ablation in patients with persistent atrial fibrillation (AF) have not yet been established, recent research showed that ablation targeting spatio-temporal dispersion electrograms (STDE) could achieve high AF-free survival. We hypothesized that EPVI plus STDE approach could reduce AF recurrence after catheter ablation of persistent AF.

Purpose

The purpose of this study is to assess the AF recurrence after the ablation in different two strategies.

Methods

We prospectively enrolled consecutive patients with persistent AF undergoing their first catheter ablation at our institution during July 2018 to March 2021. The ablation strategy was divided into 2 groups: 1) EPVI plus LVZ and 2) EPVI plus STDE ablation. STDE was defined as clusters of fractionated electrograms that displayed interelectrode time and space dispersion at a minimum of three adjacent bipolar electrodes such that activation spread over all the cycle length of AF. The definition of LVZ was bipolar amplitude of <0.5mV. Posterior wall isolation was performed if STDE or LVZ were broadly present in posterior wall. The primary endpoint was defined as AF recurrence after the ablation. The blanking period of 3 months was applied.

Results

Out of 138 patients (66±11 years, 108 men), 64 patients underwent EPVI plus LVZ and 74 EPVI plus STDE ablation. There was no difference in median AF duration (8 [interquartile range (IQR) 4-13] months vs. 12 [IQR 5-22] months; p=0.129) and left atrial volume (151 [IQR 115-168] ml vs. 151 [IQR 127-175] ml; p=0.239) between the two groups. The prevalence of concomitant hypertension (47% vs. 67%; p=0.024) and diabetes mellitus (24% vs. 42%; p=0.027) was lower in the STDE group than in the LVZ group. Posterior wall isolation was performed more frequently in the STDE group than in the LVZ group (38% vs. 19%; p=0.015). At 1 year follow-up, the STDE group achieved higher AF-free rate than the LVZ group (84% [95% confidence interval (CI), 73-91%] vs. 64% [95% CI 52-76%]; P=0.017). Multivariate Cox regression analysis demonstrated that not only AF duration (hazard ratio [HR] 1.03, 95% CI 1.01–1.04; p<0.001), and left atrial volume (HR 1.10, 95% CI 1.02–1.19; p=0.011) but also STDE ablation (HR 0.33, 95% CI 0.14-0.77%, p=0.010) were independently associated with AF recurrence.

Conclusions

Ablation guided by STDE in addition to EPVI may be a useful treatment strategy for persistent AF.
Pulmonary hypertension is an adverse risk factor for peri-procedural complications in patients undergoing pulmonary vein isolation and ablation for atrial fibrillation
Authors: Atluri R , Kodali M , Yalamanchili S Y , Shoura S
Published: November 2023

Background

Recent studies have identified Pulmonary hypertension (PHT) as a predictor for poor clinical outcomes in Atrial fibrillation (AF) with increased fold in mortality. PHT is associated with right ventricular pressure and volume overload eventually leading to right heart failure. These structural changes can lead to electrophysiological abnormalities, with AF being one of the most common. Percutaneous catheter ablation and pulmonary vein isolation is becoming more common ground for management of paroxysmal atrial fibrillation (AF). We sought to investigate the impact of PHT as an adverse risk factor for patients undergoing pulmonary vein isolation and ablation for AF.

Methods

We utilized the National Inpatient Sample from 2016-2019 to identify roughly 49,425 hospitalized adults who underwent AF Ablation. These hospitalizations were further stratified based on the presence of PHT. A multivariate regression model was used to adjust for confounders and analyze the variables.

Results

Of those who underwent AF Ablation, 5,329 (10.7%) had PHT. In-hospital mortality was higher in those with PHT (2.5% vs 0.9%; p<0.001). Figure 1 shows the Forrest plot for multivariate analysis of in-hospital outcomes when adjusted for patient demographics, comorbidities, and hospital characteristics. When adjusted similarly, patients with AF and PHT had longer length of stay (LOS) by 2.9 days (p<0.001) and had additional hospital costs (HC) of $25,122 (p<0.001).

Conclusion

In this study, patients undergoing AF ablation with co-existing PHT had significantly worse outcomes in terms of in-hospital mortality, LOS, HC, atrial flutter, ventricular tachycardia, AKI, sepsis, pneumonia, and endotracheal intubation. One major limitation of our study is the lack of outpatient follow up. Given that overall outcomes are worse in the setting of PHT, potential strategies for aggressive rate and volume control prior to the ablation for AF should be pursued to avoid negative outcomes. AF patients with co-existing PHT should be aggressively monitored during hospitalizations for AF ablation as they have the potential to have worse periprocedural outcomes.
Anemia and atrial fibrillation ablation recurrence: insights from a large-scale multicentre registry
Authors: Tanaka N , Inoue K , Kobori A , Morimoto T , Morishima I , Yamaji H , Nakazawa Y , Kusano K , Okada M , Koyama Y , Watanabe H , Okamura A , Iwakura K , Kimura T , Shizuta S
Published: November 2023

Background

Both atrial fibrillation (AF) and anemia are associated with an increased mortality, and they often coexist. Whether anemia is associated with arrhythmia recurrence after catheter ablation (CA) of AF remains unknown.

Methods

We conducted a large-scale, prospective, multicentre, observational study (Kansai Plus Atrial Fibrillation Registry). Out of 5010 consecutive patients who underwent an initial radiofrequency CA (RFCA) of AF at 26 centres, we enrolled 4966 patients whose hemoglobin data were available (age 64.4 years, 27.3% female, and 35.6% non-paroxysmal AF). The entire cohort was divided into three subgroups according to the WHO classification of anemia: normal (hemoglobin ≥ 13.0 g/dL in men and ≥ 12.0 g/dL in women, n=4300, 86.6%), mild anemia (11.0 ≤ hemoglobin < 13.0 g/dL in men and 11.0 ≤ hemoglobin < 12.0 g/dL in women, n = 519, 10.5%), and moderate-severe anemia (<11.0 g/dL in both men and women, n = 147, 3.0%). The median follow-up duration was 2.9 years.

Results

The mean age increased significantly as the anemia progressed (normal vs. mild anemia vs. moderate-severe anemia; 63.5 vs. 69.8 vs. 72.1, p<0.0001). While the normal group and mild anemia group consisted of predominantly males (74.0% and 70.5%, respectively), the moderate-severe anemia group consisted predominantly of females (57.8%, p<0.0001). The proportion of paroxysmal atrial fibrillation was 62.4% in the normal, 78.4% in the mild anemia, and 76.2% in the moderate-severe anemia group, respectively (p<0.0001). The 3-year cumulative incidence of AF recurrence after a single procedure was the highest in the moderate-severe anemia group (normal vs. mild anemia vs. moderate-severe anemia, 39.6% vs. 43.5% vs. 49.7%, log-rank p=0.0004).

Conclusion

Anemia patients experienced more frequent AF recurrences after RFCA of AF.KM curve according to anemia group
Heart rate variability and syncope free survival after endocardial ablation of ganlionated plexi in patiens with recurrent vasovagal syncope and functional sinus node dysfunction and AV block
Authors: Minguito Carazo C , Martinez Sande J L , Rodriguez Manero M , Garcia Seara J , Fernandez Lopez X A , Gonzalez Melchor L , Gonzalez Ferrero T , Garcia Rodeja F , Jimenez Ramos V , Martinon Martinez J , Sanchez Munoz E , Gonzalez Juanatey J R
Published: November 2023

Introduction

Cardioneuroablation (CNA) or ablation of the ganglionated plexi (GP) is an emergent procedure that has been used in the treatment of vasovagal syncope Conclusions: (VVS), functional sinus node dysfunction (SND) and functional atrioventricular block (AVB), however long term effects of this technique are not well defined. The aim of the present study was to describe our initial experience with this technique and to assess long term hear rate (HR) variability.

Methods

Prospective, unicentric, observational study of consecutive patients which were referred to our institution for VVS, functional SND or functional AVB. Prior the procedure, all the patients underwent atropine test and 24-hour holter monitoring. Heart rate variability was assessed at 3 and 6 months with repeated 24-hour holter monitoring. Survival from syncope and pacemaker implantation was calculated in the cohort.

Results

24 patients (52 ± 10 years, 70.8% males) were included in the study. 83.3% of the cohort had history of syncope (1.3 ± 3.4 episodes/month) and 95.8% of presyncope. Indication for CNA was SND 29.2%, AVB 25% and recurrent VVS in 45.8%. After a median follow up of 9.9 (4.3-20.7) months, 91.7% were free from syncope recurrence and only 29.2% had presyncope (p<0.001) (Figure 1). There was also a significant increase in minimum HR (p=0.01) and medium HR (p=0.02), without any differences in the maximum HR (p=NS). There was also a decrease in all the parameters used to assess HR variability (SDNN24 p=0.02; rMSSD p=0.017; pNN50 p<0.01) that was constant during the 6 months (Figure 2).

Conclusions

In our cohort, CNA was associated with a syncope free survival of 91.7% and could be a reasonable choice for patients with functional SND or AVB and recurrent VVS. There was an increase in the maximum and medium HR and a decrease in HR variability that remained constant at 6 months.Figure 1Figure 2
Hybrid convergent ablation: an evaluation of left atrial electroanatomical voltage maps
Authors: Mannakkara N N , Child N , Porter B , Khan I , Wijesuriya N D , Mehta V M , De Vere F , Elliott M K , Ahmed S , Adhya S , Razavi R , Bosco P , Rinaldi C A , Blauth C , Gill J S
Published: November 2023

Background

Hybrid convergent ablation is an effective, emerging treatment for persistent atrial fibrillation (AF) (1). Minimally invasive surgical epicardial left atrial (LA) ablation is performed via a subxiphoid incision to ablate the posterior wall, within the limits of the pericardial reflections, before endocardial catheter ablation is performed primarily to complete pulmonary vein isolation. The overall aim is to create durable, transmural posterior wall ablation to target potential drivers that may sustain persistent AF.

Purpose

We evaluated electroanatomical maps obtained during endocardial ablation to determine the site and extent of LA posterior wall scar following epicardial ablation and whether this determines outcome in patients undergoing convergent ablation.

Methods

Patients who underwent Convergent ablation at a single UK cardiac centre (2012-2019) using CARTO-3 mapping system for endocardial ablation were included. Patients who had previous AF ablation were excluded. Low-voltage areas (LVAs) were manually measured using the CARTO-3 system and defined as areas <0.5mV on bipolar voltage maps (pulmonary veins were excluded). Scar location was classified by evaluating for presence and amount of LVA in each quadrant of the posterior LA wall. AF recurrence was evaluated at 12 months post-procedure. SPSS (v. 27) was used for statistical analysis.

Results

Of the 32 patients included, 7 patients experienced AF recurrence within 12 months post-procedure (21.9%). The average amount of posterior wall LVA following convergent ablation was 54.1% of posterior wall area and 5.8% of total left atrial area, neither of which were associated with 12-month AF recurrence (see Table 1). The presence and extent of LVAs in the upper quadrants were heterogeneous amongst patients and did not relate to AF recurrence. All patients displayed LVAs in the lower quadrants post-epicardial ablation, with the majority having LVAs occupying more than 50% of these quadrants. 96.8% had LVA on the inferior LA surface. In total, 75% of patients had a significant amount of LVA (defined as LVA occupying >50% of the quadrant area) in both lower posterior wall quadrants (see Figure 1) and this feature was associated with lower AF recurrence on multivariable Cox regression analysis (see Table 1).

Conclusions

Extensive scar was observed in the LA posterior wall in patients following epicardial convergent ablation. The presence of such scar, particularly in the lower regions of the posterior wall, may influence outcomes and be associated with reduced AF recurrence.Table 1Figure 1
Atrial fibrillation patients at intermediate risk of stroke rapidly progress to high stroke risk: A nationwide registry study (AFNOR)
Authors: Anjum M , Ariansen I , Myrstad M , Hjellvik V , Kjerpeseth L J , Ellekjaer H , Skovlund E , Christophersen I E , Tveit A , Berge T
Published: November 2023

Background

Stroke risk according to the CHA2DS2-VASc score guides oral anticoagulant (OAC) treatment in atrial fibrillation (AF) patients, and OAC is strongly recommended in patients with high stroke risk. There is less evidence of the clinical benefit of OAC in intermediate risk patients (non-sex CHA2DS2-VASc score of 1), and according to guidelines, OAC should be considered. However, the stroke risk is dynamic and an increase in the CHA2DS2-VASc score with a consequent change in the thromboembolic risk profile favoring OAC treatment is expected over time.

Purpose

To investigate the temporal changes in CHA2DS2-VASc score and the incidence of acquiring each of the CHA2DS2-VASc risk factors in AF patients at intermediate risk of stroke.

Methods

We identified 27,111 individuals with non-valvular AF aged ≥18 years, with a baseline CHA2DS2-VASc score of 1 (males) or 2 (females), in data from Norwegian national registries from 2011 through 2018. AF and stroke risk factors were identified with a minimum three-year look-back period. Individuals entered the study upon registration of a first-time AF diagnosis in combination with the first non-sex CHA2DS2-VASc risk factor, whichever came last. All participants were followed until an increase in the CHA2DS2-VASc score, death, emigration or study end. We calculated time from entry to an increased score (non-sex CHA2DS2-VASc score of ≥2) and assessed the cumulative proportions with an increase in CHA2DS2-VASc score per month. Average annual incidence rates for acquirement of new stroke risk factors were calculated as cases per 100 person-years (%/year) with 95% confidence intervals (CI).

Results

During a median follow-up time of 16 months (interquartile range: 4.9-36.6), 15,397 (56.8%) patients acquired at least one new stroke risk factor(s) (figure 1). One third of the patients who increased their CHA2DS2-VASc score, attained a new risk factor during the first four months of follow-up. The average annual risk of CHA2DS2-VASc score increment was 29% (95% CI: 28.6-29.5). The annual risk for a new risk factor was 23.2% for hypertension, 12.5% for age 65-74 years, 7.9% for heart failure, 6.2% for age ≥ 75 years, 5.4% for vascular disease, 2.4% for diabetes mellitus and 1.6% for thromboembolism (ischemic stroke, transitoric ischemic attack or systemic embolism) (figure 2).

Conclusion

AF patients at intermediate risk of stroke rapidly develop an increased stroke risk. In this nationwide study, more than half of AF patients at intermediate risk of stroke acquired a new risk factor during a median follow-up time of 16 months. The average annual risk of an increase in the CHA2DS2-VASc score was 29%. Intermediate-risk AF patients should be regularly reassessed, especially to avoid undertreatment if anticoagulation has previously been withheld.
Is pre-diabetes a predictor of events in patients with atrial fibrillation?
Authors: Ledo Pineiro A , Raposeiras Roubin S , Noriega Caro V A , Gonzalez Garcia A , Iglesias Otero C , Cameselle Cortizo L , Gonzalez Fernandez D , Lizancos Catro A , Parada Barcia J A , Dominguez Erquicia P , Gonzalez Bermudez I , Abu-Assi E , Iniguez Romo A
Published: November 2023

Introduction

Diabetes mellitus (DM) not only increases the probability of presenting atrial fibrillation (AF), but it is also a predictor of ischemic stroke included in scales such as CHA2DS2VASc. However, there is limited information on the association between glycated hemoglobin (HbA1c) levels and ischemic, embolic or hemorrhagic events in patients with pre-diabetes and AF.

Objectives

This study aimed to investigate whether the presence of pre-diabetes in patients with AF increases the risk of ischemic events, hemorrhagic events, myocardial infarction or death.

Methods

We used data from the CardioCHUVI-AF registry, which included 18,285 patients with AF from a Galician health area between January 2014 and December 2019. Patients with valvular AF (n=376), with loss of follow-up (n=97), without information on baseline characteristics (n=48) and without data on HbA1c (12,473) were excluded. The final cohort consisted of 5,291 patients, 2,993 were non-diabetics (56.6%) and 2,298 with known diabetes (43.4%). This final cohort was classified according to HbA1c in diabetics if HbA1c is more than 6.5% (n= 1,546; 29.2%), pre-diabetics when HbA1c is between 5.7 and 6.4% (n =2,233; 42.2%) and non-diabetics if HbA1c was less than 5.7% (n = 1,512; 28.6%). Competing hazards regression analysis for non-fatal events (with death as the competing event) and conventional Cox regression for mortality were performed.

Results

2,993 non-diabetic patients with AF and HbA1c data were followed for 4.1 ± 1.6 years. The mean age was 73.0 ± 9.9 years, 47.4% were women, the mean CHA2DS2VASc score was 2.9 ± 1.4 points, the mean HASBLED score was 2.5 ± 1.2 points, and 2,407 (80.4%) patients were under treatment with oral anticoagulants. In the Kaplan Meier curves, no was observed a higher rate of events in pre-diabetes patients in comparison with patients with normal glycemia. In the multivariate analysis, after adjusting for the CHA2DS2VASc and HASBLED scales, as well as for anticoagulant therapy, it was observed that pre-diabetes was not associated with an increased risk of mortality ( HR= 0.80; 95% CI, 0.60-1.08), ischemic stroke (HR= 0.99; 95% CI, 0.71-1.38), major hemorrhage (HR= 0.78; 95% CI, 0.60-1.02) or myocardial infarction (HR= 1.08; 95% CI, 0.65-1.79), compared with patients with normal glycemia.

Conclusions

In our registry, non-diabetic patients with atrial fibrillation do not have a higher risk of events when their glycated hemoglobin is in the pre-diabetes range.
Plasma levels of direct oral anticoagulants in non-valvular atrial fibrillation patients at the time of acute cardioembolic or bleeding events
Authors: Godino C , Cozzani G , Nemola G , Russi A , Salerno A , Cera M , Vetrugno L , Leo G , Della Bella P , Montorfano M , Maisano F , Zangrillo A , Gaspardone C , D'angelo A , Margonato A
Published: November 2023

Background

Direct oral anticoagulants (DOACs) are approved for preventing cardioembolic events in patients with non-valvular atrial fibrillation (NVAF) (1). Unlike Heparin and vitamin K antagonists, DOACs are commonly used without the need for clotting time monitoring, which results in limited data on the correlation between plasma levels and adverse events (2).

Objective

This study aimed to evaluate, in a real-world cohort of NVAF patients, the relationship between the occurrence of acute cardioembolic or major bleeding events and the plasma levels of DOACs measured at the time of the events.

Methods and Results

This study included 400 NVAF patients on DOAC therapy from the INSIghT registry who underwent plasma drug level testing at the time of an adverse event (116 cases) or during an elective hospitalization or outpatient visit (284 controls). Out of 116 cases, 74 experienced a cardioembolic event while 42 had a major bleeding. Patients with cardioembolic events presented low (i.e., in the first and second quartiles) DOAC plasma levels (50 vs. 24, p<0.01), while patients with major bleeding events had high (i.e., in the third and fourth quartiles) DOAC plasma levels (25 vs. 14, p<0.01).

Conclusions

This study highlights the possible association between plasma levels of DOACs and the risk of adverse events, but further research is needed to fully understand the potential benefits DOAC monitoring and individualized dosing.Fig. 1Fig. 2
Silent cerebral embolism after left atrial appendage occlusion
Authors: Wang K , Wang Z I D U N , Ju W E I Z H U , Chen M I N G L O
Published: November 2023

Background

Left atrial appendage (LAA) intervention is an alternative to oral anticoagulation therapy for thromboprophylaxis in atrial fibrillation (AF). There is limited data on procedure-related silent cerebral embolisms (SCE) during LAA intervention. The aim of our study is to assess the incidence and risk factors of the new SCE after percutaneous LAA occlusion (LAAO)in AF patients and compare the rate of SCE after LAAO with LAA excision (LAAE).

Methods

Consecutive AF patients from 2 independent cohorts (LAAO cohort and LAAE cohort) between September 2018 and December 2020 were included. All patients underwent cerebral magnetic resonance imaging (MRI) before and within 7 days after the procedure. The incidence, size and location of SCE, as well as risk factors were analyzed.

Results

Forty-two patients from LAAO cohort and 32 patients from LAAE cohort were enrolled. In the LAAO cohort, patients developing SCE had significantly higher CHA2DS2-VASc scores (OR 2.172; 95% CI 1.149–4.104; p=0.017), longer LAAO placement time (OR 1.067; 95% CI 1.018–1.118; p=0.006), and lower peak activated clotting time (ACT) level (OR 0.976; 95% CI 0.954–0.998; p=0.035). Furthermore, a significantly higher incidence of new SCE was seen in LAAO cohort compared to LAAE (54.8% vs. 6.3%, p<0.001). 71.4% of SCE located in the cortex.

Conclusions

The incidence of procedure-related SCE was strikingly high in patients with percutaneous LAAO. More cardiovascular co-morbidities, longer LAAO placement time and lower ACT level were significantly associated with the development of SCE during LAAO procedure.
Effect of left atrial appendage occlusion device type and position on potential determinants of device-related thrombus
Authors: Zhong Z , Gao G , Kovacs S , Vij V , Nelles D , Spano L , Nickenig G , Sonntag S , De Backer O , Soendergaard L , Sedaghat A , Mela P
Published: November 2023

Introduction

Device-related thrombus (DRT) after left atrial appendage occlusion (LAAO) is potentially linked to adverse events. Clinical reports suggest an association between the device type/position and the DRT risk, in-depth studies of its mechanistic basis are needed.

Purpose

To generate in silico model with precise geometry of LAAO devices and assess the impact of device type and position on local hemodynamics and surrogate markers of DRT risk.

Methods

Watchman (plug-type device) and Amulet (pacifier device) LAAO devices were modeled with precise geometry and virtually implanted in different positions into a patient-specific left atrium. Using computational fluid dynamics, the following surrogate markers of thrombogenicity were quantified: residual blood, wall shear stress (WSS) and endothelial cell activation potential (ECAP).

Results

In comparison to ostium-fitted device positions, deep implantations were associated with more residual blood surrounding the device (after six cardiac cycles: plug-type device 12% vs 8%; pacifier device 6% vs 5%). Furthermore, deep implantations resulted in lower average WSS that indicates increased risk in platelet adhesion (plug-type device 0.21 vs. 0.26 Pa; pacifier device 0.30 vs 0.35 Pa) and higher ECAP that represents higher potential in endothelial dysfunction (plug-type device 2.23 vs. 0.85 Pa-1; pacifier device 0.16 vs 0.10 Pa-1). For plug-type device, an off-axis orientation towards mitral valve resulted in even more residual blood (15% vs. 8%), higher ECAP (1.10 vs. 0.85 Pa-1) and a similar average WSS as compared to an ostium-fitted device position. In addition, the precise geometry of the LAAO device models allowed indication of residual blood accumulation on the device’s atrial surface surrounding the threaded insert as well as on the lateral device surface and on the left atrium tissue around the device landing zone. Similarly, low WSS and high ECAP were mostly found in these areas, suggesting an increased risk for potential thrombus in these areas, which corresponds to the clinical observational series.

Conclusions

This study demonstrated the effect of LAAO device type and position on potential DRT risk factors. In comparison to the plug-type device, the pacifier device showed lower blood stasis, platelet adhesion and endothelial dysfunction and, therefore, lower DRT risk. For both device types, deep implantations are associated to higher surrogate markers of DRT compared to ostium-fitted device positions. In addition, an off-axis device position of plug-type device were associated with higher DRT risk.
Association between brachial-ankle pulse wave velocity and new-onset atrial fibrillation: A report from Kailuan Study
Authors: Song W , Song Z , Zhang N , Tse G , Li G , Lip G Y H , Wu S , Liu T
Published: November 2023

Background

Several risk factors are common between atrial fibrillation (AF) and atherosclerosis. The brachial-ankle pulse wave velocity (baPWV) is a marker of arterial stiffness.

Objectives

To investigate the predictive value of baPWV for new-onset AF.

Methods

All participants without AF as of December 31, 2020 from the Kailuan cohort were included. Demographic characteristics and baPWV were recorded. The primary endpoint was new-onset AF. Participants were divided into three groups according to baPWV. We analyzed the predictive value when baPWV was as a continuous variable.

Results

A total of 49872 subjects (mean age: 47.57 years old, 74.2% male) were included with follow-up of 6.17(3.95-8.46) years. Compared with normal baPWV group, the risk of AF increased with increasing baseline baPWV, whereby the adjusted hazard ratio (aHR) of the high baPWV group and the atherosclerotic group were 1.82 (95% confidence interval [CI]: 1.18-2.80) and 2.08 (95% CI: 1.31-3.30), respectively. As a continuous variable, for every 361 cm/s increase in baseline baPWV, the risk of AF increased by 21.7% (aHR:1.22; 95% CI: 1.08-1.37). In subgroup analysis of non-hypertensive patients, the risks of AF in the high baPWV group (aHR: 3.16, 95% CI: 1.74-5.74) and atherosclerotic group (aHR: 2.26, 95% CI: 1.02-5.05) were significantly higher, compared with normal baPWV group. In overweight patients, the risk of AF in atherosclerotic group was significantly higher than that in normal baPWV group (aHR: 1.69, 95% CI: 1.00-2.83).

Conclusions

The risk of AF increases with the increase of baPWV, and baPWV is of predictive value in occurrence of AF.
The novel P-Wave Area index predicts low voltage areas in patients undergoing pulmonary vein isolation for treatment of atrial fibrillation
Authors: Seewoester T , Nedios S , Dagres N , Marinov K , Hindricks G , Bollmann A , Dilk P
Published: November 2023

Introduction

Presence of low voltage areas (LVA) mirrors progression of atrial fibrillation (AF) and is associated with an impaired rhythm outcome after AF ablation. P-wave indices can predict LVA, however accuracy is depending on myocardial mass, therefore the P Wave area was indexed for the left atrial area. The aim of current analysis was to investigate the association between the novel P-Wave Area Index (PWAi) and the presence of LVA.

Methods

Patients undergoing first AF ablation were included into analysis. LVA were determined using high-density maps and defined as <0.5 mV. All patients underwent CMR imaging (Ingenia 1.5T Philips) and received 12 lead ecg in sinusrhythm before intervention. CMR data (LA area) and P-Wave Area in Leads I ( PWA(I)) and II (PWA(II)) were measured in all patients. Afterwards the P-Wave Area was indexed for LA area to create the PWAi.

Results

A total of 264 consecutive patients were included in the analysis (65 years, 41% females, 57% persistent AF, 30.6% LVAs). Of all analyzed P-Wave indices, P Wave Area in lead II could effectively identify LVA (AUC: 0.813, p<0.001). In patients with LVA, PWAi below 0.4781 msec*mV*m²/cm² identified patients with LVA with an accuracy of 81% (81% sensitivity, 81% specificity, 65% pos. predictive value and 91% neg. predictive value) and was the strongest predictor among all analyzed parameters (OR: 20,578, AUC; 0.860)

Conclusion

The PWAi is a highly significant tool to identify potential LVA before AF Ablation. This findings help to further individualize AF treatment.Multivariate AnalysisROC analysis
Patterns of comorbidities and influence on the natural history of patients with atrial fibrillation: a latent class analysis from a prospective observational european AF registry
Authors: Romiti G F , Corica B , Mei D A , Vitolo M , Bisson A , Fauchier L , Boriani G , Proietti M , Lip G Y H
Published: November 2023

Background

Patients with Atrial Fibrillation (AF) usually present with multiple comorbidities at diagnosis, and their combinations heterogeneously influence management and outcomes. While the effect of multimorbidity on the natural history of AF is well-known, the influence of patterns of multimorbidity is far less understood.

Purpose

To identify and analyse subgroups of AF patients according to their comorbidities, through a latent class analysis of a contemporary cohort of AF patients.

Methods

We used data from a European-wide prospective observational AF registry, and performed a latent class analysis, according to the presence of chronic diseases (including cardiovascular, respiratory, metabolic and other conditions); class membership was assigned according to the modal posterior probability. Multivariable logistic regression models were used to analyse odds of receiving oral anticoagulant (OAC) prescription and type of OAC received; the risk of the primary outcome of all-cause death and MACE was assessed using multivariable Cox-regression model.

Results

9,613 AF patients were included in this analysis (mean age 68.9 ± 11.4 years, 40.2% females), and were grouped in 5 classes, which were different according to the burden of comorbidities: low morbidity pattern (46.1%), cardiovascular pattern (25.0%), metabolic pattern (11.3%), heart failure pattern (9.7%) and multisystemic pattern (8.0%) (Figure 1). Patients in the multisystemic pattern were older and more frequently frail and with polypharmacy compared to other classes. Compared to the low morbidity pattern, odds of receiving OAC was lower in those with cardiovascular pattern (OR [95%CI]: 0.73 [0.62-0.86]), heart failure pattern (OR [95%CI]: 0.60 [0.48-0.75] and multisystemic pattern (OR [95%CI]: 0.28 [0.22-0.36]), while those with metabolic pattern were more likely prescribed OAC (OR [95%CI]: 1.55 [1.20-2.00]). All patterns were less likely treated with NOAC compared to VKA (Figure 2). When analysing the risk of the primary composite outcome, all patterns except for the metabolic pattern were associated with higher hazard of events, with highest magnitude observed for the heart failure pattern (HR 2.68 [95%CI: 2.22-3.25]) and the multisystemic pattern (HR 2.67 [2.13-3.35]) (Figure 2).

Conclusions

Comorbidities are heterogeneously distributed in the AF population, and different phenotypes of AF patients may be identified according to the combination of other chronic diseases, with different OAC use for stroke prevention and an unequal impact on long-term prognosis. These findings reinforce the need for tailored preventive strategies to improve outcomes in AF patients, especially those with multimorbidity.Figure 1Figure 2
Mobile health technology integrated care in atrial fibrillation patients according to atrial fibrillation subtype: a subgroup analysis of the mAFA-II randomised trial
Authors: Corica B , Guo Y , Romiti G F , Mei D A , Proietti M , Zhang H , Lip G Y H
Published: November 2023

Background

Atrial fibrillation (AF) is clinically categorised into different types (e.g. paroxysmal, persistent and permanent AF) according to the duration of the arrhythmia and whether it is accepted by physician and patient. These types of AF usually recognise different arrhythmic substrates, any may show different response to rate and rhythm control treatments. The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) prospective cluster randomised trial proved the efficacy of a mobile health (mHealth) implemented ‘Atrial fibrillation Better Care’ (ABC) pathway (mAFA intervention) for the integrated care management of patients with AF. Whether the effect of mAFA intervention could differ between different types of AF is still unknown.

Purpose

To assess the efficacy of mAFA intervention according to the type of AF.

Methods

mAFA-II was a cluster randomised trial which recruited 3,324 adults AF patients between June 2018 and August 2019 in 40 centres in China. Clusters were randomised in a 1:1 ratio to mAFA intervention or usual care. In this analysis, we included patients with either paroxysmal, persistent or long-standing/permanent AF; we then assessed the interaction between these three types of AF and the effect of mAFA intervention on the risk of major outcomes using multivariable Cox regression analysis. Results were expressed as adjusted Hazard Ratio (aHR) and 95% Confidence Intervals (95%CI). The primary outcome was the composite of ischemic stroke/thromboembolism, all-cause death, and rehospitalizations.

Results

2,489 AF patients were included in this analysis (mean age: 69.6±13.2, females 37.8%). Of these, 1,333 had paroxysmal AF (673 allocated to mAFA intervention), 828 had persistent AF (380 allocated to mAFA intervention), and 328 had long-standing/permanent AF (104 allocated to mAFA intervention). Patients with long-standing/permanent AF were older and more likely burdened by several comorbidities. On multivariable Cox regression analysis, the efficacy of the mAFA intervention on the risk of the primary composite outcome was similar in the three groups, without statistically significant interaction (p for interaction=0.337), with the highest effect seen among patients with persistent AF (aHR: 0.27, 95%CI: 0.11-0.66).

Conclusions

A mHealth-technology implemented ABC pathway showed a similar effect on the reduction of the primary composite outcome among patients with different subtype of AF. These findings support the implementation of integrated care approach also in patients with more advanced form of AF.Cox-regression models for interaction
Impact of chronic obstructive pulmonary disease on the natural history of atrial fibrillation: a report from the GLORIA-AF registry phase II & III
Authors: Romiti G F , Proietti M , Corica B , Mei D A , Frost F , Bisson A , Boriani G , Olshansky B , Chao T F , Huisman M V , Lip G Y H
Published: November 2023

Background

The relationship between chronic obstructive pulmonary disease (COPD) and atrial fibrillation (AF) remains unclear. COPD may influence the management and prognosis of AF and may affect treatments, including beta-blockers prescription.

Purpose

To investigate the association between COPD and AF, and assess the impact of COPD on treatment patterns and major adverse outcomes in a large contemporary global cohort of AF patients.

Methods

The GLORIA-AF Registry enrolled newly diagnosed AF patients with at least 1 stroke risk factor. Diagnosis of COPD and treatments (including oral anticoagulant [OAC]) prescribed were recorded by investigators at baseline. We evaluated clinical characteristics associated with the diagnosis of COPD at baseline, OAC and other treatment prescription, and risk of OAC discontinuation. Adjusted Cox-regression models were utilized to analyse the relationship of COPD with major outcomes including a primary composite outcome of all-cause death and major adverse cardiovascular events (MACE).

Results

36,263 patients (mean age 70.1±10.5 years, 45.3% females) were included in this analysis. Patients with COPD (n=2,261, 6.2%) were older, and had higher thromboembolic risk. Increasing age, smoking status, BMI and cardiovascular comorbidities were associated with higher odds of COPD diagnosis at baseline. COPD was associated with higher odds of receiving OACs (Odds Ratio [OR] and 95% Confidence Interval [CI]: 1.31, 1.15-1.49), and with a higher risk of discontinuing OACs during follow-up (hazard ratio (HR): 1.14, 95%CI: 1.03-1.27). COPD patients were more likely prescribed with digoxin and verapamil or diltiazem, with lower prescription of beta-blockers (OR [95%CI]: 0.79, 0.72-0.87; Figure 1) and amiodarone (OR [95%CI]: 0.83, 0.73-0.96). Patients with COPD were at higher risk of the primary outcome of all-cause death and MACE (Hazard Ratio [95%CI]: 1.78, 1.58-2.01; Figure 2), and were also found at higher risk of all-cause mortality, cardiovascular death, MACE and major bleeding, while no statistically significant differences were observed for thromboembolism. There was no statistically significant interaction between beta-blocker use and risk of the primary composite outcome in COPD patients.

Conclusions

COPD is associated with different treatment patterns in AF patients, higher risk of OAC discontinuation, and ultimately a poorer clinical prognosis, with an increased risk of all-cause death, MACE and major bleeding. Beta-blocker use appeared safe in COPD patients.Figure 1Figure 2
Kidney function by creatinine and cystatin c and adverse cardiovascular outcomes in patients with atrial fibrillation
Authors: Schweigler A , Hennings E , Aeschbacher S , Rodondi N , Stauber A , Moschovitis G , Bolt L , Mueller A , Coslovsky M , Meyer-Zuern C , Bonati L E O H , Conen D , Osswald S , Kuehne M , Krisai P
Published: November 2023

Background

Atrial fibrillation (AF) patients with chronic kidney disease are at an increased risk for ischemic and bleeding events and all-cause mortality. Accurate kidney function estimation is key for risk assessment. Creatinine is commonly used to calculate the Glomerular Filtration Rate (GFR). However, cystatin c has been described to be more sensitive than creatinine independent of muscle mass, autoimmune disease, inflammation or consuming diseases. Thus, cystatin C might be superior for risk assessment in patients with AF.

Aim

We aimed to investigate the associations between kidney function, assessed by creatinine and cystatin c, and major adverse cardiovascular events (MACE), its individual components, and major bleedings.

Methods

We enrolled 3865 AF patients into two prospective, multicenter cohort studies. Creatinine and cystatin c were measured at baseline and clinical outcome events were assessed yearly. We calculated GFR using the Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI] formula based on either creatinine (GFRcr), cystatin c (GFRcy) or both (GFRc2). Primary outcome was MACE, defined as a composite of stroke or systemic embolism, myocardial infarction and cardiovascular death. Secondary outcomes were the individual components of MACE and major bleeding. Multivariable adjusted Cox regression analyses were built to investigate the associations between kidney function and adverse outcome events.

Results

Mean age was 71 ± 10 years and 28% were female. Mean creatinine and cystatin levels were 103 ± 32 μmol/l and 1.2 ± 0.4 mg/l, respectively, translating to a GFRc2 of 63.8 ± 21.7 ml/min/1.73 m2. Over a median follow-up of 6 years, the incidence rates for MACE (per 100 person-years) across quartiles (Q1-Q4) of GFRc2 were 22.0, 19.6, 17.4 and 15.9, respectively (Figure). When using multivariable adjusted Cox regression analysis, MACE was significantly associated with GFRcr (per 1 standard deviation: HR 0.87 (95%CI 0.77; 0.97) p=0.01), GFRcy (HR 0.68 (CI 0.58; 0.78), p<0.001) and GFRc2 (HR 0.75 (CI 0.66; 0.86), p<0.001). This association was mainly driven by cardiovascular death (Table). Major bleeding was associated with GFRcy (HR 0.73 (0.60-0.88) p=0.001) and GFRc2 (HR 0.80 (0.67-0.95), p=0.01), but not with GFRcr (HR 0.91 (95% CI 0.78-1.07) p=0.25).

Conclusion

Among AF patients, GFR equations including cystatin c were associated both with MACE and bleeding events, while creatinine based GFR equations were only associated with MACE. Therefore, Cystatin c based GFR equations might offer more comprehensive risk stratification in AF patients.Figure 1Table 1
Clinical characteristics and ablation outcomes of recurrent atrial tachyarrhythmia after maze operation -a multicenter study in a single city
Authors: Kawai S , Tanaka A , Sakamoto K , Inoue S , Nagaoka K , Okahara A , Tokutome M , Matsuura H , Takase S , Nozoe M , Tsutsui H , Mukai Y
Published: November 2023

Backgrounds

Catheter ablation of atrial tachyarrhythmia after Maze operation is challenging.

Methods and Results

Twenty-eight cases who underwent catheter ablation of post-Maze procedure atrial tachyarrhythmia (42 sessions; 1.5 per patient) in our 5 teaching affiliate hospitals were retrospectively analyzed. Cox-IV Maze procedure and left atrial Maze were performed in 19 cases and 5 cases, respectively. Median interval between surgery and index ablation was 35 months. In total, 46 atrial tachyarrhythmias were studied. Atrial tachycardia (AT) was the most common (n=36), whereas 4 atrial fibrillation (AF) and 2 focal AT were also observed. Identified tachyarrhythmia circuits were as follows; 16 mitral AT, 9 left atrial localized reentry (4 septal, 3 posterior, 1 left atrial appendage, 1 anterior), 6 right atrial lateral incision-related AT, 5 cavo-tricuspid isthmus (CTI)-dependent AT, 3 roof-dependent AT, 2 right atrial localized reentry (1 coronary sinus (CS), 1 CTI), 2 focal AT (1 para His, 1 CS), 1 bi-atrial AT, 1 pulmonary vein tachycardia, and 1 slow-fast AVNRT (Figure 1). Termination of targeted tachyarrhythmia was confirmed in 34 sessions (81%). AT/AF recurrence free rate at 12, 24, 36 months of follow-up were 91.8%, 81.6%, and 65.3%, respectively (Figure 2). Seven cases underwent multiple sessions (2 2nd sessions, 3 3rd sessions, 2 4th sessions). In these cases, de-novo atrial tachyarrhythmias were detected.

Conclusions

Most of the tachyarrhythmias after Maze operation were incision/gap-related ATs, among which mitral AT and LA localized reentry were the most prevalent. Although these challenging tachyarrhythmias can be treated with the contemporary mapping techniques, de-novo tachyarrhythmias can emerge in a remote period.Maze AT Figure 1Maze AT Figure 2
Transverse conduction across the crista terminalis with pseudo-focal activation pattern in patients with upper loop reentry atrial tachycardia
Authors: Ishihara T , Takasugi N , Tochibora R , Masuda Y , Sahashi Y , Naruse G , Watanabe T , Yamada Y , Kanamori H , Okura H
Published: November 2023

Background

Upper loop reentry (ULR) is a rare form of macroreentrant atrial tachycardia (AT) and an area of slow conduction exists in the crista terminalis (CT) where ablation is successful in eliminating the circuit. Transverse conduction across the CT during ULR AT has not yet been fully investigated.

Purpose

To investigate the transverse CT conduction during ULR AT

Methods

One hundred and five consecutive patients with macroreentrant AT were enrolled. The diagnosis of ULR was made based on endocardial activation mapping and entrainment pacing from multiple sites around the superior vena cava (SVC). Pseudo-focal pattern was defined as follows; (1) unsuccessful termination of ULR AT after extensive ablation along the CT and (2) distance from the earliest activation site (breakthrough) to the linear scar along the CT >5 mm and a later activation site exists between the breakthrough and the CT.

Results

Nine (8.6%) of the 105 patients were diagnosed with ULR AT and studied. Seven (77.8%) of the ULR patients had a history of cardiac surgery or cavotricuspid isthmus ablation. Pseudo-focal pattern was observed in 4 (44.4%) patients who exhibited a linear scar along the CT connecting the SVC with the inferior vena cava. The median missing tachycardia cycle length (TCL) was 49.5 ms on the endocardial activation map. The median distance between the early-meets-late line (linear scar along the CT) and the breakthrough was 12 mm. RF application at the breakthrough successfully eliminated the ULR AT in all patients.

Conclusions

Nearly half of the patients with ULR AT exhibited pseudo-focal pattern suggesting a transverse conduction across the CT utilizing an epicardial connection such as the intercaval bundle. Ablating the breakthrough site is a better therapeutic option than ablating within the linear scar along the CT.Patient characteristicsRepresentative case