bluuebunny/crossref_metadata_2025 huggingface dataset:
Age-dependent detection of Atrial Fibrillation with implantable cardiac monitors in patients with cryptogenic stroke
Authors: Uhe T , Keilitz J , Berrouschot J , Wacher R
Published: November 2023

Background

Prolonged and intensified rhythm monitoring is recommended to detect atrial fibrillation (AF) in patients with cryptogenic stroke (CS). Continuous monitoring using implantable cardiac monitors (ICM) results in AF detection rates of up to 30%. Although higher age has been identified as an independent risk factor for AF in patients post CS, there are no specific recommendations for the implantation of ICM in younger patients.

Furthermore, the temporal relationship between AF and recurrent stroke in patients with continuous monitoring is a relevant issue and scarcely investigated.

Objectives

(1)To analyze age-related AF rates in patients with CS and continuous rhythm monitoring using ICM.

(2)To determine the rates of oral anticoagulation and recurrent strokes in patients with ICM-detected AF after CS.

(3)To describe the temporal relationship of AF detection and recurrent stroke in these patients.

Methods

From 02/2014 to 11/2021, patients with CS provided with ICMs were systematically followed. All patients underwent 72-h ECG monitoring, transcranial doppler ultrasound and transthoracic echocardiography according to current guidelines prior to ICM insertion. Follow-up was performed by means of a regular outpatient presentation every three months and included medical history, physical examination, and interrogation of the ICM. AF was defined as any episode of absolute arrhythmia >30 seconds.

Results

One hundred and eighty-six patients (mean age 65 ± 12 years) were included in this analysis. AF was detected in 62 patients (33 %) during a mean follow-up of 36 ± 23 months. AF was found in 6 % (3/52), 27 % (17/62), 56 % (31/55) and 65 % (11/17) (p < 0.001) in patients aged < 60 years, 60-69 years, 70-79 years and ≥ 80 years, respectively (see Figure 1). All patients with AF under 60 years had an impaired systolic left ventricular function (left ventricular ejection fraction < 50 %). Oral anticoagulation was initiated in 85% of the patients with AF. Recurrent stroke occurred in 34 patients (18.3%) of whom fifteen had a diagnosis of AF. In nine patients, AF was diagnosed before the occurrence of a recurrent stroke. In four patients, AF was diagnosed after recurrent stroke and in one patient, AF and recurrent stroke occurred simultaneously (see Figure 2).

Conclusion

AF was absent in cryptogenic stroke patients with preserved ejection fraction and younger than 60 years. AF prevalence increased with age. The temporal relationship of AF and recurrent stroke was weak. Further research is needed to better identify stroke patients at risk of AF and recurrent stroke.

Figure 1: Time to first detection of Atrial fibrillation in patients aged < 60 years, 60-69 years, 70-79 years and ≥80 years, respectively.

Figure 2: Temporal relationship of first detected atrial fibrillation (AF) and recurrent stroke in patients with cryptogenic stroke.Figure 1Figure 2
Atrial fibrillation high power radiofrequency ablation: efficiency and safety
Authors: Martinho M , Grade Santos J , Almeida S , Miranda R , Ferreira B , Santos Cunha D , Baltazar O , Ilchyshyn N , Mirinha Luz J , Budzak K , Cale R , Briosa A , Sebaiti D , Brandao Alves L , Pereira H
Published: November 2023

Introduction

High power-ablation index (HP-AI) guided radiofrequency (RF) ablation of atrial fibrillation (AF) is increasingly being used as an alternative to conventional power (CP) ablation due to its better procedural performance and similar safety profile. Some evidence suggests that the lower RF time used in HP-AI may also have a protective effect in contact related complications. Despite this evidence, this strategy is still not widely used.

Purpose

Compare procedural efficiency and safety between HP-AI vs CP-AI-guided ablation in AF patients (pts).

Methods

Retrospective single-center study of consecutive pts submitted to AI-guided ablation, between 05/2018 and 10/2022. RF power and AI were 25W/500 and 45W/500 for the anterior wall and 20W/380 and 35W/380 for the posterior wall in CP-AI and HP-AI, respectively. Procedure related complications incidence were checked at 1 month.

Results

Of a total of 83 pts included in the study, mean age was 62±10y and 57.8% were males. HP-AI was performed in 61.4% (n=51). 39.2% had persistent AF (vs 25% in CP-AP, p=0.235). HP-AI was associated with significantly lower median procedure duration (150.0[140.0-180.0]min vs 192.0[180.0-235.0]min, p<0.001), fluoroscopy time (9.2[7.3-11.3]min vs 12.2[9.7-14.3]min, p=0.003) and RF time (26.3[20.4-28.4]min vs 34.3[30.1-39.6]min, p<0.001). These times were significantly reduced for both paroxysmal and persistent AF (figure 1). Electrical isolation of all the pulmonary veins was achieved in all patients. There were no early complications related to the procedure in either CP-AI or HP-AI groups.

Conclusion

HP-AI guided AF ablation significantly reduced procedure duration without impairing safety. It was also associated with lower RF application time, which may potentially lead to a reduction in procedure related complications. Data regarding long-term effectiveness will eventually support HP-AI as the best option for RF AF ablation.Comparison of median procedural times
High-density, high-resolution mapping in patients with recurrent atrial fibrillation after cryoballoon pulmonary vein isolation: findings and outcome after repeat ablation
Authors: Musat D , Milstein N S , Shaw R , Bhatt A , Habibi M , Preminger M , Sichrovsky T , Mittal S
Published: November 2023

Background

Some patients have recurrent atrial fibrillation (AF) after cryoballoon (CB) pulmonary vein isolation (PVI). When these patients undergo repeat ablation, radiofrequency (RF) energy is used. However, there are scarce data from high-density, high-resolution mapping in these patients and the outcome after repeat ablation.

Objectives

We sought to determine the rate of PV reconnections in these patients and the impact of repeat ablation on long-term freedom from recurrent AF or atrial tachycardia (AT).

Methods

Following CB PVI, 70 (27%) out of 264 patients required repeat ablation. This cohort evaluated the 43 (61%) patients in whom high-density, high-resolution three-dimensional mapping and subsequent ablation were performed with the Boston Scientific RHYTHMIA system. All patients had an implantable loop recorder (ILR) capable of daily remote data transmission; all recurrences of AF/AT were adjudicated.

Results

The mean age of the 43 patients was 68 ± 9 years; 28 (65%) patients were male and the CHA2DS2-VASc score was 2.8 ± 1.8. The median AF burden (AFB) in the cohort was 2.23% (IQR: 0.40, 11.0); recurrences were paroxysmal in 27 (63%) patients. Recurrent PV connection was seen in 32 (74%) patients; these were limited to 1 or 2 veins in 26 (81%) patients. PVI alone was performed in 15 (35%) patients; the other 28 (65%) patients underwent PVI, if needed, and additional lesions. During the next year, 23 (53%) patients continued to have recurrent AT/AF with an overall median AFB of 0.36% (IQR: 0, 7.19). Outcome was similar in patients who had PVI alone and those who had additional lesions with/without PVI (Figure).

Conclusions

Following CB PVI, persistent PVI was observed in only a quarter of patients when assessed by high density, high-resolution mapping. A targeted ablation strategy based on mapping data resulted in continued AF in half the cohort, though the AFB was reduced by 84%. There is a need to identify optimal mapping and ablation strategies in patients who continue to have AF after CB PVI as well as the optimal endpoint after repeat ablation.
Left atrial posterior wall isolation using pulsed-field ablation: procedural characteristics, safety, myocardial injury and short-term outcomes
Authors: Weidlich S , Schweigler A , Serban T , Krisai P , Voellmin G , Knecht S , Sticherling C , Kuehne M , Badertscher P
Published: November 2023

Background

Pulsed-field ablation (PFA) has emerged as a novel treatment strategy for patients with atrial fibrillation (AF). Among targets beyond pulmonary vein isolation (PVI), ablation of the left atrial posterior wall (LAPW) has gained increased interest in patients with persistent AF. PFA offers a novel ablation technology possibly able to overcome the obstacles of incomplete isolation and concerns of damage to adjacent structures.

Purpose

To assess procedural characteristics, safety, myocardial injury and short-term outcomes of patients undergoing LAPW ablation in a clinical setting.

Methods

Consecutive patients undergoing PFA PVI with LAPW isolation were included. Using a multi-spline PFA catheter in a flower configuration, two anchor lesions per vein extending to the LAPW were deployed. Then, the wire was pulled back into the lumen, the PFA catheter and sheath were rotated along the entire LAPW in a flower configuration thereby creating overlapping lesions as assessed by a 3D-electro-anatomical mapping system. First-pass isolation was controlled using a multipolar mapping catheter. Complications were checked with an echocardiogram, high sensitivity cardiac troponin T was measured the next day and for recurrence detection a Holter ECG was performed during follow up.

Results

25 patients with persistent AF undergoing PVI were included (age 69 ± 12 years, left atrial volume index 37 ml/m2). 17 patients underwent redo-PVI with LAPW and 8 patients first time PVI with LAPW ablation. The median number of applications to perform LAPW isolation using PFA was 24 (IQR 14-28). The median procedure time was 69 min (IQR 56-81). The median LA dwell time was 59 min (IQR 49-72). The median fluoroscopy time was 10 min (IQR 8-14). First-pass isolation was achieved in 24/25 cases (95%). There were no complications. High sensitivity cardiac troponin T level post-procedurally was 951 ng/L (IQR 717-1189). Median duration of follow-up were 95 days, (IQR 84-184), AF recurrence was observed in 2 patients (8%).

Conclusion

LAPW ablation with PFA appears safe and results in high acute isolation rates. The optimal technique to perform LAPW ablation using PFA needs to be defined. Data on long-term outcomes are missing.
Pulmonary vein isolation with posterior wall isolation versus pulmonary vein isolation alone for patients with persistent atrial fibrillation: a systematic review and meta-analysis
Authors: Rivera A , Nascimento B N S R , Miyawaki I A , Menezes Junior A
Published: November 2023

Background

Pulmonary vein isolation (PVI) is considered the cornerstone of atrial fibrillation (AF) ablation, with a better success rate in paroxysmal AF vs. persistent AF. Although recent evidence suggests that additional ablation targets such as the left atrial posterior wall (LAPW) may play a role in improving the efficacy of AF ablation, the effectiveness of PVI combined with posterior wall isolation (PWI) remains unclear in patients with persistent AF.

Purpose

We aimed to perform a systematic review and meta-analysis of PVI with vs. without PWI in patients with persistent AF.

Methods

We systematically searched PubMed, EMBASE, Cochrane and ClinicalTrials databases for randomised controlled trials (RCTs) comparing PVI alone and PVI with PWI. The systematic review and meta-analysis followed Cochrane and PRISMA recommendations. Review Manager 5.1 was used for statistical analysis. Heterogeneity was examined with I2 statistics. Random-effect models were used if I² > 25%.

Results

We included 10 RCTs with a total of 1,415 patients, of whom 702 (49.6%) were assigned to the PVI alone group. Freedom from AF recurrence did not differ significantly between groups (OR 1.40; 95% CI 0.95-2.05; p=0.09; Figure 1A), nor did freedom from all recurrence of any atrial arrhythmia (OR 1.33; 95% CI 0.80-2.21; p=0.28; Figure 1B). No significant differences were found between the two groups in terms of left ventricular ejection fraction (p=0.24) or left atrial diameter (p=0.71). There was also no significant difference found in adverse events, including phrenic nerve injury (p=0.73), pericarditis (p=0.71), and cardiac tamponade (p=0.59). Total procedure time (MD 22.7 minutes; 95% CI 15.6-29.9; p<0.01; Figure 2A) and ablation time (MD 13.56 minutes; 95% CI 8;06-19.07; p<0.01; Figure 2B) were significantly lower in the PVI group.

Conclusion

Our findings suggest that freedom from recurrence of AF, freedom from recurrence of atrial arrhythmias, and adverse events is not significantly different between patients who undergo PVI for persistent AF with or without PWI. As expected, adding PWI to PVI was associated with a longer procedure and ablation time.Figure 1Figure 2
Left atrial fibrosis-guided ablation in patients with atrial fibrillation: a systematic review and meta-analysis of randomized trials
Authors: Ahn H J , Lee S R , Lee K Y , Choi J M , Kwon S , Choi E K , Oh S
Published: November 2023

Background

Left atrial fibrosis is related to atrial fibrillation (AF) recurrence after AF ablation. However, the benefit of patient-specific substrate modification guided by fibrosis delineated on voltage mapping or magnetic resonance imaging (MRI) is conflicting.

Objective

To compare the efficacy and safety of additional modification of left atrial fibrosis [identified by low-voltage area (LVA) or late gadolinium-enhancement on MRI] vs. circumferential pulmonary vein isolation (PVI) with or without stepwise ablation not targeting fibrosis in AF.

Methods

A systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials was performed from inception to November 2022. Only randomized studies investigating the utility of fibrosis-guided substrate modification beyond conventional PVI were included. The primary outcome was a recurrence of any atrial arrhythmia. Major adverse events and procedural, fluoroscopic, and total ablation time were defined as secondary outcomes. We calculated pooled estimates of the outcomes by a random-effect model and reported them as risk ratio (RRs) and 95% confidence interval (CI).

Results

A total of 9 studies (8 randomized controlled clinical trials and 1 randomized design within a prospective study) and 2135 patients with AF were included. The atrial arrhythmia recurrence was lower in the additional fibrosis-guided ablation group (RR 0.82; 95% CI 0.71-0.94; p=0.006) (Figure 1A). No differences were found between fibrosis-guided substrate modification and conventional PVI group in major adverse events [RR 1.25 (0.55-2.81), p=0.598)] and mean differences of procedural time [-2.88 (-40.34 to 34.57) min], fluoroscopic time [1.82 (-1.86 to 5.49) min], and total ablation time [-14.28 (-48.70 to 20.14) min]. In the stratified analyses, there were no interactions of the lower atrial arrhythmia recurrences within the modality of fibrosis identification (LVA vs. delayed enhancement on MRI), type of AF (paroxysmal vs. persistent), the burden of LVA (no or low vs. high), and strategy of the control group (PVI only vs. PVI plus stepwise ablation) (Figure 1B).

Conclusion

By incorporating two modalities of left atrial substrate evaluation – voltage mapping and MRI – we conclude that the individually tailored fibrosis-guided ablation in AF is associated with a lower recurrence after catheter ablation.
An international multicentre experience with the third-generation laser balloon system: safety, efficiency, and efficacy
Authors: Martignani C , Bartoli L , Spadotto A , Tilz R R , Heeger C H , Giaccardi M , Miracapillo G , Forleo G B , Schiavone M , Giomi A , Arena G , Ciconte G , Pappone C , Montemerlo E , Rovaris G
Published: November 2023

Background

Pulmonary vein isolation (PVI) with endoscopic laser balloon systems (ELBS) is an innovative option for catheter ablation of atrial fibrillation (AF). The third-generation ELBS has several structural improvements, including a novel feature (RAPID mode), potentially allowing a high-speed and precise circumferential PVI. Nevertheless, there is a need for large, multicentre studies on its use.

Objective

To assess the safety, efficiency, and efficacy of the third-generation ELBS in a multicentric, international cohort of patients.

Methods

We analyzed the data of all consecutive patients who underwent PVI using the third-generation ELBS between June 2019 and December 2022 in eight Italian and one German Hospital. For each pulmonary vein (PV), the maximum amount of laser delivery with the RAPID mode was attempted. When RAPID mode was not feasible, the operator used point-by-point laser delivery.

Results

We enrolled 429 patients (mean age 61.1±10.7 years, persistent atrial fibrillation 27.7%, female patients 27.7%). The operators isolated 1654 pulmonary veins. 93 (21.7%) patients had an anatomical variation of the left atrium, 60 of them had either a left or a right common trunk, and 33 had a middle PV. Mean total procedural and fluoroscopic times were 115.4±58.2 min and 19.3±12.8 min, respectively. Information on the use of RAPID mode was available for 336 patients: mean use of this feature was possible for 86±18.2 % of the PVs circumference. The operators could use the RAPID mode for at least 90% of all PVs circumference in 148 of 336 patients (44%), and ablation using only RAPID mode was possible in 79 of them (23%). 12 (2.8%) periprocedural complications occurred. There were 6 (1.4%) episodes of phrenic nerve palsy, of which only 1 (0.2%) did not completely resolve during follow up. 3 (0.7%) pericardial tamponades occurred, with a subsequent need for pericardiocentesis. Finally, there were 3 (0.7%) periprocedural transient ischaemic attacks (TIA), which resolved without sequelae. 219 patients were followed up for at least six months (mean follow-up 12.3 ± 6 months). Among these, 63 (28.8%) presented a clinical and/or subclinical recurrence after the blanking period.

Conclusion

This is the largest multicentre cohort of patients treated with the third-generation ELBS. In this multicentric international experience, the system proved to be safe, efficient and effective and the RAPID mode showed optimal applicability.
Novel technique for significant reduction of phrenic nerve injury in cryoballoon pulmonary vein isolation
Authors: Phkhaladze K , Omran H , Thale J , Sciacca V , Fink T , Isgandarova K , Braun M , Khalaph M , Guckel D , El Hamriti M , Sohns C , Vogt J , Sommer P , Imnadze G
Published: November 2023

Background/Introduction

Pulmonary vein isolation (PVI) in cryoballoon (CB) technique is a golden standard for AF treatment. However, collateral damage of non-cardiac structures, such as phrenic nerve injury (PNI) remains an Achille’s heel of CB technology.

Purpose

The purpose of this study was to develop a therapeutic concept while establishing a new technique with three consecutive steps during the procedure in order to significantly decrease the occurrence of PNI in the intervention group in comparison with control group.

Methods

We conducted a retrospective, multicenter, observational review involving 1000 patients with symptomatic, treatment-resistant atrial fibrillation (AF) within last 8 years evaluating incidence and clinical characteristics of PNI during cryoballoon PVI. Patients were divided into the control (n=750) and intervention (n=250) groups. Patients in the intervention group were treated according to the new technique with three additional consecutive steps:

A-Phrenic nerve stimulation close to the stimulation threshold (double output) instead of 10V stimulation.

B-Advance approach for right superior pulmonary vein (PV) using the pre-freezing technique.

C-Pull away after vein isolation and/or after achieving -40°C for both right-sided PVs.

Results

A total of 1000 patients with a mean age of 63 (±11) years (62.3 % male) were investigated. 59.5% (n=595) of patients were admitted with paroxysmal AF, while 40.3% (n=403) suffered from persistent and 0.2% (n=2) from permanent AF. In 95.8% (958) it was the first PVI procedure. Two subtypes of PNI including permanent (without recovery until discharge) and transient (recovery until discharge) PNI were investigated. Transient PNI occurred in 8 patients (3.2%) in the intervention group compared to 46 patients (6.1%) in the control group, p=0.07. Persistent PNI occurred in one patient (0.4%) in the intervention group compared to 23 (3.1%) in the control group, p=0.017. Any PNI occurred in 9 patients in the intervention group (3.6%) compared to 69 patients (9.2%) in the control group, p=0.004.

Conclusion

This retrospective study provides insights into the use and effectiveness of our novel technique for PVI, which could markedly reduce the incidence of PNI, especially persistent PNI.
Anticoagulation therapy in patients with atrial fibrillation and active cancer
Authors: Jaakkola J , Teppo K , Halminen O , Linna M , Haukka J , Putaala J , Mustonen P , Kinnunen J , Hartikainen J , Airaksinen K E J , Lehto M
Published: November 2023

Background

Atrial fibrillation (AF) is common among cancer patients. Oral anticoagulation therapy (OAT) is important to prevent stroke in AF patients, but active cancer may also predispose to bleeding. Current knowledge on the use of OAT among AF patients with active cancer is scarce.

Purpose

To assess the influence of active cancer on the initiation of OAT in patients with AF and to explore cancer features predicting withholding OAT.

Methods

The nationwide FinACAF registry linked data from several registries covering all levels of care as well as drug purchases and included all 123 618 patients diagnosed with incident AF in Finland during 2011- 2018 with an indication for OAT (≥1 non-sex CHA2DS2-VASc point). Patients were considered to have active cancer if they had received a new cancer diagnosis or treatment for cancer during the preceding year from AF diagnosis. The primary outcome was the initiation of OAT (including non-vitamin K oral anticoagulants (NOAC) and warfarin) and the secondary outcome the initiation of any anticoagulation therapy (AAT; including OAT and low molecular-weight heparin) during the first year from AF diagnosis.

Results

The mean age of the patients was 73.9 (standard deviation 11.5) years and 62 955 (50.9%) of them were women. Altogether, 7015 (5.7%) patients had active cancer at AF diagnosis. The median CHA2DS2-VASc (3 [interquartile range 2-4] for both groups) and HAS-BLED (2 [interquartile range 2-3] for both groups) scores were similar in patients with active cancer and those without cancer history. Patients with active cancer, compared to those without cancer history, less often initiated OAT (47.7% vs. 70.5 %) or AAT (61.8% vs. 71.8%) (Figure). In Fine-Gray regression analyses with all-cause mortality as a competing risk, after adjusting for confounding factors, active cancer remained associated with lower likelihood of OAT (adjusted subdistribution hazard ratio (aSHR 0.501) (95% confidence interval (CI): 0.485-0.518), p<0.001) as well as AAT (aSHR 0.745 (95%-CI 0.723-0.769, p<0.001) initiation. Among cancer patients, metastases, gastrointestinal cancer and radiotherapy were associated with lower likelihood of OAT initiation, while only metastases predicted lower likelihood of AAT initiation (Table). Among patients initiating OAT, active cancer was associated with lesser likelihood of choosing a NOAC over warfarin compared to those without cancer (36.0% vs. 39.2%; adjusted hazard ratio 0.712 (95%-CI: 0.640-0.792), p<0.001).

Conclusion

AF patients with active cancer are less likely to initiate anticoagulation therapy, and those starting OAT are less likely to initiate with NOACs, compared to patients without cancer history. Metastases are the most important predictor of withholding anticoagulation therapy among AF patients with cancer.
Individual risk prediction of anticoagulation in atrial fibrillation patients with cirrhosis
Authors: Kim I , Lee H W , Kim B K , Seo J W , Min P K , Choi E Y , Yoon Y W , Lee B K , Hong B K , Rim S J , Kwon H M , Kim J Y
Published: November 2023

Background

We aimed to assess absolute risk and benefit from OAC therapies in individual AF patients with liver cirrhosis (LC), and to develop the optimal dose selecting risk calculator for each patient.

Methods

We derived and validated a prediction model for major bleeding (MB) and stroke/systemic thromboembolism (SSTE) in AF patients with LC from two-center observational cohort (n=420 in derivation cohort, n=180 in validation cohort) with 4 treatment options (standard-, low-dose NOACs, warfarin, and no OACs). Readily available clinical variables were included in machine learning-based ensembled risk calculation models.

Results

Model calibration and discrimination was adequate with c-statistics of 0.77[0.66-0.87] for MB and 0.74[0.74-0.84] for SSTE. Three-year absolute risk increases (ARIs) for MB with standard-dose NOACs ranged from <10% in 37% of patients to >30% in 18% of patients, with low-dose NOACs ranged from <10% in 47% of patients to >30% in 12% of patients compared without OACs. Three-year absolute risk reductions (ARRs) for SSTE with standard-dose NOACs ranged from <7% in 48% of patients to >15% in 22% of patients, with low-dose NOACs ranged from <7% in 57% of patients to >15% in 17% of patients compared without OACs. The ARI cutoff for MB and ARR cutoff for SSTE with OAC were shown as >2.4%/year and >1.2%/year (c-statistics 0.81[0.78-0.83], 0.75[0.72-0.79]).

Conclusions

Artificial intelligence combining clinical variables was found to predict individual patient’s bleeding and stroke/systemic embolism risks well and it can also guide each patient’s appropriate OAC dose in AF patients with LC (web-calculator can be accessed as: https://riskcalc.shinyapps.io/AFLC/).
Predicting incident atrial fibrillation in patients with embolic stroke of undetermined source
Authors: Chousou P A , Chattopadhyay R , Ring L , Khadjooi K , Warburton E , Mukherjee T , Bhalraam U , Tsampasian V , Potter J , Perperoglou A , Pugh P , Vassiliou V
Published: November 2023

Introduction

Atrial fibrillation (AF) is an important potential embolic source in patients who have suffered an embolic stroke of undetermined source (ESUS). AF has been detected in over 40% of patients when monitored with an implantable loop recorder (ILR). Recent clinical trials, however, have suggested that empirical anticoagulation of all patients with an ESUS is not an effective approach to reduce stroke risk. Thus predicting which patients are most likely to develop AF is of increased importance. Risk models for predicting incident AF exist but they do not incorporate modern techniques such as advanced echocardiographic parameters to create a comprehensive risk model.

Purpose

We sought to create a multi-parametric risk score for the prediction of incident AF in patients with ESUS.

Methods

This was a single-centre retrospective study. Consecutive adult patients referred for ILR implantation following ESUS, between March 2009 and November 2019, without prevalent AF or atrial flutter, were included.

Patients’ notes were reviewed for clinical and anthropometric data. Each patients’ echo was re-reviewed both for conventional measures, and advanced parameters including left atrial strain using speckle-tracking (figure 1) and atrial electromechanical delay utilising the time from onset of the electrocardiographic P-wave to the lateral tissue Doppler A’ wave- "lateral PA".

Univariate and multivariable analyses were performed, and a subsequent Lasso regression analysis used to develop a risk prediction model. Bootstrapping was used to perform internal validation.

Results

A total of 323 patients with ESUS who underwent a loop recorder implantation were included. Incident AF was detected in 142 patients (47.1%). Increased duration of the time between the electrocardiographic P-wave and the lateral tissue Doppler A’ wave (greater lateral PA), older age, higher diastolic blood pressure, abnormal left atrial reservoir strain were most strongly associated with increased AF risk. These were combined to form the PADS score below. Model discrimination was good, with an area under the curve of 0.72.

Conclusion(s)

The PADS score is a novel risk score for the prediction of incident AF in patients who have suffered an ESUS, based on the duration of the P-wave to the lateral tissue Doppler A’ wave, Age, Diastolic blood pressure and left atrial strain reservoir . Further work is required to assess whether the PADS score can be used to risk stratify patients into a high risk group which would derive benefit from immediate anticoagulation, an intermediate risk group who require prolonged continuous monitoring and a low risk group who can continue on conventional management for their stroke.PADS formulaLA strain using speckle strain analysis
A cardiac rehabilitation and those effects using cardiopulmonary exercise testing in patients undergoing catheter ablation for atrial fibrillation
Authors: Maeda S , Kamata T K , Yonai R Y , Kawashima T K , Kawabata M K , Okishige K O , Atarashi H A , Hirao K H
Published: November 2023

Background

Patients with atrial fibrillation (AF) are more likely to have impaired social and physical function, impaired general health and mental and reduced quality of life and exercise tolerance (ET). From the AHA guideline, the indications of cardiac rehabilitation (CR) are for the patients with heart failure, coronary artery disease including coronary artery bypass graft surgery and percutaneous coronary intervention, after valve replacement, a pacemaker or implantable cardioverter defibrillator, however, the patients undergoing catheter ablation (CA) for AF is not included.

Purpose

The relationships between burden of AF and ET, and CR and those effects in patients undergoing CA for AF are unclear.

Methods

To evaluate ET, exercise intensity (METs) and oxygen consumption (VO2/W) at peak and anaerobic threshold (AT) points were measured using cardiopulmonary exercise testing (CPX) at 3 and 12 months later after the ablation procedure.

Results

This study included 50 consecutive patients (mean age: 68±12 y.o.) undergoing 1st ablation procedure for paroxysmal (PAF: n=28) or persistent AF (PEF: n=22), and all patients kept sinus rhythm after the procedure. Before ablation and after ablation 3 months later, value of exercise intensity and oxygen consumption were significantly lower in PEF patients at AT point ([Before] PAF vs. PEF = 3.3±0.7vs. 2.8±0.6 METs, p=0.02, 12.0±2.6 vs. 9.8±2.1 ml/kg/min, p=0.01, [3 months later] PAF vs. PEF = 3.7±0.9vs. 3.1±0.7 METs, p=0.04, 13.0±3.4 vs. 10.4±3.1 ml/kg/min, p=0.03, Figure 1). However, there were no significant differences between 2 groups at 12 months later. On the other hand, twenty patients received CR at hospital for 3 months (group-R) and 30 patients were recommended exercise at home (group-E). Interestingly, at 12 months after the ablation procedure, the value of exercise intensity at AT point was improved in 100% of patient in group-R versus those of 68% in group-E (+0.5±0.4 vs. +0.3±0.6 METS, p=0.02), and value of oxygen consumption at AT point was also improved in 100% of patient in group-R versus those of 68% in group-E (+2.4±2.4 vs. +1.3±3.0 ml/kg/min, p=0.02) (Figure 2).

Conclusion

This study demonstrates that AF is associated with ET and CA is effective for the improvement of their capacity. In patients with PEF, ET recovers close to PAF patients at 12 months. In addition, a CR is effective for further improvement of their capacity of ET in patients undergoing CA for AF.Figure 1Figure 2
Paradigm shift of catheter ablation of atypical atrioventricular nodal tachycardia: 3D mapping-based ablation of exits of slow pathway
Authors: Kawabata M , Maeda S , Kamata T , Kawashima T , Yonai R , Okishige K , Atarashi H , Hirao K
Published: November 2023

Background

In current practice, the ablation target of atypical atrioventricular nodal tachycardia (AVNRT) is the earliest atrial activation site in the coronary sinus (CS) or conventional slow pathway (SP) region.

Objectives

The purpose of this study was to map the site of earliest retrograde atrial activation using electroanatomic 3D mapping during atypical AVNRT and to evaluate successful ablation sites.

Methods

Forty-two patients with a total of 49 AVNRTs (slow/fast 30; fast/slow 15; slow/slow 4) underwent EP study and ablation. Among them there were 14 patients (10 women, 60±19 y/o) in whom 19 atypical AVNRT (fast/slow 15; slow/slow 4) were induced.

Results

The intracardiac electrocardiograms or 3D mapping of the exit site during tachycardia revealed that 7 patients had exit sites solely inside the CS (left inferior extension=LIE), 3 solely in the right postero-septal tricuspid annulus (TA) (right inferior extension=RIE), and 4 had both LIE and RIE exits. The distance from the CS ostium to LIE exits was 14±6 mm. RIE exits were located on the TA posterior to the CS ostium (between 5 and 6 o’clock in the LAO projection). Ablation targeting these exits or traditional SP succeeded in long term elimination of AVNRT in 13 of the 14 patients (93%). There were no complications.

Conclusions

Catheter ablation targeting the exit sites of LIE or RIE mapped at the CS or TA holds promise as an effective and safe alternative approach to the current targets of ablation for atypical AVNRT cases.Distribution of exit sites during atypicthe circuit of atypical AVNRT：the exit s
Recurrence after resolution of symptomatic atrioventricular block and correction of transient causes, should we keep an eye on everyone?
Authors: Grade Santos J , Ferreira B , Martinho M , Cunha D , Da Luz J , Ilchyshyn N , Baltasar O , Briosa A , Sebaiti S , Miranda R , Almeida S , Brandao L , Pereira H
Published: November 2023

Introduction

Atrioventricular block (AVB) can be associated with secondary causes, some of which are potentially reversible. Permanent Pacemaker (PPM) implantation is not recommended in transient causes that can be corrected and prevented. However there is a high rate of recurrence which eventually warrant PPM implantation.

Purpose

Our aim was to characterize the population which had recurrence of symptomatic AVB after having recovered from an index event and having corrected secondary causes.

Methods

We performed a retrospective analysis between February 2011 and November 2022 of all patients admitted with symptomatic second degree AVB (including 2:1 and high-grade), third degree AVB and atrial fibrillation with AVB who had a reversible cause capable of being corrected and had a recovery of rhythm without PPM implantation, in a single expert centre. AVB secondary to Acute Coronary Syndromes and patients who required PPM to tolerate bradycardia inducing drugs were excluded from analysis. Medical records were analysed for demographics, clinical data and outcomes.

Results

Of the 135 patients analysed, 25 fulfilled all inclusion criteria and were analysed. The mean age at analysis was 77±8 years with a male preponderance (52%).

The rhythm of presentation had been complete AVB for most of the cohort (68%). A prior ECG was obtained for most patients (92%), with atrioventricular (AV) conduction abnormalities identified in 28% of patients and intraventricular (IV) conduction abnormalities identified in 56% of patients. At index admission, bradycardic drug therapy was the most identified reversible cause (92%) and significant hyperkalaemia (categorized as above 5,5 mmol/L) was identified in 40% of patients.

In 20 patients (80%) there was recurrence of symptomatic AVB during follow-up (median time to recurrence of 11,5 months, minimum less than a month and maximum 130 months) which warranted a PPM implantation.

The independent predictors of recurrence were the presence of hyperkalaemia as a causal factor at index admission and of non-recurrence the dual therapy with bradycardic drugs at index admission (Qui square test for both p<0,05).

The age, sex, prior of chronic kidney disease (with or without dialysis) prior AV or IV conduction abnormality, high dose bradycardic drug therapy at index admission, association between hyperkalaemia and bradycardic drug therapy and presentation rhythm different from complete AVB were non-significant.

Conclusions

Patients with a transient cause for symptomatic AVB which recovers with its correction have a high rate of recurrence in follow-up, particularly if the transient cause was hyperkalaemia , and only the initial presence of dual bradycardic drug therapy which was suspended predicted sustained recovery.
First month global longtudinal strain for predicting early pacemaker-induced left ventricular dysfunction (PIVD) six month after pacemaker implantation
Authors: Istananda V , Iqbal M , Hasan M
Published: November 2023

Background

Pacemaker-induced ventricular dysfunction (PIVD) and pacemaker-induced cardiomyopathy (PICM) emerged as a complication following right ventricular permanent pacemaker (PPM) implantation, showing a great occurrence in the first year. Finding an early predictor of PIVD and PICM is crucial in order to alleviate mortality, morbidity, and increase health-care cost efficiency.

Purposes

to find new predictor by analyzing effect of first month GLS using 2D-speckle tracking echocardiography and reduction of left ventricular ejection fraction (LVEF), known as PIVD, in the first 6 month after PPM implantation.

Methods

A single center, prospective cohort study was conducted to all patients with normal LVEF, indicated for PPM implantation. Data of GLS was measured before and after one month of PPM implantation. Data of LVEF was measured before and six month after PPM implantation. The change of GLS in one month after PPM implantation was measured as delta GLS, and the change of LVEF in six month was measured as delta EF.

Results

Fifty-three patients from May 2018 until October 2020 was enrolled for this study based on inclusion and exclusion criteria. Patient’s baseline characteristics show 62±14 years of age, most of them had hypertension (54.7%) and had single chamber pacemaker implantation (81.1%). Study analysis reveals that ejection fraction (EF) reduce significantly after six months pacemaker implantation (66,5±5,6% become 60,7±10.7%; p= <0,00001). There were 6 patients (11.3 % ) suffering PICM. Correlation analysis between the change of GLS in the first month and the change of LVEF in the first six months after PPM implantation was statistically significant with moderate correlation (p<0.00001; r= -0.486). Linear regression analysis shows that every 1 point decrease of first month GLS, affecting 1.83 point decrease of sixth month LVEF (b= -0.1837, p=<0.00001).

Conclusion

There is significant moderate correlation between the change of GLS in the first month and early reduction of LVEF in the first 6 months after PPM implantation.The Scheme of Research Sampling Method
Procedure feasibility and mid-term follow-up of left bundle branch area pacing using stylet-driven pacing leads with a fixed-curve delivery sheath in patients with structural heart disease
Authors: Lee S R , Ahn H J , Kwon S , Choi E K , Oh S
Published: November 2023

Background

Recently, left bundle branch area pacing (LBBAP) has been performed using style-driven extendable screw-in leads with newly introduced pre-shaped delivery sheath in South Korea. There are limited data on the feasibility of LBBAP in patients with structural heart disease (SHD).

Purpose

To evaluate LBBAP procedure feasibility and mid-term follow-up data of LBBAP lead profile in pateints with SHD

Methods

Patients, in which LBBAP was attempted, were consecutively enrolled at the Seoul National University Hospital from January 2021 to December 2022. LBBAP was performed with stylet-driven lead (Solia S60, Biotronik) delivered through a delivery sheath (Selectra 3D, Biotronik). Procedure feasibility, LBBAP success rate, and mid-term LBBAP lead threshold were evaluated in patients with or without various type of SHD.

Results

A total of 121 patients were enrolled (mean age 73.5±12.2 years). Atrioventricular block was the most common indication (n=94, 77.7%), followed by atrial fibrillation with slow ventricular rate (n=12, 9.9%), sick sinus syndrome (n=10, 8.3%), and heart failure indicated cardiac resynchronized therapy (n=5, 4.1%). LBBAP success rate was 89.3% of total study population, deep septal pacing was achieved in 4.1%, and right ventricle apex pacing were performed in 6.6%. Fifty-one patients (42.1%) were accompanied by SHD (Figure). Patients with SHD had significantly lower left ventricular ejection fraction than those without SHD (54±13% vs. 62±5%, p<0.001). Baseline QRS duration was longer in patients with SHD (107±26 ms vs. 135±35 ms, p=0.005). Although LBBAP success rate was significantly lower in patients with SHD than those without in total study population (80.4% vs. 95.7%, p=0.007), LBBAP success rate was not differ between two groups after excluding first 30 cases (98.1% in patients without SHD vs. 97.4% in patients with SHD, p=0.811) (Figure). Among patients with successful LBBAP, total procedure time was longer in pateints with SHD, but there was no significant difference of fluoroscopic time, bipolar V sensing, V pacing threshold, and V impedance between the two groups (Figure). Pateints with SHD had longer left ventricular activation time (LVAT) (80±13ms vs. 72±9 msec, p=0.003), but there was no statistically significant difference in the final QRS duration between the two groups (104±14 ms in patients without SHD vs. 111±14 msec in patients with SHD, p=0.955). During mean 19±6 months follow-up, there was no significant V threshold increase in both groups.

Conclusion

LBBAP using stylet-driven pacing leads in patients with SHD is feasible and safe as in patients without structural heart disease, even by an early experienced operator with LBBAP procedure.
Exploring underlying reasons for the difference in sex-specific survival following out-of-hospital cardiac arrest - a mediation analysis
Authors: Miedel C , Jonsson M , Rawshani A , Riva G
Published: November 2023

Background

Previous studies have indicated a poorer survival among women following out-of-hospital cardiac arrest (OHCA), but the mechanisms explaining this difference remains largely uncertain. This study aimed to assess the survival after OHCA among women men and explore the role of potential mediators, such as resuscitation characteristics, prior comorbidity, and socioeconomic factors.

Methods

This was a population-based cohort study including all emergency medical service-treated OHCA reported to the Swedish Registry for Cardiopulmonary Resuscitation in 2010-2020, linked to nationwide Swedish healthcare registries. The relative risks (RR) of 30-day survival were compared among women (exposure) and men (comparison) using modified Poisson regression and third variable effect analysis to investigate the importance of potential mediators in a stepwise approach.

Results

A total of 43,226 OHCAs were included, of which 14,249 (33.0%) were women. The crude 30-day survival among women was 6.2% compared to 10.6% for men (RR 0.58, 95% CI=0.54-0.62). Stepwise adjustment for shockable initial rhythm attenuated the association to RR 0.85 (95% CI=0.80-0.92), and further adjustments for age and resuscitation factors (witness status, emergency medical service response time, and location) attenuated the survival difference between sexes to null (RR 0.98; 95% CI=0.92-1.05). Third variable effect analysis showed that shockable initial rhythm explained approximately 50% of the negative association of female sex on survival. Older age and lower disposable income were the second and third most important variables. Previously known comorbidities explained only a very small portion of the sex difference in survival.

Conclusion

Women have a lower 30-day survival following OHCA compared to men. The poor prognosis is largely explained by the absence of shockable initial rhythm, older age at presentation and lower disposable income.Results from regression analyses
Coronary artery disease and the risk of life-threatening cardiac events after age 40 in long QT syndrome
Authors: Barsheshet A , Goldenberg I , Bjelic M , Buturlin K , Erez A , Goldenberg G , Chen A Y , Polonsky B , Mcnitt S , Aktas M , Zareba W , Golovchiner G
Published: November 2023

Background

Long QT syndrome (LQTS) and coronary artery disease (CAD) are both associated with increased risk of ventricular tachyarrhythmia. However, there are limited data on the incremental risk conferred by CAD in adult patients with congenital LQTS.

Objective

We aimed to investigate the risk associated with CAD and life threatening events (LTEs) in patients with LQTS after age 40 years.

Methods

The risk of LTEs (comprising aborted cardiac arrest, sudden cardiac death, or appropriate defibrillator shock) from age 40 through 75 years was examined in 1020 subjects from the Rochester LQTS registry, categorized to CAD (n=137) or no-CAD (n=883) subgroups.

Results

Survival analysis showed that patients with CAD had a significantly higher rate of LTEs from 40 through 75 years (35%) compared with those without CAD (7%; p<0.001 for the overall difference during follow-up [figure]). Consistently, multivariate analysis showed that the presence of CAD was associated with a 2.5-fold (HR=2.47; p=0.02) increased risk of LTEs after age 40 years. Subgroup analyses showed that the presence of CAD vs. no CAD was associated with a pronounced >4-fold (p=0.008) increased risk of LTEs among LQTS patients with a lower-range QTc (<500 msec). The increased risk of LTEs associated with CAD was not significantly different among the 3 main LQTS genotypes.

Conclusions

Our findings suggest that CAD is associated with incremental risk of life threatening cardiac events in patients with LQTS. The incremental risk associated with the presence of CAD is pronounced in lower risk LQTS patients with QTc<500 msec.
Novel scoring system for predicting mortality in patients with ventricular arrhythmias: Analysis from a 24,000 patient cohort
Authors: Deb B , Rogers A J , Tjong F V Y , Somani S , Desai Y , Azizi Z , Chang H J , Bhatia N K , Clopton P , Narayan S M
Published: November 2023

Background

Several scoring systems have been developed to predict mortality in ventricular tachycardias (VT) in selected populations (for example, patients undergoing ablation) with limited follow-up times. We aimed to develop a simple scoring system to predict all-cause mortality in a large cohort of VT patients followed up for >10 years.

Methods

We mined electronic data from 2008 to 2022 from a large suburban academic and community healthcare system, for the endpoint of all-cause mortality in adults diagnosed with ventricular tachycardia using the ICD 10 code of I47.2. We related the endpoint to covariates including sex, race, socioeconomic factors and comorbidities identified with standard ICD codes (prior to the diagnosis of VT) using cox-proportional hazards model. We then tested a scoring system using coefficients developed in the training cohort (70%) in an independent test cohort.

Results

We identified 24278 adult patients diagnosed with VT. Of these, 2921 (12%) died within 249 (23,1095) days of diagnosis. Figure 1 shows factors associated with mortality, adjusted for race, gender and ethnicity, which were: congestive heart failure [HR:1.78; (1.62,1.96)] chronic kidney disease [HR:1.75; (1.60,1.91)] ,atrial fibrillation[HR:1.53; (1.40,1.67)], diabetes [HR:1.47; (1.35,1.61)] , coronary artery disease [HR:1.57; (1.43, 1.72)] , peripheral arterial disease [HR:1.29; (1.17,1.42)] , hypertension [HR:1.39; (1.26,1.54) , COPD [HR:1.21,1.50)] , and hyperlipidemia [HR:-.87; (0.80 -0.95)] . The novel 9-point (CKAD(ICV)SHL) score predicts mortality with a C-index of 0.66.

Conclusions

In a population of over 20 thousand patients with ventricular arrhythmias, a scoring system based on heart failure, CKD, AF and other factors predicts mortality. This may form a basis for revised efforts for screening, risk stratification and trial design for ICD placement and guideline directed medical management.