bluuebunny/crossref_metadata_2025 huggingface dataset:
Simple clinical parameters could help to identify the patients with a high probability of new-onset atrial fibrillation in acute myocardial infarction
Authors: Raczkowska-Golanko M , Puchalski W , Gruchala M , Raczak G , Danilowicz-Szymanowicz L
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

New-onset atrial fibrillation (NOAF) is a significant complication of acute myocardial infarction (AMI) associated with a poor prognosis. The knowledge and understanding of risk factors of this arrhythmia are still the subjects of interest. Purpose: We aimed to investigate which clinical, routinely checked parameters could have the most predictive power on NOAF occurrence in AMI patients.

Patients and methods

This single-center, retrospective study was conducted on 954 consecutive patients admitted to our university clinical center with AMI diagnosis from January 2017 to December 2018. Patients underwent routine clinical assessment and laboratory investigations. AF detected at the time of admission or during a hospital stay, without a prior history of persistent or paroxysmal AF, was diagnosed as NOAF. Detailed medical history, routinely checked laboratory and echocardiography parameters, invasive and pharmacological treatment, as well as complications and in-hospital mortality, were taken into consideration.

Results

  NOAF was documented in 106 (11%) AMI patients at median age 74 (66 - 84) years old, and was significantly associated with in-hospital mortality [OR 4.53, p < 0.001). There were some clinical factors significantly predicted NOAF in univariate logistic regression analysis: age ≥ 66 years old (odds ratio [OR] 3.09, p < 0.001), B-type natriuretic peptide (BNP) ≥ 340 pg/ml (OR 5.28, p < 0.001), C- reactive protein (CRP) ≥ 7.7 mg/l (OR 3.53, p < 0.001), high-sensitivity troponin ≥ 1.85 ng/ml (OR 2.4, p < 0.001), total cholesterol  ≤  195 mg/dl (OR 2.17, p < 0.002), low-density lipoprotein ≤ 128.5 mg/dl (OR 2.03, p < 0.007), potassium level ≤ 4.2 mmol/l (OR 1.92, p < 0.002), hemoglobin ≤ 14 g/dl (OR 1.71, p < 0.020), leucocytes ≥ 10.2 x10^9/l (OR 1.76, p < 0.009), neutrophil to lymphocyte ratio ≥ 4.6 (OR 1.85, p < 0.004), left atrium size ≥ 41 mm (OR 2.14, p < 0.001), and left ventricular ejection fraction (LVEF) ≤ 44% (OR 2.99, p < 0.001). Age, BNP, CRP, and LVEF at mentioned above pre-specified cut-off values turned out to be the most important independent predictors of NOAF development in multivariate analysis.

Conclusions

NOAF is a multifactorial, significant complication of AMI, leading to a worse prognosis. Older age, higher BNP and CRP level, and lower LVEF are independently associated with the probability of NOAF.
Predictors of perioperative atrial fibrillation in non cardiac elective surgery: the Hart score
Authors: Stronati G , Mondelli C , Principi S , Silenzi M , Urbinati A , Ciliberti G , Barbarossa A , Compagnucci P , Casella M , Dello Russo A , Guerra F
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND 

Postoperative atrial fibrillation (POAF) is defined as de novo onset of atrial fibrillation in the post operative period, in patients with no previous history of atrial fibrillation. It affects almost 3% of all over 45 year old patients undergoing non cardiovascular surgery and is associated with a higher risk of stroke and mortality.

PURPOSE 

To assess independent predictors of POAF in elective non-cardiac surgery. 

METHODS 

Retrospective observational database including all patients attending a cardiological preoperative assessment from the 1st of January 2016 to the 31st of December 2019. The primary endpoint was the occurrence of POAF. Individual predictors of the primary endpoint were tested through a series of multivariable logistic regression models, including only those variables with a p<.01 in the univariable models. Independent predictors were entered into a score, and assigned points according to their odd ratios. Performance of the risk score was tested with the receiver operating characteristic  curve. A bootstrap procedure was employed for internal validation of both the multivariable logistic regression model and the risk score, using 10000 bootstrap samples and bias-corrected and accelerated confidence intervals.

RESULTS 

A total of 2048 patients were enrolled (1350 men, age 71 ± 12 years). Fourty-four patients experienced POAF (2.1%) – median 3 days (1st-3rd quartile 2-3 days). Age (OR 1.03 for each year; 95% CI 1.01-1.07), hypertension (OR 3.43; 95% CI 1.22-9.63), thyroid dysfunction (OR 2.70; 95% CI 1.35-5.42) and intermediate or high risk surgery (OR 18.28; 95% CI 2.51-33.09) resulted as independent predictors of POAF (all p < 0.05). We therefore created the HART score according to Table 1 (OR 2.59 for each point; 95% CI 1.79-3.75; p > 0.001). A cut-off score ≥ 5 has a 70% sensitivity and a 72% specificity in detecting POAF in our population (AUC 0.74). Bootstrapping for internal validation confirmed the overall results.

CONCLUSIONS

A four items point-based risk score such as the HART score, could be effective in implementing effective POAF screening and improve management. The HART score Variable Points H Hypertension 1 point A Age (65-74 years) 1 point Age (75+ years) 2 points R Intermediate Risk surgery 3 points High Risk surgery 3 points T Thyroid dysfunction 1 point
P-wave beat-to-beat morphology analysis outperforms conventional P-wave indices in detecting patients with paroxysmal atrial fibrillation
Authors: Tachmatzidis D , Filos D , Tsarouchas A , Mouselimis D , Antoniadis A , Bakogiannis C , Chouvarda I , Lazaridis C , Triantafyllou C , Fragkakis N , Maglaveras N , Vassilikos V
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) - the most common sustained cardiac arrhythmia - while not a life-threatening condition itself, leads to an increased risk of stroke and high rates of mortality. Early detection and diagnosis of AF is a critical issue for all health stakeholders.

Purpose

The aim of this study is to compare the performance of standard P-wave indices with beat-to-beat P-wave morphological variability parameters in identifying patients with history of Paroxysmal Atrial Fibrillation (PAF).

Methods

Three-dimensional 1000Hz ECG digital recordings of 10 minutes duration were obtained from a total of 39 PAF patients and 60 healthy individuals. Following artifacts and ectopic beats removal, P‑wave morphology analysis was performed based on the dynamic application of the k‑means clustering process and main and secondary P-wave morphologies were identified. The percentage of P-waves following the main or the secondary morphology in each lead was calculated, as well as established indices such as Advanced Interatrial Block, P-wave duration, axis and area, P-wave Terminal Force in lead V1 and Orthogonal Leads Type 1, 2 or 3.

Results

9 out of 24 parameters studied, were found to be significantly different between the two groups. 7 of these indices were derived from morphology analysis and 2 from P-wave area. Logistic regression revealed that the percentage of P-waves allocated to main morphology in X axis performed better than all other indices in identifying patients with PAF history from healthy volunteers in terms of total accuracy and F1 measure.

Conclusion

P-wave beat-to-beat morphology analysis can identify PAF patients during normal sinus rhythm more efficiently than standard P-wave indices. Abstract Figure.
Impact of rate control in hospitalized patients with atrial fibrillation and sepsis: a systematic review and meta-analysis
Authors: Romiti GF , Proietti M
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial Fibrillation (AF) is a common complication in patients with sepsis, and imposes a worse prognosis and challenging clinical management. Administration of antiarrhythmics is often needed, to achieve rate or rhythm control, especially in the occurrence of AF with rapid ventricular response; however, it is unclear whether different classes of antiarrhythmics are associated with better outcomes in patients with sepsis and AF.

Methods

We performed a systematic review and meta-analysis according to PRISMA Guidelines. Pubmed and EMBASE databases were systematically searched for studies reporting outcomes in patients with sepsis and AF, according to the use of Beta-blockers (BBs), calcium-channel blockers (CCBs), digoxin and amiodarone. Random-effect models were used to provide pooled estimates; fixed-effect models were also performed as a sensitivity analysis.

Results

Among 4,166 studies, 2 articles were included from the literature search, and an additional 1 from the author’s knowledge, yielding a total of 40,593 patients with sepsis and AF included. According to the data available from the included studies, the meta-analysis was performed only for in-hospital mortality. BBs were associated with a reduced risk of in-hospital mortality compared to amiodarone (OR 0.52, 95% CI: 0.46-0.58; I2 = 0%, Figure 1, Panel C), while no significant differences were observed for BBs. vs. CCBs (Figure 1, Panel A) and for BBs vs. digoxin (Figure 1, Panel B). In the pre-specified sensitivity analysis using a fixed-effect model, BBs resulted associated with a lower risk of in-hospital mortality compared with both CCBs and digoxin).

Conclusion

In patients with AF during sepsis, BBs were associated with reduced risk of in-hospital mortality, compared to amiodarone; inconclusive results emerged for the comparisons between BBs and CCBs or digoxin, although with a benefit of BBs observed in the fixed-effect models. Further studies are needed to provide definitive data and to guide physicians in the choice of the best rate control strategy in this clinical setting. Abstract Figure.
Concomitant utilization of radiofrequency ablation during atrial fibrillation cryoballoon ablation procedures
Authors: Gaitonde RS , Martel JA , Porterfield CP , Koide NS , Kobori A , Altemose GT , Brown KH , Dell"orfano J , Gora P , Mathew S
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Use of cryoballoon ablation (CBA) for the treatment of atrial fibrillation (AF) has become increasingly common in recent years. While various techniques have been described for use of the cryoballoon to achieve PVI and create selective additional lesion sets, the need for concomitant radiofrequency (RF) ablation in delivering touch-up ablation or non-PVI lesion sets has not been quantified.

Purpose

To quantify the rate of RF ablation catheter use in AF CBA procedures, and to evaluate whether indication for ablation can be used as a predictor of the need for supplementary RF ablation.

Methods

Self-reported data was prospectively collected in AF CBA procedures. Procedural characteristics including concomitant utilization of RF ablation catheters and lesion set delivery were recorded and analyzed. Post-hoc statistical analysis was completed utilizing a two-sample t-test of significance.

Results

Data was collected in a total of 246 AF CBA cases across 44 centers in the USA, Europe, and Japan. Included in the analysis were 170 paroxysmal atrial fibrillation cases (PAF group); 70 PersAF and 6 LsPersAF cases (PersAF group). Utilization rates for RF ablation catheters did not differ between the two groups; 35.9% and 36.8% of cases in PAF and PersAF, respectively (p = 0.885). The number of patients in which non-PV lesion sets were delivered also did not differ between groups; 38.2% and 40.8% in PAF and PersAF, respectively (p = 0.706). The choice of non-PV lesion sets varied as shown in Table 1. Upon completion of ablation, more patients were in sinus rhythm in the PAF group compared to the PersAF group, but the difference did not reach statistical significance; 88.2% and 78.9%, respectively (p = 0.057).

Conclusions

RF ablation catheter utilization rates were similar between groups, suggesting that indication (PAF vs. PersAF) alone is not a good predictor of whether concomitant RF ablation catheter utilization will be required during an AF CBA procedure. Table 1 Incidence Lesion Set PAF (n = 170) PersAF (n = 76) CTI Line 26.5% (45/170) 15.8% (12/76) Isolation/Homogenization of Fibrotic Areas 2.9% (5/170) 3.9% (3/76) CFE 2.9% (5/170) 0.0% (0/76) Posterior Wall Isolation 1.8% (3/170) 21.1% (16/76) Roof Line 1.8% (3/170) 7.9% (6/76) Other 9.4% (16/170) 27.6% (21/76) Utilization rate of non-PVI lesion sets
Clinical and electrophysiological characteristics of extra-pulmonary vein triggers in patients who underwent catheter ablation for atrial fibrillation
Authors: Hwang T , Yoon M , Kim M , Kim I , Yu H , Kim T , Uhm J , Kim J , Joung B , Lee M , Pak H
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Extra-pulmonary vein (PV) triggers play significant roles in atrial fibrillation (AF) recurrence after AF catheter ablation (AFCA).

Purpose

We explore the clinical and electrophysiological characteristics of extra-PV triggers in de novo and repeat-AFCA procedure.

Methods

We included 2,151 patients who had de novo AFCA and 319 repeat AFCA (female 28.0%, 59.1 ± 10.8 years old, paroxysmal AF 65.1%) those underwent post-procedural isoproterenol (ISO) provocation tests. We analysed the clinical, electrophysiological, and procedure-related factors associated with extra-PV triggers.

Results

Extra-PV triggers were documented in 11.9% (1.19 ± 0.42 foci) after de novo-AFCA and 27.0% (1.37 ± 0.65 foci) after repeat-AFCA (p = 0.004). LA volume index (OR 1.02 [1.01-1.03], p = 0.004), history of vascular disease (OR 0.55[0.31-0.91], p = 0.028) and Lead I amplitude of electrocardiogram (OR <0.01 [<0.01-0.62], p = 0.032) were independently associated with the existence of extra-PV triggers in de-novo procedure. Women (OR 1.84 [1.03-3.25], p = 0.037) and LA appendage volume (OR 1.04 [1.01-1.07] p = 0.027) were independently associated with extra-PV triggers during the redo-mapping procedure. Septum (28.4%), coronary sinus (24.0%), and superior vena cava (19.6%) were common extra-PV foci, and septal foci were more commonly found in repeat mapping (38.4% vs. 25.0%, p = 0.025). Among 65 patients who showed extra-PV at the repeat procedures, 19 (29.2%) matched with previous focal or empirical extra-PV ablation sites and 9 (13.8%) were multiple or unmappable sites. AF recurrence rates were significantly higher in both patients with extra-PV triggers after de novo procedures (Log-rank P <0.001; HR 1.93 [1.58-2.36], p= <0.001) and repeat procedures (Log-rank P <0.001, HR 1.87 [1.29-2.70], p= <0.001).

Conclusion

ISO provoked extra-PV triggers commonly found in AF patients with significant remodelling and previous empirical or focal extra-PV ablations. Existence of extra-PV triggers were independently associated with poorer rhythm outcome after both de novo and repeat AFCA. Denovo AF ablation outcome OverallExtra-PV triggers (-)Extra-PV triggers (+)p-value(n = 2151)(n = 1895)(n = 256)Age, yrs58.98 ± 10.9558.73 ± 11.0360.76 ± 10.200.006Male, (%)1550 ( 72.1)1389 ( 73.3)161 ( 62.9)0.001Follow up duration, month50.30 (37.71)51.65 (37.95)40.71 (34.58)<0.001Early recurrence (%)579 ( 27.8)455 ( 24.9)124 ( 48.4)<0.001Clinical recurrence (%)699 ( 33.6)584 ( 32.0)115 ( 44.9)<0.001Abstract Figure. AF free survival according to Extra PVT
3D mapping versus cardiac computed tomography guided cryoballoon ablation for atrial fibrillation
Authors: Varnavas V , De Schouwer K , Abugattas JP , Wolf M , De Greef Y , Schwagten B
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac computed tomography (CCT) is an essential tool for an efficient ablation for atrial fibrillation. 3D mapping guided ablation could also deliver sufficient results in the setting of cryoballoon ablation (CBA) with additional advantages regarding total patient radiation exposure, fluoroscopy and procedural time.

Purpose

To compare the 3D mapping with the Achieve® catheter versus the CCT on the procedural characteristics and acute outcome during CBA.

Methods

Consecutive patients who underwent CBA with the second-generation cryoballoon (CB) were retrospectively enrolled from a single centre registry. Baseline and procedural characteristics of patients with pre-procedural CCT (CT-Group) were compared to those with peri-procedural 3D mapping (Ensite PrecisionTM ) with the 1st generation Achieve® catheter (3D-Group).

Results

A total of 696 patients were enrolled, 327 (47%) in the CT-Group and 369 (53%) in the 3D-Group. Baseline characteristics were comparable between the two groups. Similar pulmonary vein (PV) anatomical variations were identified in both groups and all PVs were acutely isolated. The mean CB temperature (T) at 60s, the nadir T, the time to PV isolation, the T of isolation and the mean thaw time did not differ significantly. However, the total procedural and fluoroscopy time were significantly shorter as well as the dose area product was significantly less  in the 3D-Group.

Conclusion

3D mapping guided CBA using the Achieve® catheter is associated with significantly shorter fluoroscopy and procedural time and less patient radiation exposure. The anatomical acquisition of the PVs and the acute ablation outcome is non inferior to the CCT guided CBA. Procedural characteristics CT-Group n = 327 3D- Groupn = 369 p-value Paroxysmal AF 214 244 0.87 Total procedure time (min) 73.3 ± 23.1 65.1 ± 18.9 < 0.01 Fluoroscopy time (min) 14.9 ± 7.7 12.6 ± 7 0.02 DAP (Gy·cm2) 5924 ± 4991 4890 ± 3790 0.04 LCPV 37 41 1.00 RMPV 20 21 0.87 Mean T at 60s(oC) -41.9 ± 8.5 -40.6 ± 10.7 0.10 Mean nadir T(oC) -49.5 ± 6.4 -48.4 ± 7.8 0.18 Mean PVI time(s) 42.4 ± 26.3 38.1 ± 24.3 0.11 Mean PVI temperature(oC) -33.4 ± 11.6 -31.1 ± 22 0.16 Mean thaws time(s) 51.5 ± 20.5 51.8 ± 20.3 0.85
Potential value of the low frequency/high frequency ratio of heart rate variability to guide atrial fibrillation ablation procedures
Authors: Gregoire JM , Gilon C , Hellinckx J , Carlier S , Bersini H
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background.

The  differentiation  between  vagally  and  non-vagally mediated  atrial fibrillation (AF)  could be useful  to decide  adding  ganglionated  plexi  ablation  (GPA)  to  pulmonary vein isolation (PVI)  in  patients with vagally mediated  AF  onset.

The role of the autonomic nervous system in triggering paroxysmal AF can be analyzed through heart rate variability (HRV) parameters. The low frequency/high frequency ratio (LF/HF) is used as an index of sympatho-vagal interaction. Based on clinical criteria, values of LF/HF <1.5 are considered to reflect an increase of vagal modulation. 

Purpose

Identify  patients with paroxysmal AF who may benefit from GPA in addition to PVI, based on analysis of HRV parameters

Material and methods

From our database of unselected Holter recordings containing paroxysmal AF episodes, 199 analyzable AF onsets were labelled. We analyzed HRV frequential parameters by segments every 300 RR intervals to identify adrenergic and vagal onsets of AF episodes. We categorized AF onsets, depending of their respective values of LF/HF. We also checked the relationship of these parameters to heart rate (HR). We followed the evolution of the mean normalized values of LF/HF from the beginning of the recordings to the AF onsets (see figure).

Results

We found a progressive increase of LF/HF  in normalized units  (mean [95% confidence interval]) from  2.44  [2.12-2.76]  to 3.12  [2.85-3.39]  in the adrenergic group  (n = 113)  and a  progressive decrease of LF/HF from  1.51 [1.28-1.75]  to 1.02 [0.95-1.09]  in the  vagal group (n = 86). Differences between adrenergic and vagal AF were highly significant using Mann-Whitney test (p < 0.001). A given patient shows the same type of AF in 80% of cases.  We found no correlation between frequential parameters and HR.

Conclusions

Our data show  potential  added value of  frequential  HRV  analysis  to  guide additional ganglionated  plexi ablation  to PVI. This  remains  to be demonstrated in a prospective study. The ratio LF/HF should be  considered  to optimize the decision-making process for  the ablation procedure. Abstract Figure. Frequential HRV parameters before AF
Catheter ablation outscores all other treatment modalities in reducing all-cause mortality and heart failure related morbidity in patients of persistent atrial fibrillation with systolic heart failure
Authors: Khanra D , Mukherjee A , Deshpande S , Padmanabhan D , Mohan S , Khan H , Kella D , Kathuria N
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation in the setting of persistent AF (PeAF) with heart failure (HF) is challenging and often has poor outcome. However, guideline and studies indicate ablation strategy in this group to reduce mortality and HF-related hospitalization.

Purpose

We have conducted a network meta-analysis (NMA) of all-cause mortality and improvement of HF-related QOL in patients of PeAF with systolic heart failure comparing  rate controlling drugs (RCDs), anti-arrhythmic drugs (AAD), catheter ablation (CA) of PeAF and AV nodal ablation with univentricular or biventricular pacing (AVNA).

Method

Bayesian network meta-analysis of randomized controlled studies comparing mortality and QOL among individual treatment arms (e.g. RCDs, AADs, CA and AVNA) and pair-wise network meta-analysis comparing CA and other treatment arms (RCD, AAD and AVNA) were performed using MetInsight V3.  Markov chain Monte Carlo (MCMC) modeling was used to estimate the relative ranking probability of each treatment group.

Results

Published data of 14 studies including 3698 patients were included in the NMA with a median follow-up of two years (1A, 2A). The Bayesian modelling with MCMC analysis for pair-wise comparison clearly demonstrated that, AAD [OR (95% CrI): 2.10 (0.43-9.0)], AVNA [OR (95% CrI): 1.32 (0.14-11.7)] and RCDs [OR (95% CrI): 2.76 (0.5-14.1)] have higher all-cause mortality than CA but not within the radar of statistical significance (1B). The Bayesian modelling with MCMC analysis for pair-wise comparison clearly demonstrated that, AADs [MD (95% CrI): 8.02 (-8.32-27.8)], AVNA [MD (95% CrI): 17.0 (-1.9-33.1)] and RCDs [MD (95% CrI): 13.0 (0.1-24.5)] have lesser improvement in QOL than CA but not within the radar of statistical significance (2B). Based on the Bayesian model, CA results in lower all-cause mortality and highest improvement of QOL in the patients of AF with HF (3A, 3B).

Conclusion

This shapes way for future treatment guidelines in patients with PeAF with HF group and points towards CA to be undertaken before medical therapy fails. This also paves way for further research to confirm the longevity of the beneficial effects and to find the specific subsets of AF with HF patients that would be benefited most from CA. Abstract Figure
Ablation Index-guided 50W radiofrequency ablation for atrial fibrillation: lesion level analysis to ascertain determinants of safety
Authors: Ding WY , Bierme C , Tovmassian L , Obrien J , Kozhuharov N , Chu G , Snowdon RL , Gupta D
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The safety of Ablation Index (AI)-guided 50W ablation of atrial fibrillation (AF) remains uncertain, and the effects of this high power on other ablation parameters have not been described. We aimed to compare the safety profile of AF ablation using 50W and 35-40W.

Methods

59 patients undergoing AI-guided Pulmonary Vein Isolation were enrolled including 31 with 50W and 28 with 35-40W. A contact force (CF)-sensing ablation catheter (Thermocool SmartTouch) was used to deliver point-by-point ablation according to the CLOSE protocol targeting AI values of 550-600 on the left atrial (LA) anterior wall and 400-450 on the LA posterior wall. The generator impedance graph was monitored in real-time for each lesion application. All VisiTags (n = 3766) across both groups were analysed retrospectively. Excessive ablation was defined as AI >600 on the anterior wall and >500 on the posterior wall.

Results

The mean AI was significantly higher in patients receiving 50W ablation (512 [±61] vs. 500 [±63] with 35-40W ablation, p < 0.001). Excessive ablations were more frequently observed in the 50W group (10.1% vs. 5.4%, p < 0.001), for both anterior and posterior wall segments (both p < 0.001). There was no steam pop, and no complications in either group.

Scatterplots showing the relationships between contact force (CF) and ablation time for the anterior and posterior segments of the LA for both groups are shown in the Figure. For the anterior wall, the slope of the regression line for the 50W group was -1.0 and for the 35/40W group was -0.5. Overall, there was moderate correlation between the variables CF and time in both groups (50W group: r -0.490, p <0.001; 35-40W group: r -0.527, p < 0.001).

In the 50W group, high CF was an important predictor of excessive AI. The AUCs for anterior and posterior wall 50W ablations were 0.844 (95% CI, 0.774-0.914; p < 0.001) and 0.680 (95% CI, 0.633-0.727; p < 0.001), respectively. On the anterior wall, limiting the CF to 15g would reduce the number of excessive ablations to 3% and limiting CF to 10g on the posterior wall would reduce the number of excessive ablations to 9%.

Conclusion

Use of 50W ablation appears to be safe. but may lead to AI overshoot. Our study suggests that operators should strive to limit CF to 15g on the anterior wall and 10g on the posterior wall. Abstract Figure. Relationship between CF and abl time
Long-term cardiovascular outcomes of patients with extreme obesity following atrial fibrillation ablation
Authors: Adomako REES , Payne JASON , Schleifer W , Khan FARIS , Easley ARTHUR , Windle JOHN , Anderson DANIEL , Tsai SHANE , Naksuk N
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Obesity and extreme obesity increase risk of recurrent atrial fibrillation (AF) and perioperative complications following AF ablation. However, long-term outcomes following AF ablation among obese patients is unknown.

Purpose

To examine long-term cardiovascular (CV) mortality and hospitalization among obese patients undergoing AF ablation

Methods

This retrospective study included 830 consecutive patients undergoing AF ablation from January 2013 to June 2019 at a tertiary referral medical center. Patients with obesity defined as body mass index (BMI) ≥30-39.9 kg/m2 and a subgroup of patients with extreme obesity with BMI ≥40 kg/m2 were identified. Patients were monitored for mortality and hospitalization during a median follow-up time of 819 days. Multivariate model adjusting for CHA2DS2-VASc score and history of obstructive sleep apnea (OSA) was performed.

Results

Mean age was 62 ± 10 years and 67.5% were male. Obese patients (n = 493, 59%) had a higher CHA2DS2-VASc score, and greater prevalence of OSA. These patients tended to have higher all-cause mortality and hospitalization (adjusted HR, 1.21 95% CI 0.98 to 1.51; P = 0.078), as well as greater non-CV outcomes (adjusted HR 1.45, 95% CI 1.02 to 2.08; P = 0.04). However, CV death and admission were comparable among patients with and without obesity (adjusted HR 1.14, 95% CI 0.90 to 1.45; P = 0.28). A subgroup of 111 (13.4%) extremely obese patients were identified. In comparison with obese patients with BMI ≥30-39.9 kg/m2, patients with extreme obesity with BMI ≥40 kg/m2 had similar CV (adjusted HR 1.07, 95% CI 0.75 to 1.50; P = 0.70) and non-CV adverse outcomes (adjusted HR 1.11, 95% CI 0.69 to 1.72; P = 0.65), Figure.

Conclusions

Obesity is not associated with increased CV mortality or admission following AF ablation. Non-CV events are the major cause of adverse outcomes among obese patients. Identification and reversal, where possible, of non-CV comorbidity may result in improved long-term outcomes following AF ablation. In addition, extremely obese patients with BMI≥40 kg/m2 pose a similar risk of having adverse outcomes to obese patients with BMI≥30-39.9 kg/m2. Thus, patients with extreme obesity should not be excluded from catheter ablation as a management option of AF based solely on their BMI. Abstract Figure. Cumulative-Incidence Curves
First clinical experience using a novel temperature-guided ablation catheter in a routine workflow for atrial fibrillation ablation
Authors: Braun M , Bergau L , Piran M , El Hamriti M , Imnadze G , Khalaph M , Guckel D , Sommer P , Sohns C
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Recently, a novel irrigated RF catheter was designed with a diamond-embedded tip for rapid cooling and 6 surface thermocouples to reflect real-time tissue temperature. The new technology allows for temperature-controlled irrigated ablation, very high-resolution electrograms (EGMs) from the split-tip electrode, as well as real-time rapid lesion assessment.

Aim

This study aimed to access clinical performance in terms of lesion formation and procedural safety of the novel DiamondTemp (DT) ablation catheter for atrial fibrillation (AF) ablation under routine clinical conditions.

Methods

In this prospective observational study, 20 patients underwent pulmonary vein isolation (PVI) with the DT catheter in a temperature control mode (60C°/50 W/ 10 seconds). The ipsilateral pulmonary veins (PV) were divided into 6 anatomical segments (12 segments in total) to record ablation data. All patients underwent preprocedural imaging (computer tomography or magnetic resonance imaging (MRI)) and 10 patients received additional postprocedural late gadolinium enhancement (LGE) MRI of the left atrium 3 months after ablation to access lesion formation for each anatomical PV segment and to rule out PV stenosis.

Results

Acute PVI was achieved in all patients. Two patients received additional ablation at the cavotricuspid isthmus due to typical atrial flutter. No charring at the catheter tip was found and no procedure related complications were observed. The mean procedure duration (skin-to-skin) was 106 ± 31.9 minutes, mean LA dwell time was 83 ± 27.0 minutes. RF time was 13.5 ± 5.5 minutes with a mean of 74 ± 32.8 RF applications. We measured a mean impedance drop per RF application of 10.7 ± 4.1 ohm. Fluoroscopy time was 4.2 ± 2.3 minutes and the fluoroscopy dose was 221 ± 215.3 cGy*cm2 at a. LGE MRI at 3 months after ablation demonstrated a homogeneous and continuous ablation lesion set around the ipsilateral PVs and there was no evidence for PV stenosis.

Conclusions

This first clinical series demonstrated that temperature-controlled irrigated ablation resulted in rapid, efficient, and durable PV isolation under routine clinical conditions.
Pulmonary vein isolation using Cryo Balloon ablation versus RF ablation using ablation index following the CLOSE protocol: a Prospective Randomized Trial
Authors: Theis C , Huber C , Kaiser B , Kaesemann P , Pirozzolo G , Bekeredjian R
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The single procedure success rates of durable pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) varies between 80 and 90 %.

This prospective, randomized study investigated the efficacy of Cryo-Balloon PVI versus pulmonary vein isolation with RF-energy following the CLOSE protocol (ablation index (AI), interlesion distance ≤ 6 mm, surround flow catheter) in terms of single-procedure arrhythmia-free outcome, safety and procedural time.

Methods and results

A total number of 150 patients undergoing de-novo catheter ablation for paroxysmal AF were randomized to two different treatment arms in a 1:1 fashion. In group-A patients, PVI was performed with the 23 or 28 mm Cryo-Balloon (Articfront Balloon, Medtronic Inc).

The ablation procedure in group B was performed with RF-energy, using AI and following the CLOSE protocol.

During a mean follow-up of 15 ± 6 months after a single procedure, 69 (92%) patients of group A were free of arrhythmia recurrence versus 68 (90.67%) patients in group B (p = ns). A total of 10 patients (group A: 4, group B: 6; p = ns) underwent a redo-procedure. No difference between both groups was observed in terms of patients with PV recovery (group A: 2 (2,67%) vs. group B: 3 (4%); p = ns). In 2 patients of group A and 3 patients of group B the PVs were durably isolated. Two patients of each group had continued paroxysmal AF but did not undergo redo-procedure.

Significantly more patients of group A experienced AF recurrence during blanking period, whereas the outcome after 6 month showed no significant differences (group A 11 (14,66%), group B: 6 (8%); p< 0.05).

With regard to the procedural data, the procedure time was significantly shorter in group A (115.35 ± 15.38 versus 70.53 ± 16.13; p < 0.01), the flouroscopy time and dose area product showed no significant differences (Table 1). Both procedures were performed with a low number of complications, in group A two patients had a significant groin hematoma, no PE. 

Conclusions

Cryo-Balloon PVI and PVI using ablation index following the CLOSE protocol are equally efficient in achieving durable PV-isolation. Approximately 7 % of the patients with clinically paroxysmal AF are having extra-pulmonary vein AF sources. Cryo-Balloon ablation leads to significantly more AF recurrence during the blanking period. Procedural data Cryo-Balloon(group A) Ablation Index(group B) p-value Proc. Time (min) 70.53 ± 16.13 115.35 ± 15.38 <0,01 Fluoro time (min) 8.56 ± 3.18 9.66 ± 3.86 0,06 Dose Area Product(cGy/m2) 390.34 ± 268.57 330.84 ± 150.36 0,10
Is the optimal blanking period duration after cryoballoon pulmonary vein isolation impacted by use of antiarrhythmic drugs?
Authors: Musat D , Milstein NS , Saberito M , Bhatt A , Habibi M , Sichrovsky T , Preminger MW , Shaw RE , Mittal S
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon pulmonary vein isolation (CB) is an accepted method for ablation in patients with atrial fibrillation (AF). A three-month blanking period (BP) is commonly used in clinical trials and practice. However, when the optimal BP duration differs in patients (pts) on or off an antiarrhythmic drug (AAD) at time of ablation remains undefined.

Objective

To compare the BP duration in pts undergoing CB while either taking or not taking an AAD.

Methods

We enrolled consecutive pts with AF who had CB PVI while on an AAD. All pts had an implantable loop recorder (ILR). We prospectively followed all pts and determined the time to last AF episode during the 90-day post-PVI BP. This was then correlated with likelihood of having an AF recurrence between 3-12 months post-PVI.

Results

The cohort included 164 pts (66 ± 9 years; 97 [60%] male; 90 [55%] PAF; CHA2DS2-VASc 2.7 ± 1.7). Ablation was performed with 92 (56%) pts taking an AAD, which was stopped at a median of 80 [36, 105] days post-PVI. We defined 4 distinct groups: (1) no AF in 90-day BP (n = 75 [46%]); (2) last AF within 30 days of PVI (n = 32 [20%]); (3) last AF within 60 days of PVI (n = 17 [10%]); and (4) last AF within 90 days of PVI (n = 40 [24%]). Following the 90-day BP, 81 (49%) pts had a recurrence of AF. Long-term freedom from recurrent AF was similar in pts who did and did not use an AAD, irrespective of BP duration (Figure).

Conclusion

Our data suggest that the optimal BP duration in AF patients undergoing CB PVI while taking an AAD is 30 days. An AF recurrence after 30 days is associated with a very high likelihood of recurrent AF during longer-term follow-up, irrespective of whether an AAD is being used or not. Abstract Figure.
Characterization of conduction gaps at the pulmonary vein antra by omnipolar voltage mapping
Authors: Merino JL , Kim S , Castrejon S , Relan J , Sanroman-Junquera M , Martinez-Cossiani M , Escobar C , Carton A
Published: May 2021

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Abbott provided some software to perform special maps

Introduction

Voltage mapping of atrial tissue may be influenced by the direction of the activation front. Omnipolar electrograms may result in better characterization of the atrial tissue. However, little is known about characterization of the pulmonary vein (PV) antra with omnipolar mapping in patients with recurrent atrial fibrillation (AF) following PV isolation (PVI). 

Purpose

To study differences in voltage between regions with (Gap) and without (No-Gap) conduction recurrence at the PV antra by both omnipolar and conventional bipolar mapping in redo PVI procedures.

Methods

Single centre prospective study  of consecutive patients who underwent a redo PVI procedure for AF ablation. Activation and voltage bipolar maps were developed on a electroanatomical system (Ensite Precision) by a steerable catheter with a 16 grid-patterned electrode configuration (HD-Grid) during coronary sinus pacing at both 500 and 300 ms.  Precise location of conduction gaps in the PV antra was attempted by atrial and PV pacing. Only conduction gaps that were ablated by ≤3 focal radiofrequency applications were included in the analysis. Electrograms recorded within 1 cm at both sides of the RF application site were considered related to the gap region. Off-line omnipolar voltage maps were developed with a dedicated experimental software after the procedure .

Results

11 patients were included in the study and 18 gaps were found in 9 patients. 6762 (2688 Gap and 4074 No-Gap)  electrograms were analyzed. Compared with No-Gap PV regions, Gap regions showed significantly (P < 0.0001) higher voltages by omnipolar mapping (0.3 ± 0.6 mV vs 1.1 ± 1.4 mV)  and by absolute (0.2 ± 0.5 mV vs 0.8 ± 1.2 mV),  grid-along (0.3 ± 0.5 mV vs 0.8 ± 1.2 mV) and grid-across  (0.3 ± 0.5 mV vs 0.8 ± 1.1 mV) bipolar mapping.  Omnipolar mapping resulted in higher voltage electrograms when compared with absolute bipole, longitudinal and horizontal bipolar electrograms (P < 0.0001). ROC curves (figure) to differentiate between Gap and No-Gap regions were slightly better for omnipolar electrograms (AUC 0.79) than for conventional grid -along or grid-across bipolar mapping (AUC 0.76 and 0.77) with the best discrimination value of 0.3 and 0.2 mV respectively.  Conclusion: There are significant differences in voltage between conduction Gap and No-Gap regions at the PV antra which are more apparent with omnipolar than with conventional bipolar mapping. 0.3 mV and 0.2 mV values are the best to differentiate between PV conduction Gap and No-Gap regions with ominpolar and conventional mapping respectively
Efficacy and safety of hybrid convergent procedure vs endocardial catheter ablation for the management of atrial fibrillation
Authors: Abdul Razzack A , Rahman S , Pasam T , Pasam C , Saeed T , Khokhar HT , Pothuru S , Adeel Hassan S , Mandava S , Theja Reddy K , Kumar R , Kumar S , Sattar Y
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background- Little is known regarding the efficacy and safety of hybrid convergent epicardial and endocardial approach (CVP) that has emerged as an alternative to endocardial catheter ablation (CA) for the management of persistent and paroxysmal atrial fibrillation.

Methods-Electronic databases ( PubMed, Embase, Scopus) were searched from inception to Jan 6th, 2020. Unadjusted odds ratios (OR) were calculated from dichotomous data using Mantel Haenszel (M-H) random-effects with statistical significance to be considered if the confidence interval excludes 1 and p < 0.05. The primary outcome of interest was recurrence of atrial tachyarrhythmia {Atrial fibrillation (AF)/Atrial flutter(AFL) /Atrial tachycardia(AT)} Secondary outcomes included any intervention (DC Cardioversion (DCCV), repeat ablation) and major adverse events (MAE).

Results- A total of three studies with 336 (CVP = 190, CA = 146) participants were included. CVP was associated with significantly higher freedom from atrial tachyarrhythmia recurrence compared with CA therapy (RR 0.60, 95% CI 0.45-0.78; p = 0.0002; I2 = 0). Patients receiving CVP had lower odds of requiring any re-intervention (DCCV, repeat ablation) when compared to CA therapy (RR 4.11, 95% CI 1.17-14.46; p = 0.03; I2 = 0). However, CVP was associated with significantly higher rate of major adverse events (RR 0.44, 95% CI 0.30-0.65; p= <0.0001; I2 = 0).

Conclusion-Treatment with Hybrid convergent ablation seems to be superior than endocardial catheter ablation for prevention of arrhythmia recurrence but may also cause more severe adverse effects. Abstract Figure.
Number needed to treat for net effect of anticoagulation in atrial fibrillation
Authors: Ding WY , Rivera-Caravaca JM , Marin F , Li G , Roldan V , Lip GYH
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The benefit of oral anticoagulation (OAC) in atrial fibrillation (AF) must be balanced against any potential risk of harm. We aimed to evaluate the "NNT for net effect" (NNTnet) using CARS in anticoagulated patients with AF.

Methods

We used patient-level data from the real-world Murcia AF Project and AMADEUS clinical trial. Baseline risk of stroke was calculated using CARS while major bleeding was estimated from prior studies. Stroke and major bleeding events at 1-year were determined. NNTnet was calculated as a reciprocal of the net effect of ARR with OAC (NNTnet= 1 / (ARRstroke - ARIbleeding)).

Results

3,511 patients were included (1,306 [37.2%] real-world patients and 2,205 [62.8%] clinical trial). The absolute 1-year stroke risk was similar across both cohorts and the main results are presented in the Table.

In both cohorts, the NNTnet was significantly lower in patients with an excess stroke risk of ≥2% by CARS. Among real-world patients with a very high (>10%) baseline stroke risk, the use of OAC was associated with an ARRstroke of 10.9% and ARIbleeding of 1.2%, generating an overall NNTnet of 11. In the clinical trial, the use of OAC was associated with an ARRstroke of 11.0% and ARIbleeding of 0.6%, generating an overall NNTnet of 10.

Conclusion

Overall, the NNTnet approach in AF incorporates information regarding baseline risk of stroke and major bleeding, and relative effects of OAC with the potential to include multiple additional outcomes and weighting of events based on their perceived effects by individual patients. This simple and intuitive metric may be useful to improve communication and optimise the patient-centred management of AF. NNT in Real-World and Clinical Trial Real-World Clinical Trial Ischaemic stroke risk at 1-year Baseline risk without anticoagulation (%) 5.7% (95% CI 5.5 - 6.0) 5.1% (95% CI 4.9 - 5.3) Anticoagulation-mediated risk (%) 1.7% (95% CI 1.1 - 2.6) 1.3% (95% CI 0.8 - 1.8) Absolute risk reduction (%) 4.0% 3.8% NNTbenefit 25 27 Major bleeding risk at 1-year Baseline risk without anticoagulation (%) 2.3% 2.3% Anticoagulation-mediated risk (%) 3.3% (95% CI 2.4 - 4.4) 3.9% (95% CI 3.1 - 4.8) Absolute risk increase (%) 1.0% 1.6% NNTharm 100 63 NNTnet 34 46
Contemporary data evaluating 1-year clinical outcomes in patients with atrial fibrillation and coexisting valvular heart disease: the ETNA-AF-Europe study
Authors: De Caterina R , Ricci F , De Groot JR , Deharo JC , Waltenberger J , Weiss TW , Kirchhof P
Published: May 2021

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe

OnBehalf

ETNA-AF-Europe investigators

Background

Valvular heart disease (VHD) is a common comorbidity in patients with atrial fibrillation (AF); the optimal anticoagulant treatment of such patients remains largely unexplored. Purpose: To evaluate differences in the baseline characteristics and 1-year event profiles of edoxaban-treated AF patients with or without VHD. Methods: ETNA-AF-Europe prospectively enrolled 13,980 patients with AF from 825 centres in 10 European countries. Baseline characteristics and 1-year annualised event rates for edoxaban-treated AF patients with or without VHD were compared using descriptive analyses. VHD was defined as reported by investigator. Results: Of the 13,092 AF patients who completed the 1-year of follow-up, 2,314 patients had VHD and 10,778 did not have VHD at baseline. Patients with VHD were older, had lower body weight and worse renal function, a higher stroke score, and were considered more frail by their physician than patients without VHD (Table). Patients with VHD had higher annualised event rates of all-cause mortality, stroke or systemic embolic events and bleeding events than those without VHD (Figure). However, rates of intracranial haemorrhage and myocardial infarction were similar between those with and without VHD. Conclusions: Patients with or without VHD had low rates of adverse events on receiving edoxaban treatment. Patients with VHD had more comorbidities at baseline and a higher risk of mortality, major bleeding and stroke but not of ICH versus those without VHD after 1 year of treatment. Baseline characteristicsOverall (n = 13,092)Patients with VHD (n = 2314)Patients without VHD (n = 10,778)Male, n (%)7430 (56.8)1245 (53.8)6185 (57.4)Age (years), mean ± SD73.6 ± 9.575.9 ± 8.673.1 ± 9.6Body weight (kg), mean ± SD81.0 ± 17.378.0 ± 15.981.6 ± 17.5CrCl (Cockcroft-Gault) (mL/min), mean ± SD74.3 ± 30.466.0 ± 26.476.0 ± 30.9CHA2DS2-VASc, mean ± SD3.1 ± 1.43.5 ± 1.33.0 ± 1.4Modified HAS-BLED, mean ± SD2.5 ± 1.12.8 ± 1.12.4 ± 1.1Frailty, n (%)1392 (10.6)381 (16.5)1011 (9.4)Current AF type Paroxysmal Persistent Long-standing persistent & permanent7039 (53.9)3159 (24.2)2864 (21.9)1083 (46.9)578 (25.0)648 (28.0)5956 (55.4)2581 (24.0)2216 (20.6)*Frailty was subjectively assessed as perceived by the investigator. AF, atrial fibrillation; CrCl, creatinine clearance; OD, once daily; SD, standard deviation; VHD, valvular heart disease.Abstract Figure. One-year outcomes
Short dual antiplatelet strategy following left atrial appendage closure with Watchman and Watchman FLX: 1-year outcomes
Authors: Briosa E Gala A , Pope MTB , Monteiro C , Leo M , Betts TR
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left atrial appendage occlusion (LAAO) is an effective stroke prevention strategy in patients with non-valvular atrial fibrillation and high bleeding risk. Oral anticoagulation or dual antiplatelet (DAPT) therapy is recommended for the period of device endothelisation but confers an increased bleeding risk.

Purpose

This study sought to examine the one-year outcomes of a short DAPT strategy following LAA occlusion in a large UK tertiary centre.

Methods

This retrospective study included all patients discharged on a short DAPT strategy (6-8 weeks) following a LAAO device implantation from January 2010 and December 2020 in our institution. Medical notes, procedural, and imaging reports were reviewed and adverse event rates were calculated at one year. Yearly bleeding risk was extrapolated from the Swedish National Cohort study according to CHA2DS2-VASc and HASBLED score.

Results

A total of 140 patients (106 Watchman and 36 Watchman-FLX) were discharged on a planned short DAPT strategy (age 74 ± 9 years, 70% male, 71% had previous bleeding on OAC, 95% previous major or life-threatening bleeding episodes, 52% previous ischaemic stroke, CHA2DS2-VASc score 4.5 ± 1.2, HASBLED score 3.2 ± 0.7). The median time to switching to either single antiplatelet (APT) or no ATP was 62 days. After first follow-up, 90% were either on SAPT (46.3% aspirin and 39.3% clopidogrel) or no ATP (6.4%). Seven (5%) patients had device-related thrombus on transoesophageal echocardiography and were started on anticoagulation and 4 (3.5%) patients remained on DAPT. At one year, of the 129 patients on a short DAPT strategy the composite of death, ischaemic stroke and non-procedural bleeding occurred in 11 patients (KM 8.9%; 95% CI, 3.7% -13.8%).  Four patients (3.1/100 patient-years) suffered a major bleed and 3 (2.3/100 patient-years) had an ischaemic stroke on SAPT (mean time of 315 days). Compared to estimated annual stroke and bleeding risk adjusted for CHA2DS2-VASc and HASBLED score, this represents a 65% and 38% relative risk reduction in ischaemic stroke and major bleeding, respectively.

Conclusion

In our cohort, a short DAPT strategy following LAAO device appears safe with reduction of both thromboembolic and major bleeding events at 1-year. Abstract Figure 1