bluuebunny/crossref_metadata_2025 huggingface dataset:
Single-center outcome after ablation of atrial fibrillation using very high-power short duration pulmonary vein isolation
Authors: Rohrer U , Manninger M , Reischl A , Eberl A S , Kurath-Koller S , Andrecs L , Thonhofer N , Magg C , Zirlik A , Scherr D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation of atrial fibrillation is (AF) an established second line therapy for patients with symptomatic paroxysmal (PAF) and persistent AF (persAF). Novel ablation catheters with integrated thermocouples allow fast application of radiofrequency lesions with powers up to 90W.

We aimed to describe primary and secondary outcomes after very high-power short duration (vHPSD) ablation.

Methods

201 consecutive patients (127 PAF, 68 persAF, 6 longstanding persistent AF) underwent pulmonary vein isolation (PVI) using the QDOT Micro Catheter (Biosense Webster) with the ablation mode QMODE+ (90W, 4s, interlesion distance ≤4mm anterior, ≤6mm posterior).

Results

Mean age was 62±10 years, 38% were female, median CHA2DS2-VASc Score was 2 (0, 7). Median follow up duration was 196 (30, 461) days. 35% of patients had additional ablation of typical right atrial flutter.

Primary success rate to achieve pulmonary vein isolation was achieved in all patients, no catheter-related complications (e.g., charring, steam pop) occurred. First pass isolation of all 4 PVs was achieved in 53% of patients, re-ablations were necessary in the carina regions (right: 27% of cases, left: 20%), 34% at multiple regions including the ridge, 12% in other regions around the PVs. Median procedure for PVI only were 110 (36-344) minutes.

Arrhythmia-free survival was 79,3%. 21 patients underwent re-do procedures during follow-up showing most commonly showing gaps in the right PVs (RSPV 52%, RIPV 43%), the left inferior PV (48%), as well as the LSPV (38%) and the ridge (24%); with 91% of patients with recurrence showing more than one site reconnected.

Conclusion

Very high-power short duration ablation allows safe and quick pulmonary vein isolation. However, first pass isolation rate is low due to gaps in the carina regions. Arrhythmia-free survival is comparable to other pulmonary vein isolation techniques.
Clinical introduction of ultrasound-guided vascular access in catheter ablation of left atrial arrhythmias
Authors: Krimphoff A , Bordignon S , Chen S , Thohoku S , Urbanek L , Schaack D , Chun K R J , Schmidt B
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Vascular complications are a common occurrence during atrial fibrillation ablation. Observational studies show that the incidence of vascular complications can be reduced by using ultrasound (US)-guided puncture, however its routine use is not established in many centers.

Purpose

To compare the rate of vascular complications between ultrasound-guided and conventional anatomic landmark-guided vascular access during catheter ablation of left atrial arrhythmias.

Methods

Patients undergoing catheter ablation for atrial fibrillation were included sequentially. All patients receiving US-guided puncture were prospectively enrolled group A, while patients who underwent the procedure with standard puncture technique served as control group B. The primary endpoint were periprocedural vascular complications requiring intervention within 30 days of the procedure

Results

599 patients (average age: 68 ± 11 years, 63,1% male) were analyzed, 299 in group A and 300 in group B. Demographic and clinical baseline characteristics were comparable between the two groups, except higher prevalence of pre-existing Diabetes mellitus in group A (14,7% vs. group B: 8,7%, p=0.022). The majority of patients were treated with radiofrequency ablation (51,5%), followed by pulsed-field ablation (20,4%) and cryoballoon (18,7%). Other ablation techniques were laserballoon and radiofrequency balloon ablation.

The overall rate of vascular complications was lower with the ultrasound-guided puncture than the anatomic landmark-guided puncture (14/299 4,7% vs. 27/300 9%, p=0.036). The ultrasound-guided puncture resulted in a significantly reduced rate of false aneurysms (3/299 1% vs. 12/300 4%, p=0.019). In addition, arteriovenous fistula (2/0,7% vs. 4/1,3%, p=0.414) and hematoma requiring treatment (9/299 3% vs. 11/300 3,7%, p=0.655) were also lower in group A.

Conclusion

The use of ultrasound-guided vascular access for catheter ablation resulted in a significant reduction of the overall vascular complication rate.
Incidence, types and predictors of AF recurrence after AF ablation with pulsed field ablation. A single-centre experience
Authors: Eberl A , Manninger M , Rohrer U , Zweiker D , Reischl A , Kurath-Koller S , Benedikt M , Bisping E , Lercher P , Zirlik A , Scherr D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed field ablation (PFA) is an emerging method for atrial fibrillation (AF) ablation. However, there is little data about incidence, types, and predictors of AF recurrences after PFA for AF ablation.

Methods

We report our single-centre experience with PFA for AF ablation. Each procedure was performed under unconscious sedation with propofol and fentanyl. If needed, midazolam was added in rare cases. Fifteen minutes before transeptal puncture 70IU/kg of unfractionated heparin were administered, for an ACT level >300sec during the entire procedure. Isolation of pulmonary veins was started after administration of 1mg of atropine with 8 applications per vein (4 in basket, 4 in flower configuration). Afterwards all veins were checked for entrance- and exitblock to confirm isolation during SR. If needed, additional ablation was performed.

Results

In total, 124 patients undergoing AF ablation therapy with PFA between June 2021 to October 2022 were analysed. Mean age was 61±9 years, 39% were female. Mean CHADS-VASc Score was 2±1. Sixty-two percent had paroxysmal atrial fibrillation (PAF), 34% persistent AF, in 4% patients suffered from long standing persistent AF.

In 85% (n=106) of procedures first pass isolation of all veins was possible. Primary success to achieve PV isolation was accomplished in all patients at the end of procedure. In addition to PVI, in 6,5% of patients cavotricuspid isthmus (CTI) was blocked, in another 7,3% the posterior wall was isolated during the first procedure. Mean procedure duration was 76±30 minutes, mean x-ray time 11±22 minutes.

During 124 procedures, only one periprocedural complication was documented (vascular complication).

Eighteen patients (14,5%) had recurrence of dysrhythmia after a blanking period of 3 months after a mean follow-up period of 167±150 days. Mean time to recurrence was 108±101 days. Patients with recurrences after the blanking period suffered significantly more often from diabetes (OR 0,21 (0,089-0,495); p>0.01) and hyperlipidaemia (OR: 0,198 (0,070-0,498); p>0.01).

Until now we performed five re-do procedures of patients with recurrence of dysrhythmia after a PFA first-do procedure. The recurrent arrhythmia was AF (n=2), atypical AT (roof-dependent n=1, one mitral isthmus dependent n=1), and CTI-dependent flutter (n=1). All five patients had PV reconnections, and all could be successfully reablated.

Conclusion

AF ablation with PFA is associated with high SR success rate, and acceptable procedure duration and complication rates. Randomized studies are needed to further evaluate this new method compared with other ablation techniques.
Efficacy of functional substrate map-guide approach for wide circumferential pulmonary vein isolation
Authors: Kobori A , Ishikura M , Sasaki Y , Furukawa Y
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) with anatomical approach targeting closer interlesion distance (ILD) would be effective, but not efficient. A functional substrate map (FSM) can reveal the unnecessary application site including physiological block and the critical ablation site including direct epicardial connections.

Purpose

We investigated the efficacy of FSM-guide approach for wide circumferential PVI.

Methods

We enrolled 55 consecutive patients underwent radiofrequency PVI for atrial fibrillation. In earlier 27 patients were ablated by anatomical approach with closer ILD (<5mm) (control group), in latter 28 patients were by real time PV electrogram and high density electro-anatomical map guide (FSM-guide group). In FSM-guide group, characteristics of electrical conduction including voltage, direction , velocity and barrier between PV and left atrium and epicardial connection were assessed by local activation, coherent and ripple map before ablation. Distributions of the segments required or unnecessary ablation for PVI completion were examined.

Results

The success rate of first-pass isolation was higher in FSM-guide group than in control (96.4% vs. 74.1%). The number of required ablation tags for PVI were significantly lesser in FSM-guide group than control group (left-sided PV (LPV); 23.2±1.6 vs. 29.2±1.6, p=0.0112, right-sided PV (RPV); 22.6±1.7 vs. 32.4±1.8, p=0.0124, respectively). The time for PVI completion was significantly shorter in FSM-guide group than control group (RPV; 17.0±2.2 min vs. 25.2±2.8 min, p=0.0124, LPV; 18.7±1.5 min vs. 20.5±1.5 min, p=0.042, respectively). In FSM-guide group, unnecessary application sites were frequently located at posterior of RIPV (46%), anterior of LIPV (43%) and anterior of RSPV (35.7%). Frequently required segments for PVI completion were roof and carina of LPV and roof and posterior of RPV. In most cases of control group, full circumferential ablation was required (LPV 22/27(81%) and RPV 24/27(89%)). Acute reconnections during procedure were similar in FSM-guide group and control group (LPV; 6/28 (21.4%) vs. 4/27 (14.8%), p=0.7287, RPV; 9/28 (32.1%) vs. 4/27 (14.8%), p=0.2047, respectively). All of reconnection sites in FSM-guide group were ablated site.

Conclusions

FSM-guide approach for extensive PVI could reveal unnecessary application sites and result in shorter procedure with comparable ablation quality.
Sedation strategies for pulsed-field ablation of atrial fibrillation with monitored anesthesia care versus general anesthesia: a single-center experience
Authors: Carboni L , Casella M , Malacrida M , Iovinella A , Cipolletta L , Procicchiani L , Fori S , Masci F , Volpato G , Compagnucci P , Enrico R , Parisi Q , Natale A , Munch C , Dello Russo A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial Fibrillation (AF) ablation has been performed successfully under different methods of anesthesia and varies between centers, from general anaesthesia (GA) to conscious sedation. Recently, a novel pulsed-field ablation (PFA, Farapulse) technology based on non-thermal ablation has become available for clinical use. To date, no structured sedation strategy has been implemented for this specific energy source.

Purpose

We sought to compare a GA protocol and a monitored anesthesia care (MAC) protocol used at a high-volume center, with special consideration on efficiency and optimization of mapping and ablation conditions.

Methods

All consecutive patients (pts) undergoing AF ablation with PFA at our center were included. Briefly, PFA was delivered by a protocol-directed PVI using 2kV with eight applications per vein, that is, four applications each in the basket and flower poses. The choice of anesthesia’s protocol depends on the preference and experience of operator and general conditions of the patient. The MAC protocol includes propofol as only anesthetic agent and analgesia with fentanyl. The GA protocol include propofol and sevofluorane as anesthetic agents and fentanyl and remifentanyl for analgesia. Anesthesia related complications (hypotension and hemodinamic instability, respiratory complications, postoperative nausea and vomit) operative pain, chest movements, operator and patient satisfaction have been reported. Data are reported as mean±DS.

Results

Thirty-six pts were included in this analysis, 28 (78%) indicated for ablation of paroxysmal AF and 8 (22%) of persistent AF. MAC protocol was applied in 16 (44%) procedures and GA protocol in 30 (56%) procedures. No differences were found in terms of procedural and management parameters according with these two strategies, that is MAC vs GA: 114±28min vs 121±19min for lab occupancy time, p=0.3521; 66±14min vs 81±25min for total support time, p=0.0683; 63±9min vs 63±18min for skin-to-skin time, p=0.3887; and 19±6min vs 20±5min for fluoroscopy time, p=0.3313, respectively). No major procedure-related adverse events were reported. Operative pain and chest movements were less in GA protocol, operator satisfaction was greater in GA protocol. No significant differences in post-operative nausea and vomit and patient satisfaction were found.

Conclusion

The adoption of a structured workflow with proper perioperative assessment during pulsed-field ablation of AF, both general anesthesia and monitored anesthesia care showed similar efficacy and safety profile.
Impact of left atrial CT-angiography prior cryoballoon pulmonary vein isolation on procedural characteristics and outcomes
Authors: Kassa K , Kiss M , Simkovits D , Nagy Z S , Som Z , Foldesi C S , Kardos A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon (CB) ablation for pulmonary vein isolation (PVI) is a frequently performed procedure for rhythm control therapy in atrial fibrillation (AF). However, there is limited data on the impact of preprocedural computed tomography (CT) imaging on procedural characteristics and outcomes.

Purpose

We aimed to determine whether the use of left atrial CT-angiography to guide CB ablation makes a difference on procedural outcomes by revealing left atrial (LA) anatomy and pulmonary vein (PV) characteristics.

Methods

A total of 146 AF patiens (paroxismal: 58%, age: 62 ±11 years) undergoing CB ablation were randomized for conventional PVI (control group, n=74) and PVI following preoperative CT-angiography (CTA group, n=72). In the CTA group, LA and PV anatomical features were available during the procedure using 3-dimensional reconstruction images derived from an electroanatomical mapping system. A strategy of 240-second freeze time was used for each pulmonary vein with an option for extra freeze circles until PVI was achieved.

Results

Procedural time (51±13 min vs. 58±21 min, p<0.05), LA dwell time (41±11 min vs. 47±20 min, p<0.05) and fluoroscopy time (9±4 min vs. 11±5 min, p<0.05) were significantly shorter in the control group. Fluoroscopy dose (1892.4±1319.7 cGycm2 vs. 2216.6±2371.8 cGycm2, p=0.307) and 12-month success rates (control group: 61%; CTA group: 62%, p=0.835) were comparable. No major complications were observed.

Conclusions

The additional information on anatomy provided by left atrial CT angiography does not manifest in improved procedural characteristics or clinical outcome. Our findings do not support the routine use of preprocedural CTA for guidance of cryoballoon ablation.
Methods, efficacy and safety on routine clinical use of pulsed field ablation for pulmonary vein isolation in patients with atrial fibrillation
Authors: Neven K , Fueting A , Hartl S , Reinsch N
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (AF). It is also used as off-label therapy for persistent AF. Only a few small clinical studies have been published on the mid- and long-term outcome. We present data on methods, efficacy and safety on routine clinical use of pulsed field ablation for pulmonary vein isolation in patients with atrial fibrillation.

Methods

In patients with AF, PVI in conscious sedation using a steerable sheath and a pentaspline over-the-wire basket and flower PFA catheter was performed. In a subset of patients, pre- and post-ablation high-density bipolar voltage 3D maps using a pentaspline diagnostic catheter were performed. Procedural parameters, acute success and in-hospital safety were assessed.

Results

A total of 5 operators treated 304 patients (mean age 67 years (range 32-85), female 42%, mean BMI 28 kg/m2 (range 20-42), mean CHA2DS2-VaSc score of 2 (range 0-7), first-time ablation 100%, paroxysmal/persistent/longstanding persistent AF 47/17/36%, respectively. Mean duration since first AF diagnosis was 79 months (range 0-332). Most procedures were performed under deep conscious sedation using propofol and midazolam, without intubation (99%). Pre- and post-ablation high-density maps were performed in 27% of cases. Mean procedure time was 75 min. (range 23–245). Mean left atrial dwell time of the PFA catheter was 25 min. (range 8-98). Fluoroscopy time and dose area product were 18 min. (range 6-50) and 5,74 Gy.cm2 (range 0,40-36,50), respectively. Pulmonary vein isolation (PVI) was successful in 100%. There were no phrenic nerve palsies or esophageal complications. Major complications (2,6%) were pericardial tamponade (2,0%) and stroke (0,7%); one of these strokes was lethal (0,3%). Minor complications (1,0%) were vascular access related (0,7%) and transient ischemic attack (TIA) (0,3%).

Conclusions

In a large, single center cohort of unselected patients, initial experience with de novo PFA for PVI in patients with AF seems to be fast and effective. There were no PFA-specific complications, but the frequency of catheter complications (tamponade, stroke) in this relatively old patient population with a relatively long history of AF demonstrates that there is still room for improvement. The number of complications improved significantly over the course of time, indicating that the learning curve could have negatively influenced the incidence of complications.
Association of clinical characteristics and biomarkers with recurrent atrial fibrillation after hybrid ablation
Authors: Velt M J H , Magni F T , Blaauw Y , Mariani M A , Klinkenberg T J , Rienstra M , Mulder B A
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Atrial fibrillation ablation research at our institution was supported by an unrestricted grant from AtriCure.

Background

Hybrid ablation is an alternative treatment for both persisting and therapy-resistant, symptomatic atrial fibrillation (AF), combining the strengths of endocardial catheter and epicardial surgical ablation. Although results exhibit lower rates of recurrence and higher reduction of AF burden, there is a considerable risk of procedure-related complications. Therefore, the identification of patient groups who benefit most of this procedure can help in pre-procedural selection and tailoring of optimal therapy post-ablation.

Purpose

This study aimed to identify clinical factors and blood biomarkers associated with recurrence of AF within 1 year post-ablation.

Methods

A total of 96 consecutive patients undergoing hybrid ablation between January 2015 and December 2018 in a tertiary care center were enrolled. Blood samples were collected pre-ablation. Seven biomarkers [Bone Morphogenetic Protein 10 (BMP10), angiopoietin-2 (ANG2), Dickkopf WNT Signaling Pathway Inhibitor 3 (DKK3), Endothelial Cell Specific Molecule 1 (ESM1), Fibroblast Growth Factor 23 (FGF23), Insulin Like Growth Factor Binding Protein 7 (IGFBP7) and total N-terminal pro b-type natriuretic peptide (NT-proBNP)] were assayed at Roche Diagnostics based on their possible association with recurrence of AF. Clinical follow-up visits combined with 12-lead ECG and 24-hour Holter monitoring were scheduled at 3, 6 and 12 months post-procedure. Cox proportional hazards regression models were used to study the association with recurrence of AF.

Results

Out of the 96 patients (mean age 58±8 years; 18% women), 17 (17.7%) developed recurrence of AF within 1 year post-ablation. Median time to diagnosis was 191 days (range: 92-344). Comparisons between patients with and without recurrence of AF are depicted in Table 1. Multivariable Cox proportional hazard regression, adjusted for sex, showed that older age (HR 1.104, 95% CI 1.003-1.215, p=0.043), type of AF (HR 0.322, 95% CI 0.117-0.886, p=0.028), a history of peripheral vascular disease (HR 13.84, 95% CI 3.13-61.14, p<0.001) and recurrence in the blanking period (HR 14.25, 95% CI 3.99-50.85, p<0.001) were associated with recurrence of AF within 1 year post-ablation, but no blood biomarkers (Figure 1).

Conclusion

In AF patients undergoing extensive ablation, older age, type of AF, a history of peripheral vascular disease and recurrence in the blanking period were determinants of AF recurrence within 1 year post-ablation.
Morphology-Voltage-P-wave-duration (MVP) score to select patients for continuous atrial fibrillation screening to prevent stroke
Authors: Xing L Y , Diederichsen S Z , Hojberg S , Krieger D W , Graff C , Olesen M S , Nielsen J B , Brandes A , Kober L , Haugan K J , Svendsen J H
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The LOOP Study was funded by Innovation Fund Denmark [grant number 12-1352259], The Research Foundation for the Capital Region of Denmark, The Danish Heart Foundation [grant number 11-04-R83-A3363-22625], Aalborg University Talent Management Program, Arvid Nilssons Fond, Skibsreder Per Henriksen, R og Hustrus Fond, the European Union’s Horizon 2020 program [grant number 847770], Læge Sophus Carl Emil Friis og hustru Olga Doris Friis’ Legat, and an unrestricted grant from Medtronic.

Background

It is well known that atrial fibrillation (AF) confers a substantially increased risk of ischemic stroke, but data on health benefits from AF screening are scarce. The newly proposed MVP risk score combining the duration, voltage and morphology of P-wave has been demonstrated to be predictive of AF and might therefore also be useful in risk-stratifying individuals for AF screening and subsequent treatment.

Purpose

The present study sought to examine MVP risk score and its P-wave components for prediction of AF screening effects.

Methods

The LOOP Study randomized AF-naïve individuals aged 70-90 years with additional stroke risk factors to either continuous AF screening with implantable loop recorder (ILR) and subsequent anticoagulation initiation upon detection of AF episode ≥6 minutes, or usual care. In this secondary analysis, the LOOP participants with a baseline 12-lead electrocardiogram (ECG) suitable for P-wave measurement were included.

Results

Of 5759 participants included, 265 (4.6%) had had ischemic stroke during follow-up: 213 (4.9%) of 4311 in the control group versus 64 (3.6%) of 1448 in the ILR group. Among the participants in the control group, a significantly increased risk of ischemic stroke was observed for MVP score 5-6 versus score 0-2 (hazard ratio (HR) 1.66 [95% confidence interval (CI): 1.01-2.75]) and for the presence of interatrial block (IAB) versus no IAB (HR 1.85 [95% CI: 1.19-2.86]), whereas a P-wave voltage in lead I (PWVI) <100 µV was associated with risk reduction compared to higher voltage (HR 0.65 [95% CI: 0.45-0.93]). Further spline analysis revealed longer P-wave duration (PWD) to also be correlated with higher stroke risk (HR 1.49 [95% CI: 1.11-2.00] for >110 versus ≤110 ms). Compared with usual care, ILR screening did not significantly reduce the stroke risk regardless of MVP risk score, PWD, PWVI, or IAB pattern at baseline.

Conclusions

In an elderly population with additional stroke risk factors, both the P-wave parameters and the combined MVP risk score based on 12-lead ECG were associated with ischemic stroke, but these did not successfully demonstrate an association with effects of AF screening on stroke prevention.
Racial differences in atrial fibrillation-related bleeding and mortality
Authors: Kang D S , Yang P S , Kim D H , Jang E S , Yu H T , Kim T H , Sung J H , Pak H N , Lee M H , Lip G Y , Joung B Y
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Adverse outcomes associated with atrial fibrillation (AF) in Asians have not yet been fully elucidated. This study was designed to study racial differences in the risk for bleeding and the effect of new-onset AF on bleeding and mortality.

Methods

This study is based on a patient-level comparative analysis of UK Biobank and Korean National Health Insurance Service-Health Screening data. The primary outcome was intracranial hemorrhage (ICH). The secondary outcomes were major bleeding and gastrointestinal (GI) bleeding. Five-year incidence rates (IR), rate difference (IR in those with AF minus IR in those without AF) and rate ratio (IR in those with AF divided by IR in those without AF) of the outcomes were calculated.

Results

Between 2005 and 2012, we identified 422,121 Asians (mean [SD] age, 55.1 [8.4] years; 54.2% of men) and 380,763 Whites (mean [SD] age, 57.1 [8.0] years; 45.1% of men). During the five-year follow-up period, the IR of AF per 1000 person-years were 2.29 (95% CI, 2.22–2.35) in Asians and 3.55 (95% CI, 3.46–3.63) in Whites. The IR of ICH was greater in Asians with and without AF than in corresponding White groups. The rate difference for ICH was 1.84 (95% CI, 1.18–2.51) in Asians and 0.80 (95% CI, 0.56–1.04) in Whites. For major bleeding, the IR of Asians were not only higher than those of Whites, but also the rate difference was 1.3-fold higher in Asians than in Whites. However, different tendencies were observed for GI bleeding.

Conclusion

Despite the higher incidence of AF in Whites, Asians with AF have a worse prognosis in terms of ICH and major bleeding. However, further studies are needed to explain the different trends of gastrointestinal bleeding.
Immune modulating drugs and oral anticoagulation in kidney transplant recipients: comparison of direct oral anticoagulants versus antagonist of vitamin-k. results from a multicenter prospective study
Authors: Santoro F , Casanova A , Simone S , Pellegrino P L , D'arienzo G , Brunetti N D , Pesce F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

direct oral anticoagulants (DOACs) are a well-known alternative to conventional antagonist of vitamin-K (avK) and have emerged as the preferred choice due to their safety and efficacy profile. However, immune modulating drugs as cyclosporine and tacrolimus, commonly used for transplant recipients, may interfere with DOACs.

Aim of this study: evaluate safety and efficacy profile of direct oral anticoagulants (DOACs) compared to warfarin in kidney transplant recipients (KTRs) treated with immune modulating agents.

Methods

a multi-center study from 4 Italian hospitals enrolling KTRs on DOACs or avK was carried out. Sixty-nine patients on DOACs were compared with fifty patients on avK with mean estimated glomerular filtrate rate (eGFR) > 45 mL/min. Clinical follow-up and serial evaluation of renal function and serum levels of immune modulating drugs during 24 months follow-up (FU) was performed.

Results

Mean age of DOACs patients was 67±9 and mean eGFR was57±20 mL/min. Immune-modulating therapy included tacrolimus (n=47, 71%), cyclosporin (n=13, 20%), everolimus (n=10, 7%) and sirolimus (n=4, 6%). There were no changes in Tacrolimus and Cyclosporin serum levels following 14 days therapy with DOACs (+0.5 ±2 and +28 ±31, p=0.52, 0.90, respectively) and only a patient treated with dabigatran 150 mg required a dose adjustment. Levels of Tacrolimus and cyclosporin were stable at serial evaluation during follow-up.

At long-term follow-up, there were no thromboembolic events among patients treated with DOACs or avK and no differences in term of mayor bleeding (5.8% vs 4% p=0.99). There was no difference in term of eGFR decline from start therapy to 24 months FU between DOACs or avK therapy (-3.9±1 vs -3.8±2 p=0.82) (FIGURE 1).

Conclusion

DOACs are a potential therapeutic option among patients with kidney transplant recipients treated with immune modulating drugs. Careful evaluation of immunomodulating agent levels during the first two week of therapy should be recommended. No difference in term of bleeding, renal function decline was found when comparing with avK therapy.
Prognostic value of chronic kidney disease in patients undergoing left atrial appendage occlusion
Authors: Della Rocca D , Magnocavallo M , Van Niekerk C , Gilhofer T , Ha G , D'ambrosio G , Galvin J , Urbanek L , Schmidt B , Geller J C , Mansour M , Saw J , Horton R P , Gibson D , Natale A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist and share an increased risk of thromboembolic events. CKD concomitantly contributes to several pathophysiological changes predisposing towards a pro-haemorrhagic state.

Purpose

To evaluate the impact of kidney function on peri-procedural complications and clinical outcomes in AF patients undergoing left atrial appendage occlusion (LAAO) with a Watchman device.

Methods

2124 consecutive AF patients undergoing Watchman implantation at 8 different centers were categorized into CKD stage 1+2 (n=1089), CKD stage 3 (n=796), CKD stage 4 (n=170), CKD stage 5 (n=69) based on the estimated glomerular filtration rate at baseline. The primary efficacy endpoint included a composite of cardiovascular (CV) mortality, stroke, transient ischemic attack, peripheral thromboembolism (TE), and major bleeding.

Results

A non-significant higher incidence of major peri-procedural adverse events (1.7% vs. 2.3% vs. 4.1% vs. 4.3%) was observed with worsening baseline kidney function (p=0.14). The mean follow-up period was 13 ± 7 months [2226 patient-years (PY)]. In comparison to CKD stage 1+2 as a reference, the incidence of the primary endpoint was significantly higher in CKD stage 3 (log-rank p-value= 0.04), CKD stage 4 (log-rank p-value= 0.01), and CKD stage 5 (log-rank p-value= 0.001) (Fig.1A). A non-significant increase in event rates for stroke/TIA and clinically relevant bleeding was observed among the four groups. LAAO led to a TE risk reduction of 72%, 66%, 62%, and 41% in each group (Fig.1B). The relative risk reduction in the incidence of major bleeding was 58%, 44%, 51%, and 52%, respectively (Fig.1C).

Conclusion

Patients with moderate-to-severe CKD had a higher incidence of the primary composite endpoint. However, the relative risk reduction in the incidence of TE and major bleeding was consistent across CKD groups, irrespective of the very different risk profiles at baseline.
Healthcare utilization and outcomes in atrial fibrillation patients treated by drug therapy versus a catheter ablation strategy
Authors: Martinek M , Crijns H J G M , Essers B , Pruckner G J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background and Aims

Atrial fibrillation (AF) is the most prevalent arrhythmia, associated with increased mortality and morbidity and causing relevant costs. Treatment options consist of catheter ablation (PVI) and rate or rhythm control drugs (non-PVI).

Methods

We analyze inpatient and outpatient data from the Upper Austrian Health Insurance Fund. Data of patients with a first hospitalization for AF in the years 2005 to 2018 were examined, using propensity score matching (PSM) including all CHA2DS2-VASc variables and working collar.

Results

Out of 21,791 AF patients, PSM identified 1,013 well-matching pairs (PVI and non-PVI). Over a ten-year period, the PVI treatment strategy group reveals significantly higher inpatient and outpatient expenditures (€2,200/year). Positive economic effects can be demonstrated by a 5.1 percentage points (pp) higher employment rate and fewer retirements (7.6pp). Utmost important is the 5.8pp all-cause mortality reduction over 10 years in the PVI treatment strategy.

Conclusions

A PVI based treatment strategy results in higher healthcare expenditures vs. drug therapy alone. Most of these higher costs are caused by the PVI procedures during this period. Thus, more effective and efficient methods are needed to further reduce costs for the intervention and prevent repeat procedures. The benefit of a PVI treatment strategy is seen in higher employment rates, which is crucial from a societal perspective and should be a strong argument for caregivers. We show a significant reduction in all-cause mortality, which we partly attribute to the PVI procedure itself, to a stricter risk factor assessment and treatment, and a tighter medical adherence.
Spontaneous left-sided atypical flutter: revising the mechanisms in patients not submitted to prior linear ablation
Authors: Brito J , Valente Silva B , Alves Da Silva P , Nunes Ferreira A , Lima Da Silva G , Carpinteiro L , Ribeiro J , Cortez-Dias N , J Pinto F , Sousa J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

The decrease in the use of linear ablation for atrial fibrillation treatment has reduced the frequency of iatrogenic feft-sided atypical flutters (AFl). However, AFl are becoming increasingly frequent, associated with population age and risk factors for atrial scar. Revising the mechanisms of non-iatrogenic AFl may lead to a better procedure workflow.

Purpose

To describe the mechanisms of non-iatrogenic AFl.

Methods

Retrospective single-center study of AFl patients (pts) submitted high-density mapping from 2018 to 2022. Patients submitted to any prior left atrial linear ablation were excluded. Map collection was performed just visualizing the voltage map and a comprehensive workflow was applied for activation map interpretation, starting by facing the mitral annulus and following the sequence of colors to systematically identify all potential circuits, their common-isthmuses, and eventual slow-conduction sites. Entrainment maneuvers were performed to confirm the circuit interpretation if sinus rhythm was not restored with the completion of the planned ablation set.

Results

A total of 59 pts were included (male: 56% male; 67 ± 13 years), 28 previously submitted to atrial fibrillation ablation, restricted to pulmonary vein (PV) isolation. About 88% presented a macro-reentrant mechanism, either restricted to the left atrium (N=50) or biatrial (N=2) and involving 2 or 3 loops in 61% - Figure 1. Perimitral loop was the most frequent reentrant circuit, representing 60% of macro-reentrant arrhythmias (N=30) and exhibiting an evident out-of-proportion predominance of counterclockwise rotations (73% versus 27%). Among perimitral flutters with at least one additional loop, a balanced distribution was recognized of rotations around the left and right PVs (10 versus 10). As a result of the existence of additional loops producing common-isthmuses locations in various atrial regions, the classical inferior mitral isthmus line (from the mitral annulus to the left inferior PV) would only terminate as much as 53% of the perimitral AFl. The mechanism-tailored ablation strategy, particularly targeting the AFl common-isthmuses, resulted in restoration of sinus rhythm in 96.6% of pts (N=57).

Conclusions

In pts not previously submitted to linear ablations, AFl are predominantly caused by macro-reentrant circuits involving a perimitral rotation but not necessarily possible to treat with a conventional mitral isthmus line. With current high-density mapping tools, a comprehensive analysis of the substrate and activation maps and a mechanism-tailored ablation strategy results in an unprecedently high acute success rate.
Symptomatic intermittent ventricular pre-excitation in adult: a monocentric retrospective study
Authors: Robles A G , Palama' Z , Borrelli A , Borrelli A , Scara' A , De Luca L , Grieco D , De Ruvo E , Calo' L , Nesti M , Gianfrancesco D , Bartolomucci F , Penco M , Romano S , Sciarra L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Backgorund: Intermittent ventricular pre-excitation was considered a low-risk marker for sudden death. However, to date some studies do not exclude the existence of accessory pathways (APs) with high-risk intermittent antegrade conductive properties. High-risk features of APs are: ERP/SPERRI ≤250 msec (in basal or during adrenergic stimulus), inducibility of atrioventricular reciprocating tachycardias (AVRT), inducibility of pre-excited atrial fibrillation (AF), multiple APs. For these catheter ablation is recommended.

Purpose

The aim of this retrospective study was to evaluate the existence of a statistically significant difference in the risk characteristics between patients with intermittent pre-excitation (IPX) and with persistent pre-excitation (PPX), from a sample of adults with symptomatic ventricular pre-excitation (Wolff-Parkinson-White Syndrome).

Methods

Between August 2005 and December 2015, 293 adults (age ≥18 years) [males: 183 (62.5%)], without structural heart disease, with signs of ventricular pre-excitation and symptomatic for palpitations underwent an EP study [IPX: 51 (17.4%), males: 31 (60.8%); PPX: 242 (82.6%), males: 152 (62.8%)]. The APs were submitted to catheter ablation if EP study showed inducibility of arrhythmias (AVRT/AF) and, in case of non-inducibility of arrhythmias, if ERP ≤250 msec, in basal or during intravenous infusion of isoproterenol. Additionally, the presence of multiple accessory pathways was assessed during the test.

Results

The 2 groups of patients did not show statistically significant differences in age at the time of EP study [IPX: mean age 37.23±16.89 years Vs PPX: mean age 39.03±16.19 (P-value>0.05)] and gender (IPX male: 60.8% Vs PPX male: 62.8%; P-value>0.05). When measured, there were no statistically significant differences regarding ERP [IPX: mean ERP 260±45.8msec Vs PPX: mean ERP 267.7±59.6msec; P-value>0.05]. The inducibility of arrhythmias (AVRT/AF) was 59.3% in the IPX group (27 patients) vs 38% in the PPX group (92 patients), showing statistically significant differences (P-value<0.05). Multiple accessory pathways were found in 2 patients of the IPX group (3.9%), both females (100%), and in 6 patients of the PPX group (2.5%), of which 2 females (33.3%), not showing statistically significant differences (P-value>0.05).

Conclusion

In our study, patients with IPX did not shown statical significant differences in clinical and electrophysiological features Vs PPX partients. Thus, intermittent ventricular pre-excitation could not absolutely be considered a marker of lower arrhythmic risk.
Psychological stress in postural tachycardia syndrome: results of an online survey
Authors: Firth K , Fedorowski A , Daukantaite D , Hamrefors V
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Postural orthostatic tachycardia syndrome (POTS) is a chronic condition in which patients show a marked increase in heart rate on standing, but also suffer from a range of additional symptoms, which may include fatigue and unrefreshing sleep. A well accepted 10-item survey instrument, the Perceived Stress Scale (PSS; Cohen, et al., 1983), was used to investigate the levels of psychological stress experienced by POTS patients.

Methods

Sixty Swedish patients diagnosed with POTS at a tertiary investigation center were contacted by mail and a link was provided to respondents who signed the informed consent form. A 64-item, on-line survey was developed in five sections. One of the sections consisted of the ten items of the PSS scale. As an example, item three asks: "In the last month, how often have you felt nervous and ‘stressed’?". A five-point Likert scale is used with possible responses ranging from "never" to "very often". This study employed a previously translated Swedish language version, which has been validated in a sample of 3,406 respondents and showed good internal reliability (α =.84) and normative data for a Swedish population (Nordin & Nordin, 2013). Symptoms were measured using the orthostatic hypotension questionnaire (Kaufmann et al. 2012).

Results

Twenty-four POTS patients (22 female gender; mean age 35 years, SD = 8.4) completed the survey. The average age at onset of symptoms was 20 years and four months with patients waiting an average of nine years and five months for a POTS diagnosis. Scores for the PSS ranged from three to 35. The mean PSS score for this cohort was 19.38 (SD = 8.88). Fourteen respondents were in the moderate range for perceived stress (14 to 26), whilst five can be considered to have a low perception of stress and five a high perception. Patients with POTS had a statistically significant higher score for perceived stress (M = 19.38, SD = 8.88, p < .01) than the general population of Sweden (M = 13.96, SD = 5.63). However, there was no correlation between perceptions of stress and symptom severity measured by the orthostatic hypotension questionnaire.

Conclusions

Swedish POTS patients have higher levels of perceived stress, similar to other disease states such as chronic pain and multiple sclerosis (Table 1). However, this survey found no correlation between perceptions of stress and symptom severity.
Therapeutic options for syncope: a meta-analysis of trials with and without placebo control
Authors: Kaza N , Sorbini M , Johal M , Liu Z , Porter B , Nowbar A , Levy S , Dani M , Taraborelli P , Eardley P , Whinnett Z I , Francis D P , Shun-Shin M , Lim P B , Keene D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

8% of the population suffer recurrent episodes of syncope which can cause physical injury and psychological morbidity. The extent to which therapeutic options effectively reduce syncope recurrence beyond placebo remain unclear.

Methods

We performed a meta-analysis of randomised trials including pharmacological, cardiac pacing and physical interventions for syncope. We assessed the effect of these therapeutic interventions on clinical syncope recurrence. We stratified the trials by use of placebo control.

Results

There were 50 eligible trials: 22 pacing, 19 pharmacological and 9 of physical interventions including 3,975 patients.

Trials assessing syncope recurrence with placebo control were neutral for Beta-Blockers (RR 1.11, 95% CI 0.85 to 1.45, p=0.36), Fludrocortisone, (RR 0.83, 95% CI: 0.63 to 1.11 p=0.83) and conventional dual-chamber pacing (RR 0.81, 95% CI 0.61 to 1.09 p=0.287). However, they were favourable for Selective Serotonin Reuptake Inhibitors [SSRIs] (RR 0.40, 95% CI 0.25 to 0.63 p<0.001), Midodrine (RR 0.70, 95% CI 0.53 to 0.94, p=0.016) and Closed-Loop-Stimulation (CLS) pacing (RR 0.21, 95% CI 0.12 to 0.34, p < 0.001).

Non-placebo-controlled trials reported significant benefit for every category of therapy including conventional dual-chamber pacing, medicines (Beta-Blockers, Midodrine and Oral rehydration salts) and physical interventions including tilt-training.

Three categories of therapy have been trialled with and without placebo control: the non-placebo-controlled studies showed significantly different results from their placebo-controlled counterparts (beta-blockers p=0.024, midodrine p=0.006, dual-chamber pacing p=0.017) (figure 2).

Conclusion

Under placebo-controlled conditions, CLS pacing reduces risk of syncope recurrence by ~75%, whereas conventional pacing does not. SSRIs and midodrine also show significant efficacy under placebo-controlled conditions. Without placebo control, trials consistently show artefactually larger benefits. Future non-placebo-controlled trials for syncope should not be conducted.
Pharmacological inducibility of short-coupled Purkinje ectopy in patients with spontaneous short-coupled ventricular fibrillation
Authors: Laredo M , Duchateau J , Waintraub X , Gandjbakhch E , Marijon E , Lavergne T , Haissaguerre M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

In a subset of patients with idiopathic ventricular ﬁbrillation (IVF), the cause is identified as short-coupled premature ventricular complexes (ScPVCs), which mostly originate from Purkinje cells, and are often short-living and undetected. There is no consistent test allowing identification of patients vulnerable to this malignant arrhythmia. We aimed at evaluating sodium channel blocker (NaBl) testing in patients who survived IVF associated with SCPVCs.

Methods

We retrospectively reviewed data of 112 patients at 3 centers, with the diagnosis of IVF associated with spontaneous and documented scPVCs. No patient from the previous report was included. We analyzed all patients who underwent NaBl tests during evaluation of IVF. An arrhythmogenic NaB test was defined as the occurrence of ≥10 scPVCs and/or ≥ 1 repetitive form (couplet, triplet, run) during the test, without spontaneous scPVC at baseline. We defined scPVCs as an R-on-T pattern PVC. We evaluated the occurrence of scPVC during NaB infusion, the arrhythmia pattern and we compared the characteristics of the arrhythmogenic versus non-arrhythmogenic response groups. Data regarding anti-arrhythmic drug treatment and follow-up were collected at each center.

Results

In total, 48 patients were included (Table). The NaB tests were performed using ajmaline 1mg/kg/5 or 10min, or flecainide 2mg/kg/10min. Overall, an arrhythmogenic NaB test occurred in 23 of 48 (48%) patients. Isolated ScPVCs were observed in 11 patients, couplet/triplets in 10, and runs in 6. The arrhythmogenic response was reproduced in 5/5 patients who had a second NaB test during scPVC mapping before catheter ablation. There were no signiﬁcant differences between patients with arrhythmogenic or non-arrhythmogenic NaB tests in all baseline clinical variables tested including VF burden (Table). All patients were followed at least 1 year after initial diagnosis and NaB test. Under hydroquinidine (600 or 900mg/day), appropriate defibrillator shocks occurred in 7 of 8 patients with arrhythmogenic NaB test; whereas shocks occurred only in 2 of 11 patients with non-arrhythmogenic NaB test (P=0.02).

Conclusion

Sodium blockers unravel scPVCs in up to 50% of patients with IVF and may therefore represent a valuable tool to detect a potential cause for sudden cardiac death (SCD) or unexplained syncope. Additionally, the arrhythmogenic response to NaB may be associated with the success of hydroquinidine in preventing IVF recurrence, a finding that suggests the existence of distinct scPVCs phenotypes and that may have important therapeutic implications. Further functional and genetical investigations are warranted to explore the mechanisms underlying this association.
The use of cardiovascular modes of death in the office of national statistics mortality statistics
Authors: Westaby J , Gabrawi A M , Sheppard M N
Published: May 2023

Funding Acknowledgements: Type of funding sources: Other. Main funding source(s): Cardiac Risk in the Young

The office for national statistics (ONS) holds a record of all causes of death in England and Wales according to the International Classification of Diseases 10th Revision. In some cases, a mode of death, such as arrhythmia, may be given. We aimed to quantify the proportion of cardiovascular deaths being coded as a mechanism of death from the ONS.

We analysed the ONS records from 2013 – 2021. There were 4,852,897 deaths overall, of which, 836,741 (17.24%) were cardiovascular. Of these, 103,160 (12.33%) were labelled as mechanisms and 35,784 (4.28%) were nonspecific causes. The most common modes being used were arrhythmia (56,291 (6.7%)) and heart failure (46787 (5.6%)). The most common nonspecific codes being used were myocardial degeneration (12,192 (1.46%)), unascertained (10,605 (1.27%)) and cardiomegaly (6,573 (0.79%)).

Modes of death as opposed to causes of death are being used in a notable proportion of cardiac deaths and this is increasing. Modes of death do not aid in screening of blood relatives for inherited cardiac conditions. Causes should be listed as an underlying disease process such as ischaemic heart disease (IHD) or hypertrophic cardiomyopathy. This enables screening to be focussed on specific diseases. The use of a mode of death as opposed to a specific disease should prompt a referral for autopsy.

ICD-11 has coding for SADS and arrhythmogenic cardiomyopathy (ACM) and our findings highlight the importance of the transition to this update to allow accurate establishment of the burden of disease of these two important genetic conditions.