bluuebunny/crossref_metadata_2025 huggingface dataset:
Associations of general and abdominal obesity, and genetic risk with atrial fibrillation: longitudinal analyses in the UK biobank study
Authors: Choi S , Yang P S , Kim D , Jang E , Yu H T , Kim T H , Pak H N , Lee M H , Sung J H , Joung B
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Observational studies have shown positive associations general and abdominal obesity, and atrial fibrillation (AF). However, little is known about these associations in individuals with elevated genetic susceptibility for this disease.

Methods

The UK Biobank cohort study includes more than 502 421 participants aged 40 to 70 years who were recruited from 22 assessment centers across the United Kingdom from 2006 to 2010. A total of 339 003 unrelated individuals of white British descent with available genotype and matching genetic data and reported sex were included in this study from the UK Biobank population-based sample. Individuals were included in the analyses of AF. Data were analyzed from April 2006 to March 2015. Body mass index (BMI) and waist circumference (WC) were employed for general (BMI: underweight, < 18.5 kg/m²; normal, 18.5 to <25.0 kg/m²; overweight, 25.0 to <30.0 kg/m²; obese, > 30.0 kg/m²) and abdominal obesity (WC: ≥ 94 cm for men and ≥ 80 cm for women). Then we further examined these associations in individuals with different genetic burden by stratifying individuals based on their genetic risk scores for atrial fibrillation. We compared disease risk among individuals in different tertiles of body mass index, and abdominal obesity using lowest tertiles as reference.

Results

Of 343 165 individuals, 185 745 (54.1%) were female, and the mean (SD) age was 57.19 ± 8.01 years. During follow-up, 18 974 of 343 165 (5.5%) developed AF with 8.2% in general obesity (vs. 4.7% control, p<0.001) and 6.6% in abdominal obesity (vs. 3.4% control, p<0.001). Compared to the normal, subjects in the overweight (HR 1.11, 95% CI 1.07–1.15, p<0.001) and obese (HR 1.55, 95% CI 1.20–2.01, p<0.001), and abdominal obesity (HR 1.35, 95% CI 1.31–1.40, p<0.001) had a significantly higher AF risk. Genetic risk and general and abdominal obesity were independent predictors of incident AF, and there were no interactions. Compared with normal in the low genetic risk group, general obesity and abdominal obesity was associated with a hazard ratio of up to 3.98 (95% CI, 3.73–4.24) and 3.44 (95% CI, 3.19–3.70) for AF in the high genetic risk group.

Conclusions

General and abdominal obesity demonstrated positive associations with incident AF in the general population, as well as in individuals with elevated genetic risk for these diseases.
Myeloperoxidase causes both arrhythmogenic structural and electrical remodelling in neonatal rat ventricular myocyte monolayers
Authors: Al-Shama R F M , Ernault A C C , Meulendijks E R , Fabrizi B , Van Amersfoorth S C M , Boender A R , Coronel R , Boukens B J D , De Groot J R
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by Netherlands Organization for Health Research and Development

Background

Myeloperoxidase (MPO), an enzyme most abundantly expressed by neutrophils, is increased in the atrial tissue of AF patients and is associated with treatment failure. Moreover, MPO increases fibrosis and AF susceptibility in mouse atria. However, how MPO promotes AF has yet to be fully established.

Purpose

To investigate the role of MPO in electrophysiological and structural remodelling.

Methods

We incubated cultured neonatal rat ventricular myocyte (NRVM) monolayers with 1 μg/mL MPO or vehicle for 24 hours. We then performed electrophysiological mapping using an 8x8 multielectrode array (MEA) setup with 100 μm-sized electrodes and 700 μm inter-electrode distance (n=8 MPO, n=7 control) and recorded action potentials (AP) using a microelectrode during pacing. Additionally, we quantified the number of fibroblasts using vimentin staining (n=5/group) and the expression of extracellular matrix (ECM) genes (COL1A1, COL8A2, FN1, CTGF, TNC, THBS2, MMP2, MMP12) using qPCR (n=4/group). Multielectrode data were analyzed with custom-made software in MATLAB. Statistical analysis was performed in R. Data presented as median [interquartile range].

Results

NRVM monolayers incubated with MPO were unresponsive to pacing (5/8 vs 0/7 control) or had a higher pacing threshold (1300 [1000-2500] vs 500 [400-600] μA) (p=0.02). The percent of excitable tissue was lower in the MPO than in the control group, and the propagation of spontaneous activations was slower and more heterogeneous (index: 5 [3.6-9.5] vs 2 [1.5-3], p=0.004). More fractionated electrograms were present in MPO than in the control (29 [25-40] vs 11 [4-23] electrodes per grid, p=0.02). Re-entry was observed in 3/8 MPO-incubated monolayers vs 0/7 controls. Intracellular recordings revealed a less negative resting membrane potential (-50 [-24- -52] vs -69 [-56- -79] mV, p=0.04) and lower AP upstroke velocity (4 [2.5-14] vs 26 [22-28] V/s, p=0.01) in MPO-incubated cardiomyocytes than in the control. Moreover, relative to the control, MPO significantly increased the number of fibroblasts (126 [120-128] vs 87 [70-106] cells/0.26 mm^2, p=0.02) and the expression of MMP12 (1.17 (fold-change), p=0.04), whereas a trend toward increase was observed for other ECM genes, such as COL8A2 (1.5 (fold change), p=0.1).

Conclusion

Incubation of NVRM with MPO results in depolarization of cardiomyocytes and an increase in the number of fibroblasts and ECM gene expression. Thereby, MPO increases conduction heterogeneity and susceptibility to re-entry.
Mechanisms for increased healthcare expenditures among patients with device detected atrial fibrillation
Authors: Peigh G , Zhou J , Roberts A I , Rosemas S C , Longacre C , Schwab G , Soderlund D , Passman R S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

There are limited data on the mechanisms of increased healthcare costs among patients with atrial fibrillation (AF). Differences in healthcare expenditures at various sites of service may provide mechanistic insight into the cost differentials between patients with and without AF.

Objective

To assess for associations between sites of service and healthcare costs among patients with and without device detected AF (ddAF).

Methods

Using the de-identified Optum® Clinformatics® U.S. claims database (2015 to 2020) linked with the Medtronic CareLink® database, we identified CIED patients that transmitted data ≥6 months post-implant (baseline period). Annualized per-patient costs during follow-up, subdivided by site of service, were compared between patients with and without ddAF and adjusted to 2020 US Dollars. Analyses were adjusted for geographical region, insurance type, CHA2DS2-VASc Score, and implant year. The ten most common hospitalization diagnosis-related groups (DRG) were analyzed in patients with and without ddAF.

Results

Of the 21,391 patients (72.9±10.9 yrs; 56.3% male) analyzed, 7,798 (36.5%) had ddAF. Compared to patients without ddAF, those with ddAF had higher annualized total healthcare costs (adjusted cost ratio (CR) 1.21 (1.16-1.25); p<0.001). There were no differences in clinic health expenditures between patients with and without ddAF (adjusted CR 1.01 (0.98-1.04); p=0.63). Patients with ddAF had higher inpatient hospitalization (adjusted CR 1.29 (1.21-1.37); p<0.001), outpatient hospitalization (adjusted CR 1.20 (1.15-1.24); p<0.001), long-term care facility (adjusted CR 1.39 (1.24-1.55); p<0.001), and total pharmacy (adjusted CR 1.14 (1.10-1.19); p<0.001) costs than patients without ddAF (fig). Heart failure hospitalizations accounted for the highest percentage of analyzed DRGs. Patients with and without ddAF had similar percentages of DRGs for heart failure hospitalization (ddAF: 41.9%; no ddAF: 41.3%). Of the hospitalization DRGs analyzed, 9.7% were for arrhythmia-related hospitalizations in the ddAF cohort.

Conclusion

Increased hospitalization, long term care facility, and pharmacy costs are largely responsible for the healthcare cost differential between patients with and without ddAF. It is likely that arrhythmia-related hospitalizations account for a significant portion of the increased cost associated with ddAF. Further research into specific interventions that occur at various sites of service, which produce increased cost among patients with ddAF, is needed.
Outcomes associated with sodium glucose co-transporter 2 inhibitors in anticoagulated atrial fibrillation patients
Authors: Fawzy A M , Bisson A , Fauchier L , Lip G Y H
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Sodium glucose co-transporter 2 inhibitors (SGLT2i) have been associated with favourable outcomes in patients with heart failure. Studies also indicate a reduced risk of atrial fibrillation (AF).

Purpose

We performed an exploratory analysis to evaluate the impact of SGLT2 inhibitors in anticoagulated patients with AF.

Method

All anticoagulated patients with AF and type 2 diabetes between January 2014 and December 2018 were identified from a federated electronic medical record database (TriNetX), and followed up for 3 years. A 1:1 propensity score matched (PSM) analysis was performed to balance the SGLT-2i and non-SGLT-2i cohorts. The primary outcome was ischaemic stroke/ transient ischaemic attack (TIA), bleeding events, hospitalisation for AF and composite of cardioversion and ablations. Secondary outcomes included all-cause mortality, haemorrhagic stroke, ventricular arrhythmias, cardiac arrest, incident heart failure and composite of arterial and venous thrombotic events.

Results

A total of 236,493 and 20,841 were identified from the non-SGLT2 and SGLT2 inhibitor groups respectively. After PSM, each group had 17,968 patients. In anticoagulated AF patients, SGLT2 inhibitor use was associated with a significantly lower risk of ischaemic stroke/ TIA, hazard ratio (HR) 0.759 (95% CI 0.719-0.802), bleeding HR 0.657 (95% CI 0.619-0.697), hospitalisation for AF HR 0.875 (95% CI 0.855-0.897), and composite of cardioversion/ablations HR 0.705 (95% CI 0.655-0.759). A lower risk of all-cause mortality HR 0.481 (95% CI 0.453-0.510), haemorrhagic stroke HR 0.54 (95% CI 0.454-0.642), ventricular arrhythmias HR 0.766 (95% CI 0.719-0.816), cardiac arrests HR 0.539 (95% CI 0.476-0.611), incident heart failure HR 0.709 (95% CI 0.661-0.760) and composite of arterial and venous thrombotic events HR 0.737 (95% CI 0.712-0.763) were also observed with SGLT2 inhibitor use.

Conclusion

Our findings suggest that SGLT2i use is associated with a lower risk of AF-related complications such as ischaemic stroke/ TIA, bleeding, ventricular arrhythmias and reduced need for procedures such as cardioversion and ablations. Further studies are required to confirm this association.
Atrial fibrillation and in-hospital mortality in Covid-19 patients
Authors: Kotadia I , Dias M , Roney C , Parker R A , O'dowling R , O'hare D , Solis-Lemus J A , Sim I , Birns J , Sommerville P , Bhalla A , Newby D , Niederer S , O'neill M , Williams S E
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Wellcome/EPSRC Centre for Medical Engineering

Background

Although primarily considered a respiratory virus, cardiovascular manifestations have been reported in patients with Covid-19 infection. Atrial fibrillation has been observed as the most common arrhythmia with the prevalence rate reportedly as high as 16.5%(1).

Purpose

The aim of the study was to establish the incidence of atrial fibrillation in patients hospitalised with Covid-19 and evaluate the relationship between patient characteristics and disease severity with new-onset atrial fibrillation in patients with Covid-19.

Methods

A single centre, retrospective study of 1241 patients with a confirmed PCR diagnosis of Covid-19 admitted during the 1st wave of the pandemic (1st March to 31st September 2020). Patient demographic data, medical history and clinical outcome data were manually collected.

Results

The study population comprised of 1241 patients hospitalised with Covid-19. Of these, 94 (7.6%) patients were known to have pre-existing atrial fibrillation. In an unadjusted analysis, in-hospital mortality was twice as likely in patients with pre-existing atrial fibrillation compared to patients with no history of atrial fibrillation (odds ratio (OR): 2.18; 95% CI 1.29-3.59, p=0.002). However, after multi-variable matching for age, sex and CHA2DS2VASc score there was no significant difference between groups (OR: 1.13, 95% CI 0.57-2.21, p=0.732).

During their admission, 42 (3.4%) patients developed new-onset atrial fibrillation. New-onset atrial fibrillation was associated with an increased risk of mechanical­­­ ventilation (OR: 4.59, 95% CI 2.34-9.06, p<0.005), intensive care admission (OR: 7.19, 95% CI 3.52-15.61, p<0.005) and in-hospital mortality (OR: 3.58; 95% CI 1.78-7.06, p<0.005). Statistical significance remained after matched analysis (mechanical ventilation OR: 14.00, 95% CI 1.84-106.5, p=0.01; intensive care admission OR: 18, 95% CI 2.40-134.83, p<0.005, in-hospital mortality OR: 2.80, 95% CI 1.01-7.77, p=0.048).

New-onset atrial fibrillation was associated with older age (p<0.005), higher CHA2DS2VASc score (p<0.005), elevated white cell count (p=0.046), neutrophil count (p=0.010), C-reactive protein ( p<0.005), ferritin (p=0.020), lower albumin (p<0.005) and eGFR (p=0.013) at the time of hospital admission. No association was found with gender (p=0.683) or race (p=0.080).

Conclusion

New-onset atrial fibrillation during admission with Covid-19 is associated with both co-morbidity status and markers of disease severity at the time of hospital admission. New-onset atrial fibrillation is associated with elevated in-hospital mortality compared with patients with either pre-existing or no history of atrial fibrillation.
How often atrial flutter and atrial fibrillation coexist? Results from a large nationwide ECG-based study
Authors: Aro A , Eyob-Fesseha H , Haukka J , Halminen O , Putaala J , Linna M , Mustonen P , Hartikainen J , Airaksinen J , Lehto M
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Sigrid Juselius foundation

Finnish Foundation for Cardiovascular Research

Background

Atrial flutter (AFL) is often encountered in atrial fibrillation (AF) patients. There are many similarities in the etiology and treatment of these arrhythmias, including the need for anticoagulation for the majority, but there are also significant differences in their management. In many population-based studies AFL and AF are combined; thus, data are lacking on their individual prevalence in the general population.

Purpose

To investigate how common are isolated AF and AFL in the population and how often these two arrhythmias coexist in a patient.

Methods

All adult patients with an ICD-10 code I48 (including AF and AFL) in Finland 2004-2017 were identified from comprehensive national registries including primary and specialist care, reimbursement registries and hospitalization records. A subset of the cohort living in a region using an electronical ECG storage system had their ECG reports produced by the ECG analysis program retrieved for the analysis. ECGs with poor quality and paced or unspecified rhythm were excluded.

Results

Altogether, 1,248,851 ECGs from 85,690 patients (14.6 ECGs per patient) with the ICD-10 code I48 were included. Mean age was 70.7 ± 13.1 and 53.4% were men. ECGs documenting AF/AFL were available for 67,529 patients (78.8% of the entire ECG-cohort). 51,105 of them had ECG documentation of AF only (AF-only; 53.7% male), and 13,195 (20.5%) of patients with AF had also AFL documented in the ECG (AF+AFL; 47.6% male). 3,229 (4.8% of those with AF/AFL) presented with isolated AFL (AFL-only, 63.1% male). Of the total of 16,424 patients with documented AFL, 80.3% also had AF. The rest of the subjects did not have a 12-lead ECG in the retrieved electronic records documenting atrial arrhythmia.

Conclusions

One-fifth of the AF patients had also atrial flutter documented with a 12-lead ECG. Moreover, 80% of the atrial flutter patients experiences atrial fibrillation as well. These findings may have implications for the treatment and follow-up of these patients.
Diagnostic accuracy of smart gadgets/wearable devices in detecting atrial fibrillation in primary prevention: a meta-analysis
Authors: Vetta G , Magnocavallo M , Parlavecchio A , Caminiti R , Polselli M , Sorgente A , Pannone L , Chierchia G B , Rossi P , Bianchi S , Natale A , De Asmundis C , Della Rocca D G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia and an important risk factor for stroke and heart. Recent technology advances have allowed for heart rhythm monitoring using smart gadgets/wearable devices which can be used for early AF diagnosis.

Purpose

We performed a systemic review and meta-analysis to assess the accuracy of AF diagnosis by smart gadgets/wearable devices in primary prevention.

Methods

We systematically searched Medline, Embase and Cochrane electronic databases up to September 22th, 2022 for observational studies of the diagnostic accuracy of smartphone application, wrist-worn wearables and external devices in detecting AF in primary prevention. Studies with 12-lead ECG or single-lead ECG interpreted by a cardiologist as gold standard were included. We calculated the area under the curve (AUC) of the summary receiver operating characteristic curves (SROC) and pooled sensitivities and specificities.

Results

A total of 28 studies were included enrolling 13463 patients, 57%(95% CI: 55-59%) male with average age of 65.3years (95% CI: 60.1 – 70.4). The pooled prevalence of AF was found to be 13% (95% CI 10 – 15%). In the overall analysis of all devices, the AUC was 0.99 (95% CI: 0.97-0.99)(Figure 1), the sensitivity 93%(95% CI: 89 – 95%) and the specificity 97%(95% CI: 95 – 98%) (Figure 2). Wrist-worn wearables had AUC of 0.97 (95% CI: 0.94-0.99), the sensitivity 83%(95% CI: 52 – 96%) and the specificity 98%(95% CI: 87 – 100%). Smartphone applications had AUC of 0.97 (95% CI: 0.96-0.98), the sensitivity 92%(95% CI: 77 – 98%) and the specificity 95%(95% CI: 91 – 97%). External devices had AUC of 0.99 (95% CI: 0.97-0.99), the sensitivity 94%(95% CI: 91 – 96%) and the specificity 97%(95% CI: 95 – 98%). Single-lead ECG had AUC of 0.99 (95% CI: 0.97- 0.99), the sensitivity 93%(95% CI: 88 – 96%) and the specificity 91%(95% CI: 78 – 97%). photoplethysmography pulse waveform technology (PPG) had AUC of 0.97 (95% CI: 0.96-0.98), the sensitivity 91%(95% CI: 78 – 97%) and the specificity 95%(95% CI: 91 – 97%). Pulse beat interval technology had AUC of 0.99 (95% CI: 0.98-0.99), the sensitivity 95%(95% CI: 90 – 98%) and the specificity 96%(95% CI: 93 – 98%)

Conclusions

Smartphone application, wrist-worn devices and external devices have excellent diagnostic accuracy in atrial fibrillation diagnosis in primary prevention.
Rate control with calcium channel blockers versus betablockers in patients with paroxysmal and persistent atrial fibrillation - data from the AFFIRM trial
Authors: Koldenhof T , Van Gelder I C , Crijns H J G M , Rienstra M , Tieleman R G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Purpose

To investigate whether there are differences between nondihydropyridine calcium channel blockers and beta blockers on heart rate in patients with paroxysmal and persistent atrial fibrillation (AF).

Methods

In present analysis of the AFFIRM trial, the effect of rate control drugs on heart rate was evaluated during first reported AF-episode as well as the last recorded sinus rhythm episode prior to AF. Patients who used both rate control drugs or switched rate control drugs between the last sinus rhythm and the first AF episode were excluded.

Results

A total of 1195 patients were in sinus rhythm at baseline and used either betablockers (603, 50%) or non-dihydropyridine channel blockers (592, 50%). Of the total, 513 had at least one episode of AF while remaining on the same rate control drug, 257 (50%) of them using calcium channel blockers and 256 (50%) of them using betablockers. Mean age of patients treated with a calcium channel blocker was 70±8 years versus 68±8 for the betablocker treated patients (p=0.014). Forty-four percent were women, 31% with paroxysmal AF, and 69% with persistent AF. A resting heart rate <110 bpm during AF (lenient rate control) was achieved in 92% of patients using beta blockers and 93% of patients using calcium channel blockers (P= 0.724). Bradycardia during sinus rhythm (<60 bpm) occurred significantly less often in patients using calcium channel blockers (19%) versus betablockers (32% , P = 0.001). After adjusting for differences in patient characteristics, the association between calcium channel blockers and a reduction in sinus bradycardia remained statistically significant (OR = 0.40, 95% CI = 0.10-0.68).

Conclusion

In patients with persistent or paroxysmal AF included in the AFFIRM trial, nondihydropyridine calcium channel blocker as rate control treatment was associated with less bradycardia during sinus rhythm compared to betablockers. Resting heart rates <110 bpm during AF were achieved similarly in those treated with calcium channel blockers and betablockers.
Learning curves for pulmonary vein isolation using pulsed field ablation for atrial fibrillation
Authors: Reinsch N , Fueting A , Hartl S , Neven K
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (PAF). Only very limited data on learning curves after implementing this new technique in clinical practice exist. We present data from our experience with learning curves using pulsed field ablation for atrial fibrillation.

Methods

In patients with paroxysmal or persistent AF, PVI in conscious sedation using a steerable sheath and a pentaspline over-the-wire basket and flower PFA catheter was performed. No 3D mapping system was used. Total procedure time, left atrial (LA) dwell time, time from first to last ablation and fluoroscopy time were analysed over the course of time. First and last chronological tertiles of each parameter were compared for statistical significance.

Results

This study included a total of 147 patients (mean age: 66±10 years; 41% female). Mean CHA2DS2-VASc-score was 2,4±1,5. The procedures were performed by 4 operators (3 certified EP specialists and 1 EP fellow) in random teams of 2 operators. Median skin-to skin procedure time was 47 [40;61] min. There was a statistically significant decrease between the first and last tertiles: 53 [44;68] vs. 46 [41;54] min (p<0,01). Median LA dwell time of the PFA catheter was 37 [31;47] min. There was a statistically significant decrease between the first and last tertiles: 41 [34;53] vs. 38 [32;45] min (p<0,05). Median time from first to last ablation was 23 [20;30] min. There was no statistically significant decrease between the first and last tertiles: 23 [20;28] vs. 27 [20;31] min (p=ns). Median fluoroscopy time was 16 [12;19] min. There was a statistically significant decrease between the first and last tertiles: 17 [13;21] vs. 17 [12;19] min (p<0,05).

Conclusions

The introduction of a novel pulsed field ablation system for pulmonary vein isolation used by 4 operators leads to a significant decrease in total procedure time, LA dwell time and fluoroscopy time over the course of time, demonstrating streamlining of the ablation procedure as a whole. Time from first to last ablation remains constant, this is probably due to the standardized protocol of the ablation itself.
Robotic magnetic navigation guided catheter ablation establishes highly effective pulmonary vein isolation in patients with paroxysmal atrial fibrillation, when compared to conventional techniques
Authors: Noten A M E , Romanov A , De Schouwer K , Beloborodov V , Bhagwandien R , Hoogendijk M G , Mikheenko I , Wijchers S , Yap S C , Schwagten B , Szili-Torok T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation (CA) is an important treatment option for patients with atrial fibrillation (AF). Pulmonary vein isolation (PVI) is a pivotal part of any AF ablative therapy. Currently, there are multiple techniques available to realize PVI, including: manual guided cryoballoon (MAN-CB), manual guided radiofrequency (MAN-RF) and Remote Magnetic Navigation guided RF ablation (RMN-RF). However, there is lack of large prospective trials comparing contemporary RMN-RF with the conventional CA techniques.

Purpose

This study prospectively analyzed and compared three catheter ablation techniques in patients with paroxysmal AF.

Methods

This multicenter, prospective study included patients with paroxysmal AF who underwent their first CA procedure with one of the mentioned ablation techniques. Procedural parameters (including procedural efficiency), complication rates and freedom of AF during 12-month follow-up were compared between three study groups defined by the utilized ablation technique.

Results

A total of 221 patients were included in this study. Total procedure time was significantly shorter in MAN-CB (78±21 min) compared to MAN-RF (115±41 min) and compared to RMN-RF (129±32 min) (P<0.001), whereas it was comparable between the two RF groups. A 3% complication rate was observed which was comparable between all groups. At 12-month follow-up, we observed AF recurrence in 40 patients (19%). AF recurrence was significantly lower in the RMN-RF group (MAN-CB 19 (24%) AF recurrences, MAN-RF 16 (23%), RMN-RF 5 (8%), P=0.045; multivariate HR of RMN-RF on AF recurrence 0.32, 95%-CI 0,12–0.87, P=0.026; with MAN-CB + MAN-RF as the reference group).

Conclusion

RMN guided PVI results in high freedom of AF in patients with paroxysmal AF, when compared to cryoablation and manual RF ablation. Cryoablation remains the most time efficient ablation technique, whereas RMN has comparable efficiency with manual RF ablation.
Efficacy comparison of high and very high power short duration pulmonary vein isolation: the HPSD remap study
Authors: Szegedi N , Sallo Z , Nagy V K , Osztheimer I , Perge P , Ferencz A B , Komlosi F , Toth P , Lakatos B , Kovacs A , Merkely B , Geller L
Published: May 2023

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): An investigator-initiated study. Research grant received from Biosense Webster (IIS 653).

Background

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. The high power short duration ablation has shown good efficacy and safety profile. Recently, very high power short duration has been introduced, but initial efficacy results were discouraging.

Purpose

The goal of this study was to compare the long-term durability of PVI performed with a 90W vs. 50W power setting.

Methods

Patients were randomized in a 1:1 fashion to undergo PVI either with 90W or 50W power. The ablation protocol was the following: in the case of 50W, the ablation index target values were 400 on the posterior wall and 500 on the anterior wall, and the inter-lesion distance was <5 mm; while in the case of 90W, a 4 seconds application was delivered at each site, with an inter-lesion distance <5 mm (preferably <4 mm anteriorly). At the index procedure, PVI was demonstrated by entrance and exit block after a 20-minute waiting period. All patients underwent a protocol-mandated repeat electrophysiology study after 3 months, regardless of symptoms. At the repeat study, all sites of PV reconnection were identified and re-ablated.

Results

A total of 40 patients were included in the study (20-20 on each treatment arm). Age was 65±8 years, 19 were females, BMI was 30±3.5, and 23 patients had paroxysmal AF. The most frequent comorbidities were hypertension (n=32) and diabetes (n=14). Procedure time (75 min vs. 84 min, p=0.02), left atrial dwelling time (63 min vs. 71 min, p=0.01), and radiofrequency time (335 sec vs. 1035 sec, p<0.0001) were shorter in procedures performed with 90W compared to 50W. On the other hand, the number of radiofrequency applications was higher in the case of 90W compared to 50W (85 vs. 70, p=0.09). There was no difference in the first-pass isolation rate (80% vs. 85%, p=1.0) and in the acute reconnection rate (5% vs. 15%, p=0.6) between the 90W and 50W power settings. At the repeat electrophysiology study, PV reconnection was seen in 4 and 7 patients in the 90W and 50W groups, respectively (p=0.5). The durable isolation on a per vein basis was 92% in the 90W group and 88% in the 50W group (p=0.4).

Conclusions

A similarly high rate of durable PVI can be achieved both with 90W and 50W power settings if a slightly smaller inter-lesion distance is targeted on the anterior wall in case of 90W. Procedure time, left atrial dwelling time, and radiofrequency time is shorter with a 90W power setting compared to 50W.
Safety and efficacy of pulmonary vein isolation using pulsed field ablation with or without 3D mapping system for paroxysmal atrial fibrillation
Authors: Neven K , Fueting A , Hartl S , Reinsch N
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed field ablation (PFA) has recently been introduced as a novel routine ablation technology for paroxysmal atrial fibrillation (PAF). PFA can be performed "cryo-style" using fluoroscopy only, or additional pre- and post-ablation high-density 3D bipolar voltage maps can be performed to assess lesion formation and acute pulmonary vein isolation. We compared 6-month outcome after PFA using fluoroscopy only (X-ray) vs. PFA guided by 3D mapping (3D).

Methods

In PAF patients, PVI in conscious sedation using a steerable sheath and a pentaspline over-the-wire basket and flower PFA catheter was performed. In a subset of patients, pre- and post-ablation high-density bipolar voltage 3D maps (Carto 3D) were performed. Procedural parameters, acute success, in-hospital safety and arrhythmia recurrence were assessed over 6-month follow-up. Efficacy was evaluated by freedom from a ≥ 30-sec. recurrence of AF/atrial flutter (AFL)/atrial tachycardia (AT). Follow-up included 7-day Holter ECGs and/or telephonic interviews at days 90 and 180 after ablation.

Results

This study included a total of 101 patients (mean age: 65±10 years; 42% female) in whom 6-month follow-up data were available. There were no selection criteria for the use of 3D mapping. Pre- and post-ablation high-density maps were performed in 34/101 (34%) of patients. Mean CHA2DS2-VASc-score was 2,1±1,6. Median duration since first AF diagnosis was 21 [3-60] months. Skin-to skin procedure time was 56±20 in the X-ray group vs. 118±22 min in the 3D group, respectively (p<0,0001). Fluoroscopy time was 17±7 in the X-ray group vs. 21±6 in the 3D group, respectively (p<0,01). Acute pulmonary vein isolation rate was 100% in both groups. Primary adverse events occurred in 0% of patients in the X-ray group vs. 2/34 (6%) in the 3D group (2 pericardial tamponades), respectively (p=ns). During a mean follow-up of 204±82 days, 54/67 (81%) in the X-ray group vs. 27/34 (79%) in the 3D group remained free of any symptomatic or documented AF/AFL/AT episode after a single procedure (p=ns). In 4/13 (31%) patients in the X-ray group, a re-do procedure was performed, 2 patients had durable PVI with typical or atypical atrial flutter, 1 patient had reconnection of both posterior carinae and 1 patient had typical atrial flutter degenerating in AF. In 3/7 (43%) patients in the 3D group, a re-do procedure was performed, 2 patients had durable PVI with typical or atypical atrial flutter and 1 patient had reconnection of the LIPV.

Conclusions

PVI using PFA with or without 3D mapping system resulted in a similar 6-month atrial arrhythmia recurrence rate and safety profile. Procedure and fluoroscopy times were significantly shorter in the fluoroscopy only group.
Catheter ablation of atrial fibrillation is associated with reduced mortality in real-world swedish patients
Authors: Akerstrom F , Hutter J , Charitakis E , Tabrizi F , Drca N , Friberg L , Braunschweig F , Jensen-Urstad M
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Swedish heart-lung foundation

Swedish research council

Background

Catheter ablation of atrial fibrillation (AF) is effective in reducing symptomatic burden, however its long-term effect on stroke and mortality is still unclear.

Purpose

The aim of this study is to evaluate if catheter ablation reduces the risk for stroke and all-cause mortality risk in patients with AF in a large real-world Swedish cohort.

Methods

We retrospectively included 5,629 consecutive patients (cases) who underwent first-time catheter ablation for AF between 2008 and 2018 at three major Swedish electrophysiology sites. For every case, 10 control individuals with a diagnosis of AF and no prior stroke or catheter ablation were selected based on age and sex from the Swedish Patient Register, resulting in a control group of 48,682 patients. Propensity score (PS) matching was performed to produce two cohorts of equal size (n = 3,955) with similar demographics, comorbidities, health care utilization and medical therapy prior to inclusion (45 dimensions with non-significant standardized differences between the two cohorts). Cancer diagnosis was used as a falsification end-point to estimate similarity of the cohorts (hazard ratio [HR] 1.06, 95% confidence interval [CI] 0.92-1.23).

Results

Prior to PS-matching, patients who underwent catheter ablation were healthier (mean CHA2DS2-VASc scores 1.4±1.3 vs 1.7±1.5, p<0.001), more likely to be on antiarrhythmic drug therapy (58% vs 10%, p<0.001), had a higher median income (288 [193-420] vs 211 [144-306], p<0.001) and had more frequently university studies (45% vs 29%, p<0.001), when compared to the control group. Mean follow-up was 4.5±2.8 years. Following PS-matching, the mean age was 61±10 years, 70% were males and 47% had hypertension. Catheter ablation was associated with a lower risk for the combined primary end-point of stroke and all-cause mortality (HR 0.57, 95% CI 0.48-0.69) which occurred in 174 patients in the ablated group compared to 292 in the control group (figure). The primary end-point was driven by all-cause mortality (HR 0.51, 95% CI 0.41-0.63) with stroke reduction showing a trend in favor of catheter ablation (HR 0.75, 95% CI 0.53-1.07) (table).

Conclusions

Catheter ablation of AF may reduce the risk for all-cause mortality when compared to medical therapy in real-world Swedish patients.
Pulsed-field ablation: analysis of a new ablation technique for atrial fibrillation. A single centre experience
Authors: Sattin T , Fassini G , Cellucci S , Tundo F , Riva S , Moltrasio M , Bianchini L , Majocchi B , Pizzamiglio F , Sicuso R , Vettor G , Ribatti V , Dessanai M , Tondo C
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulsed-field ablation (PFA) is a new non-thermal, tissue-specific ablation technique. Through the application of a local electric field, it is possible to induce a selective electroporation of cardiomyocytes membranes, resulting in myocytic apoptosis and sparing of non-myocardial structures (nerves, connective tissue, esophagus, vessels).

Purpose

A new PFA system for atrial fibrillation (AF) ablation has recently been introduced in our hospital. The aim of this retrospective review is to share the initial results of our experience in terms of acute efficacy and safety.

Methods

A total of 41 adult patients suitable for AF percutaneous ablation underwent PFA between April and November 2022 in our Institute. PFA system consisted of a current generator, a deflectable sheath and a multielectrode PFA catheter. Once inside the left atrium (LA), the PFA catheter was directed to the pulmonary veins (PVs) ostia through an over-the-wire system. Then, 8 electric impulses were applied for each PV to achieve electrical isolation; in some cases, applications to the posterior left atrium wall (LAPW) were delivered to obtain LAPW isolation (LAPWI). A moderate-to-deep sedation was provided by an anesthesiologist during all the procedures. Acute ablation efficacy was defined as absence of intracavitary signals at the electroanatomic mapping and local capture failure at the pacing maneuvers. Intra and peri-procedural safety was defined as the absence of major complications (pericardial effusion/ tamponade, stroke, vascular complications, death) during the procedure and the hospitalization period.

Results

Of the 41 patients included, 24 (58.5%) were treated for paroxysmal AF and 17 (41.5%) for persistent AF. In almost all cases (n=40, 97.6%) pulmonary veins isolation (PVI) was performed; in 14 cases (34.1%, almost all persistent AF patients) a LAPWI was performed with the application of a variable number of pulses (mean value = 13). In most of the cases (n=28, 68.3%) an electroanatomic mapping was acquired before and after the ablation. Acute efficacy was observed in all PVI cases (n=40, 100%) and in all LAPWI cases (n=14, 100%).

No periprocedural major complications were observed (n=0, 0%).

Conclusions

PFA is a promising ablation technique capable of inducing selective myocytic apoptosis through electroporation, causing a thick damage across the muscle with no injury of other tissues, and could become a game changer in electrophysiology in the next future.

Our initial data report a combination of ease of use and high efficacy and safety profiles.
Pulsed field ablation in real-life atrial fibrillation patients: 1-year clinical recurrence, operator learning curve and re-do procedural findings
Authors: Ruwald M , Johannessen A , Hansen M L , Haugdal M , Worck R , Hansen J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Pulsed field ablation (PFA) is a novel method of cardiac ablation demonstrated in early preclinical and clinical settings. The aim of this study was to report the safety and clinical efficacy of pulmonary vein isolation (PVI) with PFA for real-world atrial fibrillation (AF) patients.

Methods and results

All-comer AF patients (n=121, 59% paroxysmal) were prospectively included and underwent PFA with 100% HD voltage maps performed after PVI. PVI was achieved with PFA-only in 119 (98%) of the cases. During the implementation phase the mean procedure and fluoroscopy time was reduced from 85 ± 34 to 72 ± 18 minutes (p=0.044) and 22 ±9 to 16 ±4 (p=0.034). We observed one phrenic nerve palsy with only partial remission at follow-up. Other adverse events were numerically comparable to standard PVI procedures. Over a mean follow-up of 308 ± 87 days a total of 22/121 (18.2%) cases experienced clinically significant recurrence or initiation of anti-arrhythmic drugs with Kaplan-Meier event-free estimate at 365 days of 80% (88% for paroxysmal versus 69% for persistent) Figure 1. HD mapping post-PVI showed insufficient acute lesion formation in up to 20% (60% of these right sided) resulting in additional PFA for sufficient isolation. In four of six re-do procedures significant gaps were located at the right pulmonary veins.

Conclusion

PFA was a highly efficient method to achieve PVI with reductions in procedure time and fluoroscopy over the implementation period. The safety, procedural data and clinical recurrence rates from initial trials were confirmed in real-life non-selected AF patients. More data is needed to investigate and understand the lesion durability and limitations of PFA.
Pulsed-field- vs. cryo- vs. radiofrequency ablation: one-year recurrence rates after pulmonary vein isolation in patients with paroxysmal atrial fibrillation
Authors: Kueffer T , Madaffari A , Muehl A , Maurhofer J , Stefenova A , Seiler J , Thalmann G , Kozhuharov N A , Servatius H , Tanner H , Haeberlin A , Baldinger S H , Noti F , Roten L , Reichlin T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

A multipolar pulsed-field ablation (PFA) catheter has recently been introduced and showed favorable data in terms of safety and procedural efficiency of pulmonary vein isolation (PVI) for atrial fibrillation (AF). Long-term outcome data in comparison to other ablation modalities however is lacking.

Purpose

To compare procedural and one-year recurrence data of patients with paroxysmal AF (paroxAF) undergoing a first PVI using PFA, cryoballoon ablation (Cryo), or radiofrequency (RFA).

Methods

Consecutive patients with paroxAF undergoing a first PVI with PFA at our institution from May to December 2021 were included. For comparison, patients with paroxAF undergoing a first PVI with Cryo or RFA between May 2020 and March 2021 were included. A 3-D electro-anatomical mapping system was used in PFA and RFA, but not in Cryo. The following ablation protocols were used to achieve acute PVI: In the PFA group, the standard 32-applications lesion-set and supplementary applications at the discretion of the operator. In the Cryo group, a time-to-effect plus two minutes strategy and in the RFA group following to the CLOSE protocol. Patients were followed with 7d-Holter ECGs 3, 6, and 12 months after ablation. The primary endpoint was recurrence of any atrial arrhythmias following a blanking period of 3 months.

Results

A total of 202 patients were included (PFA: 32; Cryo: 82; RF: 88). Age, gender, CHA2DS2-VASc score, LVEF and LAVI did not differ among the groups (Table). Median procedure times were shortest with Cryo (76 [interquartile range 60-95] min) followed by PFA (94 [82-110] min) and RFA (157 [126-211] min, p < 0.01). Fluoroscopy dose was lowest with RFA (1.4 [0.6-2.5] Gycm2) followed by PFA (4.8 [3.5-7.9] Gycm2) and Cryo (5.3 [2.8-10.2] Gycm2, p < 0.01). Median follow-up time in patients without recurrence was 12 [10-12] months for the PFA group, 12 [12-13] months for the Cryo group and 13 [12-13] months for the RFA group. There was a trend towards fewer recurrences of atrial arrhythmias with PFA compared to Cryo and RFA (PFA 7%, Cryo: 25%, RFA: 20%, p = 0.13, Figure).

Conclusion

Recurrences of atrial arrhythmias 12 months after PFA PVI for paroxAF may be lower compared to Cryo and RFA. Larger prospective randomized studies are needed to confirm this initial experience.
Utility of ST2 soluble biomarker in patients with atrial fibrillation and pulmonary veins isolation
Authors: Gonzalez-Melchor L , Garcia-Seara J , Martinez-Sande J L , Rodriguez-Manero M , Fernandez-Lopez X A , Minguito-Carazo C , Gonzalez T , Gonzalez-Juanatey J R
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): No fundings related

Background

Atrial fibrillation (AF) is the more frequent arrhythmia in clinical practice and the efficacy of pulmonary vein ablation has being widely demonstrated. There is still a lack of information about the predictive value of electroanatomical voltage maps or biomarkers to predict recurrence.

Purpose

ST2 soluble (ST2S) biomarker has being previously analyzed by our group in patients with AF and electrical cardioversion demonstrating utility to predict recurrence . So we sought to analyze the clinical utility of ST2S biomarker in patients with AF that underwent to an electrophysiology study and pulmonary isolation (PVI) to compare the predictive value of this biomarker.

Results

This was a prospective, observational clinical trial that included a total of 156 patients with AF who were referred to our hospital for a PVI from September 2016 to September 2019. We also included 40 matched control patients for the initial analysis. All the patients with AF underwent an electroanatomical voltage map in sinus rhythm and PVI. From the 156 PVI: 68 had paroxysmal AF and 88 persistent. ST2S mean value in AF patients was of (13178.5 pg/ml) and had no significant difference with matched controls (11016.2 pg/ml) in baseline analysis. There was no association of ST2S baseline values and recurrence in AF patients. When we analyzed by type of AF, persistent AF patients had a significantly higher level of the biomarker and there was also a significant elevation of the biomarker according to heart rate (>100 bpm) (p 0.038). We observed an elevation of the ST2S levels at 3 and 6 months follow-up with no difference according to recurrence. The levels of ST2S were lower in the cases with a lower voltage map area and in the cases with a wider lower map area but there was no a significant association nor with recurrence. In multivariant analysis only AF rhythm and LA index volume was a significant predictor or recurrence at 3 months follow-up.

Conclusions

We consider that even though there is an association with AF patients and ST2S biomarker levels, specially in those with persistent AF, in patients undergoing an PVI, ST2S values had a generalized elevation at follow-up probably related to inflammation and were not predictive of recurrence.
Effect of early pulmonary vein isolation in patients with heart failure and reduced ejection fraction
Authors: Toth P , Arnoth B , Komlosi F , Szegedi N , Sallo Z , Vamosi P , Perge P , Osztheimer I , Piros K , Abraham P , Szeplaki G , Merkely B , Geller L , Nagy K V
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) and heart failure (HF) often coexist leading to worse outcomes compared to AF or HF alone. According to the current guidelines, PVI as first-line therapy should be considered, however, the optimal timing of the procedure is still unknown.

Purpose

We aimed to investigate the effect of early PVI on all-cause mortality and AF recurrence in patients with HFrEF.

Methods

We analyzed the data of 162 patients with symptomatic paroxysmal or persistent AF and heart failure with LVEF < 50% who underwent pulmonary vein isolation between 2010 and 2022. The patients’ medical history, laboratory results, echocardiographic and periprocedural parameters were collected in a structured registry. Early PVI was defined as catheter ablation performed within 12 months of AF diagnosis. The median follow-up was 59.7 months, the minimum follow-up was 12 months. Our primary endpoints were AF recurrence after a 3 months blanking period and all-cause mortality at any time during follow-up.

Results

Among the 162 patients, 77 experienced AF recurrence and 39 patients died during the follow-up period. The median age was 63.2 years. The median LVEF was 40% for early PVI and 37% for deferred PVI. Out of the 63 patients who underwent early PVI, 33 (52%) were taking amiodarone. Patients who underwent early PVI had longer freedom from recurrence (median 833 days until recurrence for early PVI, median 696 days for deferred PVI). Early PVI was a predictor of AF recurrence (HR: 0.58 [0.32-0.94], p=0.029).Early ablation was not associated with mortality benefit. However, among those who experienced AF recurrence, repeated ablation was associated with better survival during univariate Cox regression (p=0.01). Furthermore, in multivariate model, reablation was shown to be protective of mortality (HR: 0.312 [0.113-0.865], p=0.025) in the whole cohort.

Conclusions

Our study shows that early rhythm control therapy with catheter ablation is more successful compared to deferred PVI in patients with AF and HFrEF. A redo-PVI was associated with better survival, thus a repeat ablation should be considered in case of arrhythmia recurrence in patients with AF and HF to reduce mortality.