bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk of embolic events in patients with Chagasic Cardiomyopathy and Atrial Fibrillation despite antithrombotic therapy: is anticoagulation enough?
Authors: Echeverria L E , Sanchez-Garcia R , Mantilla A F , Pizarro M P , Jimenez O , Rojas L Z , Gomez-Ochoa S A
Published: October 2024

Background

Chagasic cardiomyopathy (CC) differs from other heart failure causes in multiple aspects, highlighting the risk of systemic embolisms. However, few studies have evaluated the risk of embolic events in anticoagulated patients with CC compared to other cardiomyopathies.

Objective

We aimed to analyze the incidence of systemic embolisms in a cohort of anticoagulated patients diagnosed with atrial fibrillation (AF) with and without CC.

Methods

A retrospective cohort study was conducted at a fourth-level hospital from 2014-2020. All patients diagnosed with cardiomyopathy of any etiology and AF on an anticoagulation regimen were included. The primary outcome was the incidence of embolic events. A survival analysis was performed using adjusted Cox proportional hazard models. A p-value of <0.05 was considered significant. All statistical tests were two-tailed.

Results

149 anticoagulated patients with cardiomyopathy were evaluated (median age: 71 years; women: 30.20%). The cumulative incidence of embolic events was significantly higher in patients with CC (17.50%) compared to those with other cardiomyopathies (4.95%), despite that the latter had a substantially higher CHA2DS2-VASc score (p=0.013). After multivariate analysis, patients with CC had a significantly higher risk of embolic events regardless of the CHA2DS2-VASc score and the anticoagulant prescribed (HR 5.65. 95% CI 1.46-21.83; p=0.012).

Conclusions

CC was associated with a significantly higher risk of embolic events despite anticoagulation therapy in both groups. More research is required to understand the origin of this risk observed to translate this knowledge into specific indications for anticoagulation for patients with CC.Cumulative incidence of embolic events
Stratification of residual thromboembolic risk among anticoagulated atrial fibrillation patients: a hierarchical cluster analysis from a global, real-world population
Authors: Ishiguchi H , Abdul-Rahim A H , Huang B , Lam H M , Liu Y , Olshansky B , Chao T F , Huisman M V , Lip G Y H
Published: October 2024

Background

Assessment of residual thromboembolic risk among atrial fibrillation (AF) patients despite being on oral anticoagulants (OACs) poses a significant challenge. This study utilises a hierarchical cluster analysis approach to identify risk phenotypic profiles in a global prospective AF registry.

Methods

Data were drawn from recently diagnosed non-valvular AF patients receiving OACs, as recorded in phases II and III of the GLORIA-AF (Global Registry on Long-Term Oral Anti-thrombotic Treatment in Patients With Atrial Fibrillation) registry. A hierarchical cluster analysis based on patient demographics was performed to identify distinct phenotypes. The incidence and risks of thromboembolic events (ischaemic stroke, transient ischaemic attack, or systemic embolism) and relevant events (major bleeding and all-cause death) were compared across clusters.

Results

The study included 22,410 patients (mean age 70±8 years; 56% male), from which 5 phenotypes were delineated: Cluster 1 ("uncontrolled hypertension"), Cluster 2 ("young with a history of coronary artery disease"), Cluster 3 ("young and obese"), Cluster 4 ("frailty"), and Cluster 5 ("non-paroxysmal AF with tachycardia"). Cluster 4 was associated with the highest rates of thromboembolic events (1.66/100 person-years), major bleeding (1.92/100 person-years), and all-cause mortality (6.02/100 person-years). Conversely, Cluster 3 showed the lowest risk profiles across all outcomes (thromboembolic events: 0.64 events/100 person-years, major bleeding: 0.83 events/100 person-years, and all-cause death: 1.44 events/100 person-years). Cluster 1 displayed a moderate thromboembolic event rate (1.04/100 person-years), although lower rates were observed in Clusters 2 and 5 (Figure 1).

Conclusions

Hierarchical cluster analysis effectively identified distinct phenotypes within a global AF population, offering valuable insights for stratifying the risks of residual thromboembolic events and other significant outcomes in anticoagulated AF patients (Figure 2).Figure 1Figure 2
Strategy optimization for the combined procedure of left atrial appendage occlusion plus catheter ablation in patients with atrial fibrillation (COMBINATION): a multi-center, randomized study
Authors: Du X F , Chu H M , Yang B , Zhong J Q , Ruan Z B , Chen Q , Tao S M , Lai H L , Liang J Q , Xie R Q , Ye P , Zhou X H , Li Y D , Li J P , Zhao Y J
Published: October 2024

Background

The long-term efficacy and safety of combining left atrial appendage closure (LAAC) plus catheter ablation (CA) in patients with atrial fibrillation (AF) in a single procedure have been established. However, the optimal combining strategy has not been well elucidated.

Objective

To determine the impact of different combining strategies on long-term clinical outcomes.

Methods

In this prospective multicenter study, patients with non-valvular AF referred for the combining procedure were randomly assigned to the ablation-first or occlusion-first groups at a 1:1 ratio. We evaluated the outcomes of LAAC with a Watchman device and CA using a contact-force sensing catheter during long-term follow-up.

Results

Of the 202 randomized patients, 194(96.0%) completed the trial with 97 patients in each group. Baseline characteristics were comparable between groups. All procedures were accomplished with acute successful LAAC and restoration of sinus rhythm. Incidences of periprocedural complications were similar. Higher chronic peri-device leak (PDL, 15.5% vs 5.2%, P=0.031) and device-related thrombus (DRT, 8.2% vs 1.0%, P=0.035) rates were observed in the ablation-first group. The event-free survival rate of the primary endpoint (composite of stroke/transient ischemic attack, thromboembolism, clinically-relevant bleeding, cardiovascular rehospitalization/death) was significantly higher in the occlusion-first group (83.5% vs 71.1%, log-rank P=0.036, HR 0.53, 95%CI 0.29-0.95) during a median 2.5-year follow-up. Patients with male gender and higher CHA2DS2-VASc score were at lower risk in the subgroup analysis. Long-term freedoms from AF (77.3% vs 63.5%, log-rank P=0.039) and atrial tachyarrhythmias (70.1% vs 55.7%, log-rank P=0.044) were higher in the occlusion-first group, respectively.

Conclusions

The occlusion-first approach is recommended for combined procedures where a plug-like device is implanted due to its superior long-term clinical benefits.Flowchart of the COMBINATION trialIncidences of primary endpoint
Elucidating the mechanism of rapid functional recovery following atrial fibrillation ablation in patients with left ventricular systolic dysfunction
Authors: Okada M , Koyama Y , Tanaka K , Hirao Y , Harada S , Miyazaki N , Iwasa K , Watanabe H , Iwanaga Y , Okamura A , Tanaka N
Published: October 2024

Introduction

Successful sinus rhythm restoration by catheter ablation (CA) of atrial fibrillation (AF) rapidly improves cardiac function in patients with left ventricular (LV) systolic dysfunction. However, the underlying mechanism of this recovery remains unknown.

Purpose

To elucidate the mechanism of the functional recovery after CA of AF and systolic dysfunction.

Methods

We retrospectively examined 4001 consecutive patients who underwent first-time CA of AF between 2012 and 2021 at our institution. Of them, 505 patients had baseline LV ejection fraction (LVEF) of <50%. Among them, we enrolled 454 patients who received electrocardiogram-gated contrast-enhanced 256-slice multi-detector computed tomography (MDCT) (Brilliance iCT, Philips Medical Systems, Cleveland, Ohio) both at baseline and 3 months after CA. Changes in LV measures, wall thickness, and LV mass were examined based on MDCT data.

Results

A reduction of LV end-systolic volume (LVESV) (from 71 ± 37 ml to 46 ± 34 ml, p <0.001) and improvement of LVEF (from 39 ± 9% to 62 ± 14%, p <0.001) were observed after CA. However, there was no significant change in LV end-diastolic volume (LVEDV) (from 118 ± 49 ml to 116 ± 46 ml, p = 0.13). Mean wall thickness during diastole did not change (from 7.1 ± 1.4 mm to 7.1 ± 1.4 mm, p = 0.94), either. However, wall thickness during systole significantly changed after CA (from 10.0 ± 1.7 mm to 12.7 ± 2.8 mm, p <0.001). As a result, there was no significant change in LV mass after CA (from 84.3 ± 28.7 g to 84.4 ± 28.1 g, p = 0.88). A regression analysis revealed a significant inverse correlation between the delta LVEF and delta LVESV (r = -0.59, p <0.001). However, the delta LVEF was not correlated with the delta LVEDV and delta LV mass.

Conclusions

The rapid improvement of LVEF after CA of AF was attributed to a decrease in the LVESV. Unchanged LV mass indicated that this functional recovery was solely a mechanical issue, without evidence of myocyte regression.
Impact of conduction velocity in left atrium assessing with omnipolar technology in patients with atrial fibrillation
Authors: Enomoto Y , Yamamoto J , Hara H , Hiroi Y
Published: October 2024

Background

There is increased interest in exploring substrate of atrial fibrillation (AF) and recent studies have shown that atrial conduction velocity (CV) reflects the electrophysiological phenomena and plays key role in perpetuating AF. The novel omnipolar technology (OT) use three unipolar and two orthogonal bipolar signals allow us to analyze the voltage, activation direction, and CV independent of catheter position.

Objective

The purpose of the present study was to evaluate if the left atrium (LA) CV which assessed by OT predict the any atrial tachy-arrhythmia (AT) recurrence after initial AF ablation.

Methods

We enrolled 58 consecutive patients who underwent initial pulmonary vein isolation (PVI) for drug refractory AF. (mean age: 68.2±10.2 years old, 32 male(55.1%), 32 persistent AF(55.1%), CHADS2 score:1.6±0.6). After electrical PVI was achieved and remained in sinus rhythm, the LA was mapped with high density mapping catheter (Advisor HD Grid, Abott USA) utilizing with the novel OT combined with Ensite X system (Abott, USA). The conduction distance and conduction times were measured from the earliest activation site to the latest activation site in LA (Figure 1). Each conduction velocity in anterior, posterior, and septal area were also calculated as conduction distance divided by conduction time. The LA voltage was also measured.

Results

During a mean follow up period of 316±143 days, the recurrence of AT after initial PVI was observed in 9 (15.5%) patients. There were no significant differences in baseline demographics between AT recurrence and non-recurrence group (mean age:66±13.3 vs 68.5±10.5 years old P=0.66, CHADS2 score: 1.5±0.57 vs 1.68±0.62 P=0.59, proportion of persistent AF: 15.4% vs 15.5% P=0.82, LA volume: 102±35.9 vs 93.6±37.3ml P=0.63). The earliest activation site in LA were identified in 3 areas including anterior site of right pulmonary vein (51.7%), Bachmann bundle area (41.4%), and antero-septal area (6.89%) (Figure 2). In patients with AT recurrence, the CV in LA was significantly slower than those without AF recurrence(0.61±0.21 vs 0.81±0.16 m/s, P=0.036) whereas the whole LA voltage was not (1.52±0.75 vs 2.22±1.06 mv, P=0.28). The CV in each LA portion are similar between recurrence and non-recurrence AT group. (anterior:0.57±0.24 vs 0.81±0.23 m/s, P=0.18, posterior: 0.87±0.18 vs 1.2±0.49 m/s P=0.36, septal: 0.89±0.76 vs 1.15±0.39 m/s, P=0.41).

Conclusion

The earliest activation site in LA was varied in each case. The whole CV in LA is a predictor of AF recurrence after PVI whereas the CV of each LA portion and LA voltage was not.
Ablation outcome in elderly women with atrial fibrillation undergoing pulsed-field ablation for electrical isolation of pulmonary veins and left atrial posterior wall
Authors: Mohanty S , Doty B , Casella M , Schiavone M , Gabrah K , Valeri Y , Torlapati P G , La Fazia V M , Gianni C , Horton R , Al-Ahmad A , Dello Russo A , Tondo C , Nair D G , Natale A
Published: October 2024

Background

Documented evidences indicate higher prevalence of non-paroxysmal atrial fibrillation (AF) as well as in elderly women but also demonstrate the need to go beyond the pulmonary veins (PV) when treating these patients.

Objective

We compared the ablation outcome in elderly women (>70 years) with that in men in the same age group as well as in younger women (≤70 years) undergoing pulsed-field ablation (PFA) for persistent AF (PerAF).

Methods

This multicenter study included consecutive PerAF patients undergoing PFA as their first procedure. Patients were divided into 3 groups: Group 1: women >70 years, Group 2: men ≥70 years and Group 3: women ≤70 years. All received PV isolation (PVI) and isolation of left atrial posterior wall (LAPWI). Concentric overlapping lesions were placed in the LAPW. Number of applications were determined on a case-by-case basis. Isolation was confirmed by electrograms recorded on the multispline catheter. In all patients, ICE and fluoroscopy were used to optimize contact between the PFA catheter and the targeted tissue. Arrhythmia-monitoring was performed for 1-year with periodic clinic visits, event recorders and 7-day Holter monitoring.

Results

A total of 229 patients (group 1: 73; group 2: 47 and group 3: 109) were included in this analysis. Baseline characteristics of the study population is presented in table 1.

At 1-year follow-up, 15 (20.5%), 3 (6.38%) and 10 (9.17%) from group 1, 2 and 3 respectively, experienced arrhythmia recurrence off-antiarrhythmic drugs. Recurrence rate in group 1 was significantly higher than that in group 2 (p=0.034) and group 3 (p=0.029).

Conclusion

In women aged ≤70 years and in elderly men (>70 years), PVI plus isolation of LAPW using ICE-guided PFA was associated with significantly lower recurrence rate compared to that in the elderly women. Given the higher recurrence rate following PVI+LAPWI in the elderly females, the operators should consider addressing all other AF-initiating extra-PV triggers for better ablation-outcome in this subset of the AF population.
Same-day discharge after atrial fibrillation ablation: is it equally safe?
Authors: Abrantes A , Raposo M , Garcia B , Martins M , Oliveira C , Gregorio C , Cravo J , Vilela M , Cazeiro D , Araujo I , Ferreira A , Silva G , Cortez-Dias N , Pinto F , Sousa J
Published: October 2024

Introduction

Same-day discharge after atrial fibrillation (AF) ablation represents a paradigm shift in post-procedure care. This approach allows patients (pts) to return home on the same day after their ablation, promoting comfort and reducing hospitalization duration.

Purpose

To evaluate safety of same-day discharge in pts submitted to either pulsed field ablation (PFA) or cryoablation (CA).

Methods

Single-center retrospective study of AF pts submitted to ablation with either PFA or CA from May 2019 to November 2023. Ablation strategy consisted in pulmonary vein isolation complemented with ablation of the cavo-tricuspid isthmus in pts with history of atrial flutter. Pts were considered eligible to same-day discharge if an observation period of at least 6h was assured after the procedure. Safety was defined as 30-day major or minor complications. Chi-square tests were used for the comparison of continuous variables.

Results

We included 152 pts, 60 were submitted to PFA and 92 to CA, 56.6% males, median age 66±14 years, mean CHA2DS2-VASc score 2.45±1.4. Paroxysmal AF, short and long-standing persistent AF were present in 67%, 16% and 15% of pts respectively. Previous stroke was present in 8.7% of pts and 27 pts had history of heart failure. Acute success rate was 99.3%, concomitant cavo-tricuspid isthmus ablation was performed in 20% of pts, and mean procedure time was 107.5±74 min. Same-day discharge was initially considered in 70% of pts, however of these, 12 pts remained under further observation due to acute complications. No major or minor acute complications were reported in pts with same-day discharge. There were no significant differences in 30 days complications between groups. At 30 days no major complications were reported in pts with same-day discharge. One pts in which same-day discharge was halted died 4 days after ablation from hemorrhagic shock. Regarding minor complications at 30 days, 4 minor femoral hematoma were reported, 2 in each group.

Conclusion

In our population, same-day discharge proved to be a safe strategy if careful pts selection is assured. This practice enhances overall pt experience, marking a significant paradigm shift in AF management.
An in-silico comparison of anatomical and substrate based AF ablation using electro and optical flow mapping
Authors: Jaffery O A , Zolotarev A , Barera C E , Rodero C , Niederer S , Slabaugh G , Good W W , Roney C H
Published: October 2024

Background

The pursuit of improved outcomes for persistent AF may necessitate the utilization of innovative technologies and ablation methods. We hypothesize that combining electrophysiologic phase and optical flow mapping could offer a novel approach to identify ablation sites in persistent AF while minimizing ablation area, thereby enhancing the effectiveness of substrate-based ablation compared to a purely empiric strategy.

Objective

To compare the efficacy of a novel electro-optic flow-based ablation strategy (EOF) with empiric ablation for persistent AF patients using a virtual cohort of bi-atrial models.

Methods

An exploratory cohort (n=20) from a CT-derived bi-atrial in silico population was utilized to simulate AF. A pipeline was developed to assess ablation targets based on simulated AF and to automatically connect targets to closest inert boundaries. As part of target assessment, phase singularities (PS) and Horn-Schunck average optical flow maps were computed. An intersection of information assessed through PS and curl of average optical flow was utilized to generate EOF maps. 5 x strategies comprising purely anatomical, PS based and EOF guided ablations were simulated (1. PVI; 2. PVI+mitral/roof lines; 3. PVI+mitral/box line; 4. PS+anatomical; 5. EOF+anatomical). Ablation efficacy was determined by first examining change of rhythm via ablation and second by calculating the amount of tissue area ablated.

Results

Ablating PVI alone (Method 1) did not result in AF termination in any case. Ablating PVI with mitral or roof lines (Method 2) resulted in moderate outcomes (6 AF term. / 3 conv. to AT) whereas ablating PVI with mitral and box lines (Method 3) resulted in improved outcomes (9 AF term. / 4 conv. to AT). Compared to purely anatomical approaches, ablating PS or EOF targets and combining them with roof, mitral lines (Method 4 and Method 5 respectively) saw marked improvement (16 AF term. / 2 conv. to AT). Mapping based on EOF (Method 5) resulted in smaller ablation targets compared to a PS guided strategy (Method 4) with the same outcome.

Conclusion

AF termination to ablated tissue area ratio was higher for EOF based ablation targets compared to PS based or empiric ablations. Algorithmic generation of ablation lesion masks based on predicted targets can provide novel insights into ablation outcomes. Combining EOF targets with empiric lesions represents a potential ablation strategy of individualized substrate modification for persistent AF.Study Pipeline
An external validation of DOAC score in patients with atrial fibrillation following transcatheter aortic valve replacement
Authors: Harano Y , Yamamoto M
Published: October 2024

Background

Bleeding events, particularly in patients with atrial fibrillation (AF) and those with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), are a major clinical concern and are associated with a worse prognosis. The DOAC Score (1) has recently been introduced to predict bleeding risk in patients with AF taking direct oral anticoagulants (DOACs). However, further validation is required to confirm its ability.

Objective

This study aims to evaluate the predictive ability of the DOAC Score for bleeding events in Asian patients with AF undergoing TAVR.

Methods

In this multicentre, retrospective, observational cohort study, patients with AF who underwent TAVR were included. The data was obtained from the Japanese multicentre registry, which comprises 19 centres from 2013 to 2019. Bleeding was defined as any post-discharge bleeding after TAVR. The primary endpoint was the incidence of all bleeding events in 3 populations: the overall population, the DOAC cohort, and the vitamin K antagonist (VKA) cohort.

Results

This study included 1230 patients with a mean age of 84.6 ± 5.1 years, of whom 457 were males. Among them, 465 patients (37.8%) were treated with a VKA while the rest were treated with a DOAC. Patients were divided into three groups according to their DOAC Score: 380 patients (30.1%) were in the ≤ moderate risk group with a DOAC Score of 7 or less, 497 patients (40.4%) were in the high-risk group with a DOAC Score of 8 or 9, and 353 patients (28.7%) were in the very high-risk group with a DOAC Score over 10. The cumulative incidence of all bleeding at 5 years in the overall population was significantly different in the 3 risk groups: ≤ moderate: 8.4%, high-risk: 10.8%, very high-risk: 21.6%, respectively (p< 0.01). The incidence was also significantly different in the DOAC and VKA cohorts (p<0.01 and p=0.03, respectively).

Conclusion

The recently published DOAC Score is well predictive of bleeding risk in Asian patients with AF after TAVR. The score may be useful in predicting bleeding in patients taking both DOAC and VKA.Graphical abstract
Impact of left atrial appendage occlusion in atrial flow evaluated through 4D flow cardiac magnetic resonance
Authors: Anduaga Elorza I , Morales Ferez X , Cepas Guillen P , Casademunt P , Doltra A , Mill J , Flores Umanzor E , Iriarte Gea M , Sanchis L , Camara O , Freixa X
Published: October 2024

Introduction

Device-related thrombus (DRT) and peri-device leak constitute significant complications following left atrial appendage occlusion (LAAO), primarily due to its association with strokes and thromboembolic events. Patient-specific fluid simulations have been employed to explore this hypothesis(1). However, these simulations require detailed anatomical and physiological data, rely on certain assumptions when defining boundary conditions, and involve long computational times. Recently, there has been growing interest in the use of 4D flow cardiac magnetic resonance (CMR) imaging for various cardiovascular diseases, owing to its capability to reproduce blood flow. While its role in the LAAO scenario has been evaluated in silico(2), there are no reported cases of its application in patients undergoing LAAO.

Purpose

Our objective was to evaluate the impact of LAAO in atrial flow through 4D flow CMR.

Methods

Five patients undergone LAAO were included in the pilot study. A pre- and 90-days post-procedure 4D flow CMR scans were performed. One of the patients was excluded due to suboptimal image quality.

To assess the impact of LAAO on atrial flow dynamics, three parameters were evaluated: a) mean velocity, b) stasis velocity ratio, and c) endothelial cell activation potential (ECAP) index — all associated with an elevated risk of thrombus formation(3,4).

Results

Baseline and procedural characteristics, along with imaging results, are presented in Table 1. Preprocedural 4D flow CMR for all patients revealed low velocities (Figure 1A) and a high ECAP index (Figure 2A) in the left atrial appendage, indicating flow stasis and an elevated risk of thrombus formation. Successful device implantation was performed in all cases, and no periprocedural complications were detected. Postprocedural 4D flow CMR was feasible in all cases, and no artifacts were detected despite the presence of the LAAO device. An objective increase in velocities and a decrease in the ECAP index were observed in all cases following LAAO. No DRT or ischemic events were reported during follow-up.

Conclusions

Our preliminary study demonstrates that 4D flow CMR provides valuable information on left atrial flow dynamics following the LAAO procedure. Further studies are warranted to evaluate this promising technique.Table 1.Patient characteristicsFigure 1 and 2.Representative example
Cognitive behavioral therapy for symptomatic paroxysmal atrial fibrillation: effects on physical activity, sleep and heart rate variability
Authors: Skuladottir H , Sarnholm J , Hoppe K , Olafsdottir E , Ljotsson B , Braunschweig F
Published: October 2024

Background

We have devised a novel psychological intervention, cognitive behavioral therapy for paroxysmal atrial fibrillation (AF-CBT), that targets symptom preoccupation and avoidance behaviour. AF-CBT significantly improved cardiac anxiety and quality of life (QoL) in a randomized trial. To what extent this may be attributed to changes in physiological parameters is yet to be determined.

Purpose

A) to assess changes in objective and subjective measures of physical activity and sleep. B) to evaluate potential treatment effects on heart rate variability (HRV).

Methods

Patients with paroxysmal AF on optimal medical therapy (65.4±8.3 years, 58% women) and European Heart Rhythm Association Symptom Score ≥2b were randomized to a 10-week therapist-led online AF-CBT (n=65) or a control group (n=62), with the primary outcome of Atrial Fibrillation Effect on Quality-of-life (AFEQT). A Patch-Holter with an integrated accelerometer was applied for five days at baseline, post-treatment, and at three months follow-up. Each recording was divided into day and night (sleep time) based on posture, heart rate, and activity. HRV was analysed in both time and frequency domains, excluding AF episodes and aberrant beats.

Results

AFEQT increased from 62.4±14.3 to 83.7± 13.8 points in the AF-CBT group at the 3-month follow-up with a relative difference of 15.0 points. At baseline, the participants walked 8040±2600 steps/day and slept 8.0 ± 1.1 hours. AF-CBT did not increase physical activity, and there were no significant changes in objective sleep duration. The Insomnia Severity Score went from subclinical (12.2±6.7) to near normal values (8.1±5.6), which was significant as compared to controls (p=0.032). AF burden increased from 5.3% to 7.3% in the AF-CBT group and 5.0% to 9.2% in the control group, with no difference between the groups (p=0.59). We did not observe any change in heart rate or HRV indices at rest during the day or at night.

Conclusion

AF-CBT did not mediate its effects on QoL by improving objective physiological variables. Thus, our findings underline the importance of subjective, psychological, and behavioural aspects and indicate that AF-CBT might fill a void beyond medical and lifestyle interventions in comprehensive AF care.
Effect of catheter ablation vs medical therapy on cardiovascular outcomes in hypertrophic cardiomyopathy with atrial fibrillation
Authors: Kim D , Yang P S , Jang E , Yu H T , Kim T H , Uhm J S , Pak H N , Lee M H , Sung J H , Joung B
Published: October 2024

Background

Atrial fibrillation (AF) increases the risks of stroke and mortality. AF ablation in patients with heart failure (HF) was associated with a lower risk of death and hospitalisation for worsening HF. Whether AF ablation is beneficial to improve cardiovascular outcomes in patients with concomitant hypertrophic cardiomyopathy (HCM) and AF remains unclear.

Objective

To investigate whether AF ablation is more effective than conventional medical therapy for improving outcomes in HCM.

Methods

2,281 patients with HCM and AF undergoing catheter ablation or medical therapy (antiarrhythmic drugs or rate control drugs) in 2005–2015 were identified from the Korean National Health Insurance Service database. The primary composite outcome of death from cardiovascular causes, ischaemic stroke, hospitalization for worsening HF, or acute myocardial infarction was compared between catheter ablation and medical therapy using propensity score overlap weighting. The time-at-risk was counted from the first medical therapy, and catheter ablation was analysed as a time-varying exposure.

Results

Of the included (41.1% female; median age: 66 years), 145 (6.1%) underwent catheter ablation for AF during the study period. During a mean follow-up of 3.1 (IQR 1.3–5.8) years, a total of 831 composite outcomes occurred including 292 cardiovascular deaths and 401 strokes. Catheter ablation, compared with medical therapy, was associated with lower risks of the primary composite outcome (weighted incidence rate: 3.84 vs. 6.43 per 100 person-years; weighted HR 0.61, 95% CI 0.38–0.96) and ischaemic stroke (weighted HR 0.43, 95% CI 0.19–0.97). The association between ablation and a lower risk of composite outcome was more pronounced in cases of ablation success whereas no significant difference was observed in cases of ablation failure.

Conclusions

In patients with AF and HCM, catheter ablation was associated with a lower risk of adverse cardiovascular outcomes than medical therapy.
Novel approach of slow pathway ablation in common atrioventricular nodal reentrant tachycardia by peak frequency map
Authors: Takahashi M , Sasaki T , Yamaoka K , Kujiraoka H , Arai T , Hojo R , Fukamizu S
Published: October 2024

Background

It is difficult to visualize slow pathway in atrioventricular nodal reentrant tachycardia (AVNRT) even with recent high-density mapping. This could be because the slow pathway potential is buried by the potential of atrial working cells during sinus rhythm and tachycardia. In other words, it is extremely difficult for conventional 3D mapping systems to annotate slow pathway potential even though the histological run of slow pathway is known .[1], [2]

Purpose

The purpose of this study is to visualize the atrial myocardial junction of rightward inferior extension by the peak frequency map of Ensite X in common AVNRT and to evaluate whether relative high frequency (HF) sites in low voltage area extending from Koch's triangle to tricuspid annulus (TA) is effective targets of slow pathway ablation and the characteristics of junctional rhythm (JR) after radiofrequency application.

Methods

This study is single-center prospective cohort study. In 37 consecutive common AVNRT patients, novel approach and conventional approach of slow pathway ablation were performed in 17 and 20 patients, respectively. The conventional approach is anatomical and electrophysiological approach. Peak frequency map was performed during sinus rhythm with HD-grid catheter in novel approach patients. A frequency scanning is performed to locate relative HF sites on the tricuspid annulus. Radiofrequencey application is 30 W, 30-60 sec, and the end point was no inducibility or until one echo under load of isoproterenol.

Results

The success rate was 100 % with two approaches. The relative HF sites in low voltage area were distributed at the TA side from 4 to 5 o'clock in all novel approach patients, mean peak frequency in success site was 419 ± 87 Hz. The distance to His bundle from success site was farther (24.8 ± 4.9 vs. 12.8 ± 4.4 mm, p<0.001), JR was slower (93 ± 14 vs. 118 ± 10 bpm, p=0.013), time to JR occurrence was shorter (3.0 ± 1.3 vs. 7.6 ± 4.6 sec, p=0.003), and elimination rate of jump up (78 % vs. 40 %, p=0.06) was higher in novel approach.

Conclusions

The relative HF sites in low voltage area at TA side from 4 to 5 o'clock by peak frequency map could be novel target of slow pathway ablation with high success rate and sufficient safety and efficiency.peak frequency map
Importance of the left superior ganglionated plexus ablation for the denervation of atrioventricular node: the impact of patient gender and bradycardia phenotype
Authors: Wichterle D , Stiavnicky P , Jansova H , Peichl P , Stojadinovic P , Haskova J , Borisincova E , Cihak R , Kautzner J
Published: October 2024

Background

Cardioneuroablation has been proposed as a new therapeutic option in selected patients with symptomatic functional bradyarrhythmia including recurrent neurally-mediated syncope. The contribution of individual ganglionated plexi to cardiac autonomic regulations is not fully established.

Purpose

It appears that ablation of the left superior ganglionated plexus (LSGP) is inoperable for the denervation of the sinoatrial node (SAN) and infrequently required for the denervation of the atrioventricular node (AVN). We explored the conditions that are associated with the need for LSGP ablation.

Methods

The study included 177 otherwise healthy patients aged 41 ± 12 years; 55% of males; 36% with predominant AVN disorder (29% in males, 44% in females, P <0.05) who underwent their first cardioneuroablation for symptomatic bradyarrhythmias at our centre between 2019 – 2024. Anatomically-navigated radiofrequency ablation with a bi-atrial approach was performed. In all patients, we ablated first the superior paraseptal (former right superior) ganglionated plexus (SPSGP) and inferior paraseptal (former posteromedial left) ganglionated plexus (IPSGP). Extracardiac vagus nerve stimulation (ECVS) via right and left jugular vein in general anaesthesia was used to assess the residual parasympathetic modulation of the AVN. If AVN was not completely denervated after the SPSGP and IPSGP ablation, the LSGP was targeted.

Results

Ablation of SPSGP and IPSGP resulted in SAN and AVN denervation in the majority of patients. LSGP ablation was required in 39 / 177 (22%) patients; in 31% of females vs. 14% of males (P <0.01); in 41% vs. 12% (P <0.0001) of patients with predominant AVN vs. SAN disorder, respectively. The corresponding decomposition is provided in the Table. In multivariate analysis, both female gender (P <0.05) and AVN disorder (P <0.001) were independently associated with the need for LSGP ablation. When the population was dichotomized into early (September 2019 – December 2021) and recent period (January 2022 – February 2024), the need for LSGP ablation had a downward trend (28% vs. 16%, P <0.05).

Conclusions

LSGP ablation to finalize the AVN denervation is required in a minority of patients. This need is independently associated with the female gender and predominant AVN disorder. The ECVS guidance in the ablation of SPSGP and IPSGP contributes to the decreasing trend of LSGP ablation, i.e. minimizing the final lesion set.Rate of LSGP ablation
Diabetes and sudden cardiac death in a nationwide, unselected population
Authors: Skjelbred T , Lynge T H , Winkel B G , Tfelt-Hansen J
Published: October 2024

Background and purpose

Sudden cardiac death (SCD) remains a prominent cause of mortality, with individuals afflicted by diabetes mellitus (DM) bearing a heightened risk of ventricular arrhythmias and SCD. However, comprehensive investigations in a nationwide, unselected context are lacking. Therefore, this study aimed to compare the incidence rates (IR) of SCD among individuals with Type 1 Diabetes Mellitus (T1DM) and Type 2 Diabetes Mellitus (T2DM) to the general population.

Methods

The study included the entire Danish population (approximately 5.5 million individuals) in 2010. SCD cases were identified through the detailed Danish death certificates and discharge summaries, yielding 6851 cases of SCD. The Danish Register of Medicinal Product Statistics, containing comprehensive prescription data from Danish pharmacies, facilitated the identification of individuals with T1DM and T2DM. Loss of life years was estimated for both T1DM and T2DM patients.

Results

Among the identified 6851 SCD cases, 272 (4%) were diagnosed with T1DM, and 833 (12%) with T2DM. Incidence rates of SCD were consistently elevated across all age groups for individuals with diabetes, compared to the general population (Figure 1). Patients with T1DM exhibited higher incidence rates than patients with T2DM (Figure 1). Notably, individuals aged 30-40 years with DM showed the greatest differences in incidence rates of SCD compared to the general population, with incidence rate ratios of 20.0 (95% confidence interval: 11.8-80.0) and 5.6 (95% confidence interval: 2.7-14.0) for T1DM and T2DM, respectively. On average, each 30-year-old patient with either T1DM or T2DM experiences a reduction of 3.7 and 3 life-years, respectively, due to the increased risk of SCD in these groups (Figure 2).

Conclusion

This nationwide study examines the incidence rates of SCD among individuals with and without a history of DM across all age brackets. Notably, patients with DM display consistently elevated incidence rates across age groups, with a particularly pronounced risk observed in those with T1DM. For both T1DM and T2DM, SCD is an important contributing factor to their shorter life expectancy compared to the general population. The heightened risk among individuals with DM underscores the importance of improved risk stratification for these patients.Incidence rates of SCDStacked cumulative incidence curves
3D target definition and initial results from the electroanatomic substrate-guided stereotactic ablative radiotherapy for refractory ventricular tachycardia (ELSTAR-VT)
Authors: Kaya Y S , Stoks J , Hazelaar C , Elmpt W , Gommers S , Cluitmans M J M , Dilling-Boer D , De Ruysscher D K M , Verhoeven K , Volders P G A , Ter Bekke R M A
Published: October 2024

Background/introduction

Noninvasive stereotactic radiotherapy (STAR) is an emerging transmural ablative therapy for refractory ventricular tachycardia (VT). Delineation of the arrhythmogenic gross target volume (GTV) relies on electrical (exit and isthmus) VT characteristics and anatomical scar detailing. 17-AHA segmental approaches or eyeballing techniques are adopted to transfer the GTV to the treatment planning CT. An individualized 3D GTV delineated with ADAS3D based on the areas of interest of each modality could lead to a smaller GTV compared to 17-AHA segmental approaches.

Purpose

We investigated whether our workflow using ADAS3D for the delineating of the GTV renders smaller GTV compared to 17-AHA segmental approaches whilst remaining effective for VT treatment during follow-up.

Methods

We targeted 3D-personalized GTV with STAR in patients with refractory VT in structural heart disease. Electroanatomical detailing was achieved by combining high-resolution invasive and noninvasive (ECG imaging during noninvasive programmed stimulation) mapping, combined with wall thickness analyses by cardiac CT. After coregistration in ADAS3D, a 3D DICOM-radiation therapy file including the delineated target volume was generated and transferred into the free-breathing and respiration-corrected 4D CT scan. Standard STAR using a single-fraction of 20-25 Gy was applied. We compared conventional (17-AHA segmental approaches) versus 3D-based GTV demarcation, and assessed VT burden and procedural safety.

Results

From January 2023 to February 2024 STAR was successfully performed in three patients (all male, mean age 73±1 years, two ischemic cardiomyopathy, one laminopathy) with persistent VT despite ≥2 catheter-based (endocardial/epicardial) ablation procedures. The 3D-derived GTVs showed a statistical trend towards smaller volumes compared to conventional segmental delineation (11±4 versus 21±3 cm3, p=0.07). VT burden and ICD therapy was reduced by 100% over 9 patients-months (8-week blanking period). No acute or subacute adverse events occurred. One patient died of progressive heart failure.

Conclusion

3D-individualized target volume annotation may hold promise for effective and safe STAR employment.ELSTAR workflow
Neutrophil extracellular traps are an important component of chronic myocardial inflammation in patients with heart failure
Authors: Costin S , Krizanic F , Richter M , Ritter O , Pagonas N
Published: October 2024

Background and aim

We have previously shown that heart failure (HF) is characterized by chronic inflammation. However, the role of neutrophils (N) and extracellular neutrophil traps (NETs) in the myocardium of patients with HF is largely unknown. The present study investigated the number of neutrophils (N) and their proportion that develop NETs in HF.

Methods

We used quantitative confocal microscopy and NETs markers in the left ventricular biopsies obtained from 5 controls and from patients with HF due to dilated (DCM, n=7), ischemic (ICM, n=7) and inflammatory (infCMP, n=7) cardiomyopathy. We used immunolabeling for CD45 (N) and for NETs (citrullinated histone 3 (CitH3), peptidylarginine deiminase-4 (PAD-4), neutrophil elastase (NE) and myeoloperoxidase (MPO).

Results

Compared to the control, the number of N was 4.3-5.7 times higher in HF. Using single labeling for NETs marker revealed that 41.1±4.6% of N in DCM, 42.9±4.1% in ICM and 47.6±2.9% in infCMP developed NETs. The use of dual labeling (MPO with CitH3, MPO with PAD-4 and CitH3 with NE) resulted in 54.5±4.7% of N-developing NETs in DCM, 59.5±4.1% in ICM and 77.6%±4.2 in infCMP. The difference between N-undergoing NETs was statistically different in infCMP than in DCM.and ICM. The proportion of N-forming NETs in control tissue was less than 5% and was significantly different from that in HF patients regardless of etiology.

Conclusions

This is the first study to show the presence of NETs in human hearts in situ and demonstrates that NETs are an important component of chronic inflammation in HF due to cardiomyopathies.
Effect of exogenous ketone supplementation on cardiac energetics, function, and perfusion in type 2 diabetes, heart failure, and healthy participants- A single center, open labelled clinical study
Authors: Kotha S , Procter H , Giannoudi M , Plein S , Xue H , Valkovic L , Kellman P , Greenwood J P , Clarke K , Levelt E
Published: October 2024

Background

Type 2 diabetes (T2D) confers loss of cardiac metabolic flexibility in fuel selection and impaired mitochondrial function. Enhanced ketone metabolism observed in T2D may represent a compensatory adaptive mechanism as ketones are a more energy efficient resource than carbohydrates or fatty acids. Favorable energetic properties of ketones may potentially mitigate the energy starved state in T2D and heart failure (HF).

Purpose

To test whether exogenous oral ketone supplementation would reverse cardiac energetic deficit, as well as improve cardiac function and perfusion in patients with T2D, with HF with reduced ejection fraction (HFrEF), and healthy volunteers (HV).

Methods

Three groups of patients were recruited: patients with T2D (n=33); patients with HFrEF (n=29, 14 with T2D); and HVs(n=25). Participants underwent cardiovascular magnetic resonance and spectroscopy to assess left ventricular (LV) function, rest and dobutamine stress perfusion and energetics (phosphocreatine/adenosine triphosphate ratio[PCr/ATP]). After the initial visit, participants had an identical second visit following 2 weeks of oral ketone supplementation (30g daily).

Results

Participants were matched in age and sex distribution.

There were no significant differences in LV ejection fraction (LVEF) between T2D and HV groups with significantly lower LVEF in HFrEF group. Both the T2D group and the HFrEF group showed significant reductions in PCr/ATP ratio and the rest and stress GLS compared to the HV. The resting and dobutamine-stress myocardial blood flow (MBF) were only significantly reduced in patients with HFrEF compared to T2D and HV groups. Subgroup analyses of HFrEF group with and without T2D showed no significant differences in energetics, perfusion, or functional assessments.

Significant increase in PCr/ATP ratio was seen only in T2D group from baseline after 2 weeks of ketone supplementation (Visit-1:1.6[1.5,1.8] vs Visit-2:1.9[1.7,2.1]; P=0.01). This significant increment was not observed in HFrEF or HV groups. Two weeks of ketone supplementation was not associated with any significant changes in LVEF, GLS, rest or dobutamine-stress myocardial blood flow, or in myocardial lipid content (Table-1).

Conclusions

Short-term ketone supplementation is associated with isolated significant improvements in resting cardiac energetics in patients with T2D and preserved LVEF, without changes cardiac function or perfusion. In contrast to patients with T2D and preserved LVEF, short-term ketone supplementation does not lead to any significant improvements in energetics in patients with HFrEF suggesting loss of mitochondrial plasticity with transition to HFrEF. Moreover, healthy volunteers experience no further increments of myocardial energetics from the normal range values at baseline with ketone supplementation.
Age-predicted maximal heart rate reserve as an alternative prognostic parameter in patients with heart failure with preserved ejection fraction -insights from PURSUIT-HFpEF registry-
Authors: Okada M , Tanaka N , Iwakura K , Seo M , Hayashi R , Yano M , Nakagawa A , Nakagawa Y , Yamada T , Yasumura Y , Hikoso S , Okada K , Nakatani D , Sotomi Y , Sakata Y
Published: October 2024

Background

Heart rate reserve (HRR), a measure of chronotropic response, is a prognostic parameter in patients with heart failure with preserved ejection fraction (HFpEF). However, exercise testing and measuring maximum heart rate (HR) are sometimes difficult in patients with heart failure with preserved ejection fraction (HFpEF). Assessing age-predicted maximal HRR (APHRR), defined as the difference between the resting HR and the age-predicted maximum HR (220 - age), would be a simple alternative to HRR.

Purpose

To assess the impact of APHRR at discharge on prognosis in patients with HFpEF.

Methods

An analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 1231 patients hospitalized for acute heart failure (diagnosed by using Framingham criteria) met the inclusion criteria: a left ventricular ejection fraction ≥50% and brain natriuretic peptide level ≥100 pg/ml. Excluding patients with permanent pacemakers, we enrolled 918 patients (age, 81 ± 9 years; men, 45%; atrial fibrillation, 38%) whose follow-up data after survival discharge were available.

Results

There was a moderate correlation between HR (median 69, interquartile range [IQR] 61-79 beats per minute [bpm]) and APHRR at discharge (71, 59-81 bpm) (r² = 0.68, p <0.001). During the median follow-up period of 23.8 months [IQR, 12.5-36.3] after discharge, 267 patients (15.4%) died, and the mortality rates incrementally decreased according to the APHRR quartiles (Q1, 44.6%; Q2, 26.6%; Q3, 26.2%; Q4, 18.4%; p <0.001). Cox regression analysis revealed that both the resting HR (hazard ratio per quartile increase, 1.16; 95% confidence interval, 1.04-1.30, p = 0.008) and APHRR (0.67; 0.60-0.75, p <0.001) were associated with mortality. However, the diagnostic accuracy was significantly superior in the APHRR than in resting HR (area under the curve; 0.628 vs. 0.552, p <0.001).

Conclusions

Assessment of the APHRR at discharge was a simple and useful method for risk stratification of patients with HFpEF. An incremental favorable prognosis indicated the prognostic importance of having a functional reserve during physiologic stress.