bluuebunny/crossref_metadata_2025 huggingface dataset:
Resolution of leaflet thrombosis under anticoagulant therapy in patients after transcatheter aortic valve implantation: influence of prosthesis type and size
Authors: Ferstl P , Arnold M , Goeller M , Ammon F , Smolka S , Moshage M , Uehlein S , Achenbach S , Marwan M , Bittner D.O
Published: November 2020

Introduction

Leaflet thrombosis can frequently be identified by computed tomography angiography (CTA) in patients after transcatheter aortic valve implantation (TAVI). Oral anticoagulation is assumed to lead to resolution of thrombosis. We analyzed the resolution of leaflet thrombosis after TAVI by anticoagulant therapy in serial CTA and assessed the influence of prosthesis type.

Methods

Consecutive TAVI patients who underwent CTA follow-up were screened and individuals with leaflet thrombosis on CTA (defined by the presence of hypo-attenuated leaflet thickening, HALT) in whom oral anticoagulation was initiated and who underwent follow-up CTA were included. The type of anticoagulation was according to physicians' discretion. We assessed the resolution of HALT and compared patients with and without resolution of HALT regarding prosthesis type, prosthesis diameter and type of anticoagulation.

Results

Out of 395 patients screened for participation, 36 patients (mean age 80±7, 67% men) with leaflet thrombosis underwent follow-up CTA at a medial interval of 3 months (IQR: 3; 5.75 months) after anticoagulation was initiated. 36 patients received either vitamin-K antagonists (n=28, 78%) or Factor-Xa Inhibitors (n=8, 22%). A total of 22 (61%) balloon-expandable and 14 (39%) self-expandable transcatheter aortic valves were implanted. Nominal prosthesis diameter was 23, 25, 26, 27 and 29 mm in 7 (19%), 1 (3%), 10 (28%), 7 (19%) and 11 (31%) patients, respectively. 30 patients (83%) with anticoagulation showed resolution of HALT, whereas persistent HALT was detected in 6 patients (17%), of whom 1 patient with balloon-expandable and 5 patients with self-expandable valve. No difference was seen in duration of anticoagulation between patients with and without resolution of HALT (p=0.984). In univariate analysis, prosthesis type (balloon-expandable vs. self-expandable valves) showed a significant association of self-expandable valves with lack of resolution of leaflet thrombosis (p=0.017). In multivariable logistic regression analysis, this association persisted (p=0.043) and was independent of the type of anticoagulation (p=0.660) and prosthesis diameter (p=0.942).

Conclusion

Persisting leaflet thrombosis despite anticoagulation is not infrequent and seems to be associated with prosthesis-type rather than small valve diameter or type of anticoagulation. Further research is necessary to identify structural aortic valve determinants for this finding.

Funding Acknowledgement

Type of funding source: None
Texture analysis of CINE CMR image in healthy volunteers-preliminary results
Authors: Tie P , Gandy S.J , Ross R.A , Houston J.G
Published: November 2020

Background

Texture analysis (TA) is a technique that measures the MRI signal via pixel greyscale variations (figure 1), and may be useful in cardiac MR (CMR) for detecting features not visible to the human eye.

Purpose

To use TA to examine myocardial CINE MR Images in a cohort of volunteers. Major feature differences were anticipated between images at end diastole (ED) and end systole (ES), whilst minor differences were anticipated between younger and older volunteers.

Methods

Two cohorts (each n=30) were studied - young (44±3 years), and old (68±4 years). A 2D ECG-gated breath-hold segmented steady-state gradient echo sequence was used. Myocardial TA features were derived using MaZda v4.7. Measurements were made by two observers.

Results

A total of 39 TA features were significantly different between ED and ES (p<0.05), and 9 features were significantly different between the young and old cohorts (p<0.05). Finally, 15 of the original 50 TA features were repeatable (root mean squared coefficient of variation under 10%).

Conclusion

Selected TA features in CINE CMR are repeatable and can identify differences between major and minor texture changes.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Medical Research Scotland, Guerbet Group
Insight form cardiovascular magnetic resonance on cardiac sarcoidosis: a single centre experience
Authors: Alderighi C , Baritussio A , Ozden Tok O , Perazzolo Marra M , Iliceto S , Bucciarelli-Ducci C
Published: November 2020

Background

Clinically manifest cardiac sarcoidosis (CS) has a prevalence of 5%, but is more frequent in autoptic series (25%). Diagnosis is multiparametric and relies on clinical criteria and imaging findings, although a certain diagnosis, especially in the case of isolated CS (ICS), can only be based on endomyocardial biopsy. Cardiovascular magnetic resonance (CMR) has a comprehensive role in the assessment of CS: left ventricular (LV) dysfunction and extent of late gadolinium enhancement (LGE)are important predictors of prognosis, T2 mapping provides information on disease activity and global longitudinal strain (GLS) analysis can uncover subclinical LV impairment.

Purpose

To assess the prevalence of CS by CMR in patients with biopsy-proven extracardiacsarcoidosis (ECS); to describe the imaging characteristics of patients with ECS and those with high clinical suspicionof ICS; to investigate the contribution of more recent techniques to the diagnosis of CS alongside traditional LGE assessment.

Methods

We retrospectively enrolled 84 patients (66% males, mean age 59±13 years) referred to our centreforsuspected CS (biopsy-proven ECS, n=61; clinical presentation suggestive of CS,, n=23). CMR was performed on a 1.5T scanner, with a protocol comprehensive of biventricular functional assessment and post-contrast images; T2-STIR images (n=30), native myocardial T1 mapping (n=24) and T2 mapping (n=19) were also performed in selected patients. Tissue tracking analysis was perfomed in all patients using a dedicated software.

Results

Based on CMR findings, 35 patients (42%) with ECS did not show cardiac involvement (SS), 26 (31%) showed both cardiac and systemic involvement (CS-SS) and 23 (27%) had evidence of ICS (ICS). 43% of patients had history of arrhythmias, but life-threatening tachyarrhythmiaswere more frequent in patients with CS (p=0.02).Patients with CS had significantly lower LVEF (p<0,01), larger LV volumes (p<0,01) and greater LV mass (p<0,01). GLS values were impaired in all the groups but significantly more in patients with CS (p<0,01). With regards to LGE distribution, ICS patients showed a higher number of segments involved (p=0,011) as compared to CS patients. T2-STIRimages were positive in 3 out of 30 patients; T2 mapping detected myocardial oedema in 1 patient with negative T2- STIR and was positive in 7 who did not undergo traditional oedema evaluation. T1 mapping mainly confirmed the results provided by LGE, but was altered in 1 patient who could not receive gadolinium.

Conclusions

CMR findings consistent with CS were found in 49 patients referred for suspected CS. Patients with cardiac involvement, particularly if isolated, had significantly lower LVEF, greater LV volumes and more impaired GLS. Patients with SS, despite a normal LV function, showed mildly impaired GLS, subtending subclinical cardiac involvement.

Funding Acknowledgement

Type of funding source: None
Decreased global strains of the left ventricle in asymptomatic female carriers for duchenne muscular dystrophy gene using feature-tracking: a prospective study
Authors: Masarova L , Panovsky R , Pisciotti M , Kincl V , Pesl M , Opatril L , Machal J , Novak J , Holecek T , Feitova V
Published: November 2020

Background

Duchenne muscular dystrophy (DMD) is an X-linked recessive disease manifested in males predominantly by skeletal muscle wasting but also dilated myocardium. Heterozygous female carriers often have normal echocardiographic findings. Nevertheless, untreated could develop in 4th and 5th decade of life to cardiomyopathy, probably due to progressive myocardial fibrosis. CMR feature tracking (FT) is an innovative technique that measures the myocardial wall deformation and could help to detect the contractile dysfunction, even in its early stages, due to its high sensitivity. Thus, it could identify asymptomatic carriers at higher risk of developing cardiomyopathy later in life.

Aim

This prospective study aimed to assess left ventricular systolic function (LV) in DMD carriers using CMR-FT.

Methodology

Global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS) were evaluated by CMR-FT. End-systolic (ESV), end-diastolic (EDV) LV volumes and ejection fraction (EF) LV were also measured using CMR-FT.

There were 37 carriers, and 20 healthy controls enrolled in the study. The measured parameters showed a Gaussian distribution and were compared using a t-test, followed by Benjamini-Hochberg correction.

Results

Groups carriers and controls did not differ in basic demographic data (age: 39.5±9.1 vs. 39.1±10.7 years). In contrast, there were found statistically significant differences in EF LV (56±5 vs. 60±3%), and all strain parameters (GLS (−19.4±2.4 vs. −22.3±2.2%), GCS (26.8±3.3 vs. 29.5±2.0%) and GRS (59.8±12.9 vs. 70.9±14.8%, all p<0.05)).

Conclusion

Carriers had significantly lower values of all strains compared to controls using CMR-FT, although they had preserved EF LV. CMR-FT could be beneficial for early diagnosis of the developing heart disease in asymptomatic patients with a genetic predisposition.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The work was supported by project no. LQ1605 from the National Program of Sustainability II (MEYS CR).This publication was written at Masaryk University as part of the project “Evaluation of left ventricular function using the feature tracking technique of Duchenne muscular dystrophy genes carriers” MUNI/A/1493/2018 with the support of the Specific University Research Grant, as provided by the Ministry of Education, Youth and Sports of the Czech Republic in the year 2018.
Prognostic value of cardiac 123I-metaiodobenzylguanidine imaging for predicting cardiac events after transcatheter aortic valve replacement
Authors: Kadoya Y , Zen K , Tamaki N , Yashige M , Takamatsu K , Ito N , Kuwabara K , Yamano M , Yamano T , Nakamura T , Matsushima S , Yaku H , Matoba S
Published: November 2020

Background

In patients with aortic valve stenosis (AS), cardiac sympathetic nervous (CSN) dysfunction and its improvement after TAVR have been reported; however, the prognostic impact of CSN function remains unclear. This study investigated the prognostic value of cardiac 123I-metaiodobenzylguanidine (MIBG) imaging for the prediction of cardiac events after transcatheter aortic valve replacement (TAVR).

Methods

This study was a single-center prospective observational study that enrolled patients with AS or failed surgical bioprostheses between July 2017 and May 2019. MIBG scintigraphy was performed before and after TAVR to evaluate the delayed heart–mediastinum ratio (d-H/M). Patients were classified into three pairs of groups based on the baseline and post-TAVR d-H/M (≥2.0 or <2.0) and on the presence of TAVR-related improvement of d-H/M. The study endpoints were major adverse cardiac events (MACE), including all-cause death, myocardial infarction, and hospitalization due to heart failure. The association of d-H/M with MACE following TAVR was based on a Cox proportional hazards ratio model adjusted for multiple prognostic variables.

Results

Of 187 consecutive patients who underwent TAVR, 111 (31 men; median age: 86 years) were evaluated. Over a median follow-up of 366 days, 16 (14.4%) patients had MACE. The incidence of MACE was significantly lower in patients with d-H/M improvement and/or the high post-TAVR d-H/M (≥2.0). Post-TAVR d-H/M had significant impacts on MACE, with an adjusted hazard ratio of 1.326 (95% confidence interval, 0.139–2.515; p=0.027).

Conclusions

Both d-H/M improvement and high post-TAVR d-H/M were associated with better prognosis in patients who underwent TAVR. Cardiac MIBG imaging was useful for predicting cardiac events after TAVR.

Funding Acknowledgement

Type of funding source: None
Perfusion-metabolic mismatch in myocardial scintigraphy in patients with vasospastic angina: what does it mean clinically?
Authors: Teragawa H , Oshita C , Orita Y
Published: November 2020

Background

It has been reported that perfusion-metabolic mismatch (PMM) in thallium-201 (Tl) and 123I-βmethyl-p-iodophenyl-pentadecanoic acid (BMIPP) shows important information regarding myocardial ischemia in the clinical setting. Such findings have been frequently obtained, even in patients with vasospastic angina (VSA). However, it has not been fully clarified what such findings mean clinically in patients with VSA. There, we investigated the frequency of PMM in patients with VSA as well as clinical characteristics of patients with VSA who have PMM.

Methods

Seventy-eight patients (mean age: 70 yrs, 29 men and 49 women) were diagnosed with VSA by coronary angiography and spasm-provocation test (SPT). We defined VSA as the presence of more than 90% narrowing of the epicardial coronary artery on angiograms, accompanied by the usual chest symptoms and/or ischemic ST-T changes on electrocardiogram. On SPT, multi-vessel spasm was defined as the presence of spasm on ≥ two major coronary arteries. Dual myocardial scintigraphy with Tl and BMIPP was performed, and the presence of PMM was defined as the summed rest score (SRS) in BMIPP scintigraphy ≥4 and difference in SRS in BMIPP and Tl-201 ≥4. Patients were divided into two groups according to the presence of PMM: Group I (+PMM, n=30) and Group II (−PMM, n=48). Each patient with VSA was assessed for conventional coronary risk factors, numbers of angina attacks per month, and taking vasodilators.

Results

Age, gender distribution, and conventional risk factors were not different between the groups. The median number of angina attacks was higher in the Group I than in the Group II (Group I: 4.5 vs. Group II: 0.1, p<0.01), and fewer patients were taking vasodilators in Group I (Group I: 1.1±1.0 vs. Group II: 1.5±1.1, p<0.05). On SPT, the presence of multi-vessels spasm was significantly higher in Group I (76%) than Group II (44%, p<0.05). Logistic regression analysis showed that the presence of multi-vessels spasm (p<0.05) and taking a smaller amount of vasodilators (p<0.05) were associated with PMM.

Conclusions

These findings suggest that PMM in Tl and BMIPP scintigraphy are associated with multi-vessels spasm and a smaller amount of vasodilator medication. This imaging data may provide important information regarding activity of VSA and sufficient medication.

Funding Acknowledgement

Type of funding source: None
Predicting the change in the coronary calcium score in patients with diabetes
Authors: Bellinge J , Lee S.C , Francis R , Phillips M , Schultz C
Published: November 2020

Background

The rate of increase of coronary arterial calcification score (CCS) on serial CT-scans years apart is a potent marker of cardiovascular risk but identifies risk only after irreversible damage has occurred. Molecular imaging may assist in identifying patients who are at risk of developing severe arterial calcification.

Purpose

To determine if 18F-Sodium Fluoride Positron Emission Tomography (18F-NaF PET) can predict and anatomically locate the progression of CCS over 2 years.

Methods

Subjects with diabetes mellitus underwent a baseline 18F-NaF PET scan and a CT CCS. The CT CCS was repeated after 2 years. 18F-NaF PET tracer uptake was measured as the maximum tissue to background ratio (TBRmax) and using a pre-defined cut-off for positivity, arteries were dichotomised into 18F-NaF positive and negative. We compared the change in the CCS between coronary arteries that were positive and negative for 18F-NaF uptake.

Results

In forty-one participants (mean age 65.0±7.1, male: 63.4%) a total of 163 coronary arteries were included in the analysis. Fifty-two (31.9%) coronary arteries were 18F-NaF positive at baseline and 111 (68.1%) were negative. After 2.8 [2.4–3.2] years follow-up, the TBRmax at baseline correlated with the time-standardised change in the CCS (Spearmans' rho 0.33, p<0.001). The time-standardised change in the CCS was higher in coronary arteries that were 18F-NaF positive compared to negative (48.9 [13.6–119.7] v 3.3 [0–27.9], p<0.001). The time-standardised change in coronary calcium score increased across patients with increasing number of 18F-NaF positive arteries at baseline (p=0.006) (Figure 1).

Conclusions

18F-NaF PET activity at baseline is associated with new co-localised calcifications 2.8 years later

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Royal Perth Hospital Research Foundation
Diagnostic performance of advanced cardiac imaging for detection of cardiac sarcoidosis: a systematic review and meta-analysis
Authors: Ballo H , Saraste A , Doghman F , Knuuti J
Published: November 2020

Background

Advanced cardiac imaging techniques, 18F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) and cardiac magnetic resonance (CMR) imaging, have shown high accuracy for the detection of cardiac sarcoidosis (CS) in small studies. This meta-analysis was performed to evaluate the performance of FDG PET and CMR in the diagnosis of CS.

Methods

PubMed, Embase, and Cochrane Library were searched from the earliest available date of indexing to December 2019 for studies evaluating the accuracy of FDG-PET and CMR for the evaluation of possible CS defined mainly by the Japanese Ministry of Health, Labour and Welfare (JMHW) criteria. For robustness, only studies with a sample size of ≥20 patients were selected and sensitivity analysis excluding outliers was conducted. To calculate the overall performance of the diagnostic accuracy of FDG-PET and CMR, summary receiver operating curve (SROC) and area under the curve (AUC) analyses were done. Heterogeneity was evaluated with the Cochrane Q test and I2 test. Possible sources of heterogeneity were further explored by subgroup analyses.

Results

Fourteen studies used FDG-PET and six studies used CMR involving 1491 patients (mean age 53 years, 38% male) fulfilled the inclusion criteria. The pooled sensitivity of FDG-PET for diagnosis of CS was 76.7% (95% CI 71.6–81.2%; Q=4.4, P<0.0001; I2=86.2%) and the pooled specificity was 86.0% (95% CI 82.8–88.8%; Q=37.4, P<0.0001; I2=65.2%). For the CMR, the pooled sensitivity was 94.0% (95% CI 88.8–97.2%; Q=10.59, P=0.06; I2=52.8%) and the pooled specificity was 88.8 (95% CI 85.3–91.3%; Q=80.25, P<0.0001; I2=93.8%). SROC analysis demonstrated good overall accuracy for FDG-PET (AUC value of 0.91, and Q* 0.85) and CMR (AUC value of 0.96, and Q* 0.9) (figure 1). The sensitivity analysis of FDG-PET (11 studies) demonstrated a pooled sensitivity of 86.2% (95% CI 81.3–90.2%; Q=35.3, P=0.0001; I2=71.6%) and pooled specificity of 87.9% (95% CI 84.3–90.9%; Q=16.7, P=0.08; I2=40.2%). Moreover, the sensitivity analysis of CMR (5 studies) showed a pooled sensitivity of 89.3% (95% CI 78.1–96%; Q=7.3, P=0.12; I2=44.9%) and pooled specificity of 77.9% (95% CI 72.1–82.9%; Q=2.5, P=0.6; I2=0%). Meta-regression showed that the age of the patients (coefficient 0.192; P=0.04) and the size of the studies (coefficient 0.035; P=0.028) were the sources of heterogeneity in FDG-PET and CMR, respectively. The subgroup analysis by the age ≥55 years (6 studies and 276 patients) showed improvement in the diagnostic accuracy of FDG-PET with sensitivity of 92.2% (95% CI 86.1–96.2%; Q=18.9, P<0.01; I2=73.5%) and specificity of 85.1% (95% CI 78.4–90.4%; Q=4, P=0.553; I2=0%).

Conclusion

FDG-PET and CMR are useful adjunctive diagnostic tools in the evaluation of CS. Further large multi-center studies are warranted to validate the diagnostic accuracy of FDG-PET and CMR for diagnosis of CS.

Figure 1

Funding Acknowledgement

Type of funding source: None
Systematic Evaluation of KCNQ1 variant using ACMG/AMP Guidelines and Risk Stratification in Long QT Syndrome Type 1
Authors: Kashiwa A , Aiba T , Makimoto H , Yagihara N , Ohno S , Makiyama T , Hayashi K , Itoh H , Sumitomo N , Yoshinaga M , Morita H , Makita N , Kusano K , Horie M , Shimizu W
Published: November 2020

Background

Mutation/variant-site specific risk stratification in long-QT syndrome type 1 (LQT1) has been well investigated, but it is still challenging to adopt current enormous genomic information to clinical aspects caused by each mutation/variant. We assessed a novel variant-specific risk stratification in LQT1 patients.

Methods

We classified a pathogenicity of 142 KCNQ1 variants among 927 LQT1 patients (536 probands and 391 family members) based on the American College of Medical Genetics and Genomics (ACMG) and Association for Molecular Pathology (AMP) guidelines and evaluated whether the ACMG/AMP-based classification was associated with arrhythmic risk in LQT1 patients.

Results

Among 142 KCNQ1 variants, 60 (42.3%), 58 (40.8%), and 24 (16.9%) variants were classified into pathogenic (P), likely pathogenic (LP), and variant of unknown significance (VUS), respectively. The ACMG/AMP guideline-based classification was significantly associated with syncopal events (particularly those during exercise) and LQT risk score (Schwartz score) in overall population. On the other hand, arrhythmic risk was completely different between probands and families even in the same variants. The baseline QTc interval and variant location could stratify the risk in family members but not in probands, however, the ACMG/AMP-based KCNQ1 variant classification stratified the risk in LQT1 probands as well as family members. Multivariate analysis showed that proband (HR=2.52; 95% CI: 1.93–3.30; p<0.0001), longer QTc interval (≥500ms) (HR=1.41; 95% CI: 1.11–1.79; p<0.0001), variants at membrane spanning (MS) (vs. those at N/C terminus) (HR=1.40; 95% CI: 1.07–1.85; p=0.02), C-loop (vs. N/C terminus) (HR=1.58; 95% CI: 1.11–2.24; p=0.01), and P variants [(vs. LP) (HR=1.71; 95% CI: 1.33–2.23; p<0.0001), (vs. VUS) (HR=1.96; 95% CI: 1.19–3.46; p=0.007)] were significantly associated with syncopal events. A clinical score (0–4) based on the proband, QTc (≥500ms), variant location (MS or C-loop) and P variant by the ACMG/AMP guidelines allowed identification of patients more likely to have arrhythmic events (Figure A and B).

Conclusion

Comprehensive evaluation of clinical findings and pathogenicity of KCNQ1 variants based on the ACMG/AMP-based evaluation may stratify arrhythmic risk of congenital long-QT syndrome type 1.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Health Science Research Grant from the Ministry of Health,Labor and Welfare of Japan for Clinical Research on Measures for Intractable Diseases (H24-033, H26-040, H27-032) and a research grant from the Japan Agency for Medical Research and Development (AMED) (15km0305015h0101, 16ek0210073h0001)
The Admit-AF risk score: a clinical risk score for predicting hospital admissions in patients with atrial fibrillation
Authors: Meyre P , Aeschbacher S , Blum S , Coslovsky M , Beer J.H , Moschovitis G , Rodondi N , Baretella O , Kobza R , Sticherling C , Bonati L.H , Schwenkglenks M , Kuehne M , Osswald S , Conen D
Published: November 2020

Background

Patients with atrial fibrillation (AF) have a high risk of hospital admissions, but there is no validated prediction tool to identify those at highest risk.

Purpose

To develop and externally validate a risk score for all-cause hospital admissions in patients with AF.

Methods

We used a prospective cohort of 2387 patients with established AF as derivation cohort. Independent risk factors were selected from a broad range of variables using the least absolute shrinkage and selection operator (LASSO) method fit to a Cox regression model. The developed risk score was externally validated in a separate prospective, multicenter cohort of 1300 AF patients.

Results

In the derivation cohort, 891 patients (37.3%) were admitted to the hospital over a median follow-up 2.0 years. In the validation cohort, hospital admissions occurred in 719 patients (55.3%) during a median follow-up 1.9 years. The most important predictors for admission were age (75–79 years: adjusted hazard ratio [aHR], 1.33; 95% confidence interval [95% CI], 1.00–1.77; 80–84 years: aHR, 1.51; 95% CI, 1.12–2.03; ≥85 years: aHR, 1.88; 95% CI, 1.35–2.61), prior pulmonary vein isolation (aHR, 0.74; 95% CI, 0.60–0.90), hypertension (aHR, 1.16; 95% CI, 0.99–1.36), diabetes (aHR, 1.38; 95% CI, 1.17–1.62), coronary heart disease (aHR, 1.18; 95% CI, 1.02–1.37), prior stroke/TIA (aHR, 1.28; 95% CI, 1.10–1.50), heart failure (aHR, 1.21; 95% CI, 1.04–1.41), peripheral artery disease (aHR, 1.31; 95% CI, 1.06–1.63), cancer (aHR, 1.33; 95% CI, 1.13–1.57), renal failure (aHR, 1.18, 95% CI, 1.01–1.38), and previous falls (aHR, 1.44; 95% CI, 1.16–1.78). A risk score with these variables was well calibrated, and achieved a C-index of 0.64 in the derivation and 0.59 in the validation cohort.

Conclusions

Multiple risk factors were associated with hospital admissions in AF patients. This prediction tool selects high-risk patients who may benefit from preventive interventions.

The Admit-AF risk score

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swiss National Science Foundation (Grant numbers 33CS30_1148474 and 33CS30_177520), the Foundation for Cardiovascular Research Basel and the University of Basel
Three year incidence and duration of atrial fibrillation episodes among a large, real-world population of cryptogenic stroke patients with insertable cardiac monitors
Authors: Ziegler P.D , Rogers J.D , Richards M , Nichols A.J , Ferreira S.W , Koehler J.L , Sarkar S
Published: November 2020

Background/Introduction

The primary goal of monitoring for atrial fibrillation (AF) after cryptogenic stroke (CS) is secondary stroke prevention. Therefore, long-term monitoring of CS patients with insertable cardiac monitors (ICMs) is likely important to ensure appropriate secondary stroke prevention therapy, regardless of when AF is detected after the index event. However, long-term data on the incidence and duration of AF from real-world populations are sparse.

Purpose

To investigate the long-term incidence and duration of AF episodes in real-world clinical practice among a large population of patients with ICMs placed for AF detection following CS.

Methods

We included patients from a large device manufacturer's database who received an ICM for the purpose of AF detection following CS and were monitored for up to 3 years. All detected AF episodes (≥2 minutes) were adjudicated. We quantified the AF detection rate for various episode duration thresholds using Kaplan-Meier survival estimates, analyzed the maximum duration of AF episodes, and measured the time to initial AF detection.

Results

A total of 1247 patients (65.3±13.0 years, 53% male) were included and followed for 763±362 days. AF episodes (n=5456) were detected in 257 patients, resulting in a median frequency of 5 episodes [IQR 2–19] per patient. At 3 years, the AF detection rate for episodes ≥2 minutes was 24.2%. The AF detection rates at 3 years for episodes ≥6 minutes, ≥30 minutes, and ≥1 hour were 22.4%, 20.6%, and 19.1%, respectively. The median duration of the longest detected AF episode was 4.4 [IQR 1.2–13.9] hours and the median time to AF detection was 129 [IQR 45–354] days.

Conclusion

AF episodes were detected via ICMs in approximately one-quarter of CS patients within 3 years of follow-up. More than 75% of patients with AF detected had episodes lasting ≥1 hour and half had episodes lasting ≥4 hours. Detection of the first AF episode typically occurred beyond the range of conventional ambulatory monitors. Long-term surveillance of CS patients is likely important given the appreciable incidence, frequency, and duration of these AF episodes.

Funding Acknowledgement

Type of funding source: None
Dronedarone vs placebo in patients with atrial fibrillation or atrial flutter across a range of renal function: a post hoc analysis of the ATHENA trial
Authors: Vamos M , Oldgren J , Nam G.-B , Lip G , Calkins H , Zhu J , Ueng K.-C , Ludwigs U , Wieloch M , Stewart J , Hohnloser S.H
Published: November 2020

Background

The use of antiarrhythmic drugs in patients with chronic kidney disease (CKD) is challenging due to issues with renal clearance, drug accumulation and increased proarrhythmic risks. Since CKD is a common comorbidity with atrial fibrillation (AF), it is important to establish the efficacy and safety for antiarrhythmic drug treatment in patients with CKD.

Purpose

To evaluate the efficacy and safety of dronedarone in patients with AF or atrial flutter (AFL) across different stages of renal impairment.

Methods

In this post-hoc analysis of ATHENA (NCT00174785), a randomised, double-blind trial of dronedarone 400 mg BID vs placebo in patients with AF or AFL plus additional risk factors for death and a calculated glomerular filtration rate ≥10 mL/min, the primary outcome was time to first cardiovascular (CV) hospitalisation or death. Renal function (estimated glomerular filtration rate [eGFR]) was assessed using CKD Epidemiology Collaboration equation and patients were grouped by eGFR (10–44, 45–59, ≥60 mL/min). Log-rank testing and Cox regression were used to compare time to events between treatment groups.

Results

In ATHENA, 43.6% of placebo and 42.2% of dronedarone patients had mild-to-moderate CKD (Table). Median time to CV hospitalisation/death was longer in all strata for dronedarone vs placebo, reaching significance in the 45–59 and ≥60 mL/min groups (Figure 1). There was a trend towards more treatment-emergent adverse events (TEAEs), deaths and discontinuations due to TEAEs in patients with eGFR 10–44 mL/min. No clear difference in safety was seen between treatment arms except for discontinuations, which were higher with dronedarone.

Conclusions

This analysis confirms the efficacy of dronedarone, demonstrated in ATHENA, across different stages of renal impairment. Further assessment of safety will require larger populations of patients with CKD.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Sanofi
Rate control drugs differ in the prevention of progression of atrial fibrillation
Authors: Koldenhof T , Wijtvliet E.P.J.P , Pluymaekers N.A.H.A , Rienstra M , Folkeringa R.J , Bronzwaer P , Elvan A , Elders J , Tukkie R , Luermans J.G.L.M , Van Gelder I.C , Crijns H.J.G.M , Tieleman R.G
Published: November 2020

Background

In patients with paroxysmal atrial fibrillation (PAF), verapamil reduces progression to persistent AF through its intracellular calcium-lowering effects. Little is known on the effects of beta-blockade.

Methods

In this pre-specified post-hoc analysis of the RACE4 randomised trial (nurse-led care versus usual-care in newly detected AF) all patients with PAF and treated with beta-blockers or verapamil for rate control, were analyzed. Patients using class I or III antiarrhythmic drugs were excluded. The primary outcome was time to first electrical cardioversion (ECV) for non-selfterminating persistent AF. Event rates are reported using Kaplan-Meier analysis, and multivariate analysis was used to correct for baseline differences.

Results

Out of 430 patients with PAF, 383 used beta-blockers and 47 verapamil. Compared to verapamil patients, patients on beta-blocker were significantly older (60±12 versus 66±9 years), had a higher CHA2DS2-VASc score (1.5 versus 2.0) and a lower left ventricular ejection fraction (60% versus 55%). There were no other significant baseline differences between the two groups. Over a mean follow up of 36 months, 99 out of 430 (23%) patients underwent a first ECV after progression to persistent AF. In the beta-blocker group 95 of 383 (25%) patients underwent ECV, compared to 4 out of 47 (9%) in the verapamil group (P=0.013, Figure 1). After correction for baseline differences verapamil remained significantly associated with less progression (OR 0.23, confidence interval 0.08 to 0.67). Similarly, ECV or chemical cardioversion, whichever came first, was performed in 113 of 383 (30%) beta-blocker patients and 7 of 47 (15%) verapamil patients (P=0.022). In total 35 atrial ablations were performed, 34 (9%) in the beta-blocker group and only 1 (2%) in the verapamil group (p=0.075).

Conclusion

In patients with newly diagnosed PAF, verapamil was associated with less progression to persistent AF, as compared to beta-blockers. In order to draw firm conclusions, these results need to be confirmed by a prospective study

ECV free survival

Funding Acknowledgement

Type of funding source: None
Long-term outcome of patients with invasive electrophysiology procedure related cardiac tamponade
Authors: Von Olshausen G , Bourke T , Schwieler J , Drca N , Bastani H , Tapanainen J , Saluveer O , Benson L , Goedel A , Kenneback G , Insulander P , Jensen-Urstad M , Braunschweig F
Published: November 2020

Aims

Iatrogenic cardiac tamponades are a rare but dreaded complication of invasive electrophysiology procedures (EPs). Their long-term impact on clinical outcomes is unknown. This study analyzed the risk of death or serious cardiovascular events in patients suffering from EP related cardiac tamponade requiring pericardiocentesis during long-term follow-up.

Methods and results

Out of 19997 invasive EPs at our university hospital between January 1998 and September 2018, all patients with EP related periprocedural cardiac tamponade were identified (n=60) and matched (1:3 ratio) to a control group (n=180). After a follow-up of 5 years, the composite primary end point - death from any cause, acute myocardial infarction, TIA/stroke and hospitalization for heart failure – occurred in significantly more patients in the tamponade than in the control group (12 patients (20.0%) vs 19 patients (10.6%); Hazard ratio (HR) 2.53 (95% CI, 1.15–5.58); p=0.021). This was mainly driven by a higher incidence of TIA/stroke in the tamponade than in the control group (HR 3.75 (95% CI, 1.01–13.97); p=0.049). Death from any cause, acute myocardial infarction and hospitalization for heart failure did not show a significant difference between the groups. Hospitalization for pericarditis occurred in significantly more patients in the tamponade than in the control group (HR 36.0 (95% CI, 4.68–276.86); p=0.001).

Conclusion

Patients with EP related cardiac tamponade are at higher risk for cerebrovascular events during the first two weeks and hospitalization for pericarditis during the first months after index procedure. Despite the increased risk for early complications tamponade patients have a good long-term prognosis without increased risk for mortality or other serious cardiovascular events.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation
Change of the pulmonary vein anatomy after cryoballoon ablation reflecting left atrial reverse remodeling
Authors: Miyama H , Takatsuki S , Hashimoto K , Yamashita T , Fujisawa T , Katsumata Y , Kimura T , Fukuda K
Published: November 2020

Background

Cryoballoon ablation (CBA) is a widely used procedure for atrial fibrillation (AF). However, the anatomical change of pulmonary veins (PVs) and the risk factors of PV stenosis is less clear. We aimed to decipher the prevalence and the predictive factors for PV stenosis after CBA.

Methods

We analyzed the data of 320 PVs from 80 patients who underwent CBA for AF (age: 62±10 years, 59 males, 75 paroxysmal AF). All patients underwent pre- and post-procedural cardiac computed tomography (mean 6.7±3.3 months after ablation). We defined the PV stenosis when the cross sectional area of PV was less than 50% compared with that of PV before the CBA.

Results

The average cross sectional PV area decreased significantly after CBA (pre- vs. post-CBA; 2.4±1.0cm2 vs. 2.3±1.1cm2, P<0.001), whereas the volume of left atrium (LA) also decreased significantly (pre- vs. post-CBA; 75.0±23.2cm3 vs. 70.7±21.9cm3, P<0.001). There was a weak but significant correlation between the reduction rate of PV area and that of LA volume (Pearson's correlation coefficient 0.411, p<0.001). Only 6 PV stenosis were revealed, in which area reduction of more than 75% and 50–75% were observed in 2 PVs and 4 PVs, respectively. The incidence of PV stenosis was greater in female (male vs. female; 0.8% vs. 4.8%, P=0.043) and tend to be frequent in left PVs (left PVs vs. right PVs; 3.1% vs. 0.6%: P=0.107). Moreover, patients who developed PV stenosis tended to have lower weight and shorter height (PV stenosis group vs. non-PV stenosis group; 58.2±12.4kg vs. 67.7±13.0kg: P=0.078, 161.2±9.1cm vs. 167.2±8.8cm: P=0.094). There were no significant differences in the number of freezing, minimum temperature and total freezing time between PV stenosis group and non-PV stenosis group.

Conclusions

The ostial PV area decreased significantly but little after CBA, possibly due to LA reverse remodeling. The PV stenosis was more common in women and tend to be frequent in left PVs, lower weight, and shorter height patients, though severe stenosis after CBA was not observed in this study.

Funding Acknowledgement

Type of funding source: None
Impact of body mass index on atrial fibrillation ablation using cryoballoon: procedural data and clinical outcomes
Authors: Urbanek L , Chen S , Bordignon S , Tsianakas N , Bologna F , Chun K.R.J , Schmidt B
Published: November 2020

Background

The impact of body mass index (BMI) on atrial fibrillation (AF) ablation using cryoballoon (CB) has been seldom reported.

Purpose

To evaluate the impact of BMI on procedural data as well as the clinical efficacy and safety character of using CB.

Methods

Symptomatic AF patients (paroxysmal / persistent AF) with BMI ≥25 who underwent CB based pulmonary vein isolation (PVI) were enrolled. CB PVI was performed using the second generation CB (CB 2, 28mm), with 4min based freeze protocol and bonus freeze delivery in case of time-to-isolation (TTI) >75 sec. All procedures were performed under conscious sedation. Procedural endpoint was electrical pulmonary vein isolation. Clinical success was defined as no recurrence of AF/atrial tachycardia (AT).

Results

Data from 600 consecutive patients were collected. Three groups defined: BMI 25–29 (Group 1, G1 n=337); BMI 30–34 (Group 2, G2 n=149); BMI ≥35 (Group 3, G3 n=114). Patients in Group 3 were younger (G1: 67±11 y; G2: 68±10y G3 62±11y; p<0,001) and presented bigger LA (G1 39,5±4,9 mm; G2: 41,6±5,5; G3 42,4±5,1; p<0,001). Most of the patients presented with PAF (G1: 59,3% G2: 57,7% G3: 54,4%).

Among 2342 Targeted PVs, 2332 (99,6%) were isolated using solely the CB (G2: one procedure was abolished due to failed aortic puncture during transseptal access; G3: one PVI was not completed due to PNP; 6 touch up RF ablation in G1 and 2 in G3). Procedure time (G1:58,45 min; G2: 60,44 min; G3 63,19 min) and fluoroscopy time (G1: 9,3 min; G2: 9,5 G3: 10,6 min) were comparable among the groups. PN Injury was the main recorded complication: 20/600 (2,6%) patients with a transient PN palsy (PNP) and 6/600 (1%) with a persistent PNP. No sedation related complication was recorded.

Follow up survival curve analysis after one year revealed a favorable follow up in G1 (78,4%) and G2 (82,5%) compared to G3 (66,5%) (G1 Vs G3 p: 0,002 G2 vs G3 p=0,008, G1 vs G2 p=0,47). The influence of BMI on the follow up was confirmed in the subgroup of patients with paroxysmal AF but not in patients presenting persistent AF.

Conclusions

Cryoballoon ablation in obese patients is feasible and associated with a relatively low complication rate. BMI plays a role in predicting recurrences especially in patients presenting with paroxysmal AF.

Funding Acknowledgement

Type of funding source: None
Continuous, transcutaneous carbon-dioxide monitoring to avoid hypercapnia in complex catheter ablations under conscious sedation
Authors: Weinmann K , Lenz A , Heudorfer R , Aktolga D , Rattka M , Bothner C , Pott A , Oechsner W , Rottbauer W , Dahme T
Published: November 2020

Background

Ablation of complex cardiac arrhythmias requires an immobilized patient. For a successful and safe intervention and for patient comfort, this can be achieved by conscious sedation. Administered sedatives and analgesics have respiratory depressant side effects and require close monitoring.

Purpose

We investigated the feasibility and accuracy of an additional, continuous transcutaneous carbon-dioxide partial pressure (tpCO2) measurement during conscious sedation in complex electrophysiological catheter ablation procedures.

Methods

We evaluated the accuracy and additional value of tpCO2 detection by application of a Severinghaus electrode in comparison to arterial and venous blood gas analyses.

Results

We included 110 patients in this prospective observational study. Arterial pCO2 (paCO2) and tpCO2 showed good correlation throughout the procedures (r=0.60–0.87, p<0.005). Venous pCO2 (pvCO2) were also well correlated to transcutaneous values (r=0.65–0.85, p<0.0001). Analyses of the difference of pvCO2 and tpCO2 measurements showed a tolerance within <10mmHg in up to 96–98% of patients. Hypercapnia (pCO2<70mmHg) was detected more likely and earlier by continuous tpCO2 monitoring compared to half-hourly pvCO2 measurements.

Conclusion

Continuous tpCO2 monitoring is feasible and precise with good correlation to arterial and venous blood gas carbon-dioxide analysis during complex catheter ablations under conscious sedation and may contribute to additional safety.

Funding Acknowledgement

Type of funding source: None
Risk of cardiovascular events in patients with atrial fibrillation and cancer. Data from the ATHERO-AF cohort
Authors: Pastori D , Bucci T , Menichelli D , Violi F , Pignatelli P
Published: November 2020

Background

Patients with non valvular atrial fibrillation (AF) and cancer represent a high-risk subgroup of patients in whom the management of oral anticoagulation may be challenging. The relationship between cancer type and the risk of cardiovascular events (CVEs) in patients with AF is unclear.

Purpose

To investigate the incidence of CVEs in patients with AF and cancer according to cancer type.

Methods

Prospective cohort study including 2,092 consecutive AF patients on vitamin K antagonists. Principal endpoint was the occurrence of CVEs including fatal/non-fatal myocardial infarction and ischemic stroke and cardiovascular death. We also performed a subgroup analysis of cardiac and thromboembolic events separately. Patients with cancer were divided in subgroups based on cancer site as follows: group 1 gastrointestinal tract; group 2 respiratory tract; group 3 genitourinary tract; group 4 other sites.

Results

Mean age was 73.7±9.1 years and 42.1% were woman; 367 (17.5%) had cancer, of these 21% gastro-intestinal, 10% respiratory, 28% genito-urinary and 41% had other localization. Patients with cancer were older than those without but with similar clinical characteristics.

During a mean follow up of 35.9±28.0 months (6264.5 patient-years), 203 CVEs occurred (3.24%/year, 95% CI 2.81–3.72) of whom 86 were cardiac ischemia (1.37%/year, 95% CI 1.10–1.69), 70 thromboembolic events (1.12%/year, 95% CI 0.87–1.41) and 47 cardiovascular deaths (0.75%/year, 95% CI 0.55–0.99). The incidence of CVEs for AF patients with and without cancer was respectively (n=45, 3.78%, 95% CI 2.76–5.06) and (n=158, 3.11%/year, 95% CI 2.65–3.64). In particular, compared to patients without cancer, a higher incidence rate of CVEs was found in patients with gastrointestinal tract cancer (5.61%/year, 95% CI 2.90–9.79, p=0.046), and in patients with respiratory tract cancer (6.15%/year, 95% CI 2.66–12.1, p=0.055), while no difference was found in patients with genito-urinary tract cancer (2.24%/year, 95% CI 0.97–4.41, p=0.362) and other site cancer (3.11%/year, 95% CI 2.65–3.64, p=0.512).

Cox regression multivariate analysis showed that factors associated with cardiac events were COPD, dyslipidemia, TTR <70%, PPI drugs and gastrointestinal cancer (figure). Conversely, CHA2DS2VASc score and respiratory cancer were predictors of thromboembolic events.

Conclusions

Our findings suggest an association between cancer type and specific ischemic complications in AF patients. In particular, we found a higher risk of cardiac complications in patients with gastrointestinal cancer and of thromboembolic events in patients with respiratory cancer. These associations need to be confirmed in larger studies.

Funding Acknowledgement

Type of funding source: None
Simultaneous endo-epicardial mapping of programmed atrial extrasystoles in patients undergoing cardiac surgery
Authors: Kharbanda R , Van Schie M.S , Taverne Y.J.H.J , Kik C , Van Schaagen F.R.N , Bogers A.J.J.C , De Groot N.M.S
Published: November 2020

Introduction

Atrial extrasystoles (AES) are usually innocent, however they can also trigger (post-operative) atrial fibrillation (AF). It is unknown what the arrhythmogenic effect of AES is on 3-dimensional atrial conduction.

Purpose

Therefore, the aim of this study was to examine the effect of programmed AES (PAES) provoked in the right atrium (RA) on both endo- and epicardial conduction.

Methods

Simultaneous endo-epicardial mapping of the RA was performed during PAES provoked from the RA free wall in patients undergoing cardiac surgery (256 electrodes). Areas of conduction block (CB) were defined as conduction delays of ≥12ms and endo-epicardial asynchrony (EEA) as activation time differences of exact opposite electrodes of ≥15ms.

Results

Simultaneous endo-epicardial mapping of the RA during 15 PAES were analyzed and compared with sinus rhythm (SR) (n=12, 58% male, age 68±7 years). Eleven PAES were premature (>25% shortening cycle length (CL)), median preceding CL was 554.5ms [377.9–720.4] and median SR CL was 871ms [700.9–1021]. Amount of EEA (7.3% [2.6–17.8] vs 1% [1–2], p=0.002) and CB (9% [4.8–11.8] vs 1.4% [0.5–2.7, p=0.001) both increased during PAES compared to SR. Diabetes was the only cardiovascular risk factor associated with a higher incidence and degree of EEA and CB. Interestingly, CB during PAES was more severe in 4 patients (33.3%) who developed post-operative AF (11.9% [10.4–12.8] vs 5.4% [3.3–8.5], p<0.001).

Conclusion

Asynchronous activation of the atrial wall and conduction disorders, which play an important role in arrhythmogenesis, are enhanced during PAES compared to SR. Enhanced electropathology together with triggers provoked by heart surgery may initiate post-operative AF.

Funding Acknowledgement

Type of funding source: None