bluuebunny/crossref_metadata_2025 huggingface dataset:
Investigating the relationship between the leukocyte telomere length and the incidence of atrial fibrillation: a study utilizing data from the UK Biobank
Authors: Kim H J , Yang P S , Kim D H , Sung J H , Jang E S , Yu H T , Kim T H , Pak H N , Lee M H , Joung B Y
Published: May 2024

Background

Atrial fibrillation (AF) is a common cardiac arrhythmia linked to a higher risk of stroke, heart failure, and death. Telomeres are DNA-protein complexes located at the end of chromosomes, and telomere length is known to be associated with biological aging and age-related disease. However, the relationship between leukocyte telomere length (LTL) and AF has been inconsistent in the literature. This study aims to clarify the relationship between LTL and AF risk using UK Biobank data and to examine the link between AF and both biological and chronological aging.

Methods

The UK Biobank cohort of 502,421 participants aged 40-70 was recruited across 22 UK centers from 2006-2010. After excluding i) missing values (n=32,219), ii) previous AF history (n=6,746) and iii) valvular heart disease (n=3,204), a total of 460,252 participants without AF (median age, 58.0 [interquartile range (IQR), 50.0–64.0] years; 208,543 [45.3%] male) were included. Participants were categorized into four groups based on the LTL, as determined by the adjusted T/S ratio from whole blood test. To investigate the intermediate phenotype prior to the onset of atrial fibrillation, we compared each group with LA maximum volume, LA minimum volume, LA stroke volume, and LA ejection fraction. Throughout the follow-up period, new-onset atrial fibrillation was documented. Survival analysis was conducted using Kaplan-Meier analysis and Cox proportional regression analysis.

Results

Among 460,252 participants without AF, the new-onset AF group had more comorbidities and lower mean LTL. Groups with shorter LTL tend to be older, and new-onset AF is more prevalent in these groups. Additionally, the incidence of comorbidities is generally higher in the groups with shorter LTL. It was observed that as the LTL shortens, the LA stroke volume decreases. The Kaplan-Meier curve demonstrated that shorter LTL correlated with increased new-onset AF risk. (Log-rank P < 0.001) However, upon examination through a multivariable univariate Cox proportional regression analysis, telomere length did not show as an independent risk factor for new-onset AF. (aHR 1.00, 95% CI 1.00-1.00, P=0.099, Adjusted T/S ratio).

Conclusion

Even though the incidence of AF increased as LTL shortened, there was no relationship between LTL and new-onset AF when the covariate was adjusted.
Left atrial low-voltage areas, but not volume, predict the recurrence of atrial fibrillation in repeat ablation procedures
Authors: Georgi C , Bannehr M , Lochmann M , Reiners D , Haase-Fielitz A , Seifert M , Butter C
Published: May 2024

Background

Left atrial (LA) low voltage areas (LVA) are a controversial target in atrial fibrillation ablation procedures. However, LVA and LA volume are good predictors of arrhythmia recurrence in ablation-naïve patients. Their predictive value in pre-ablated, myopathic atria is uncertain.

Purpose

Patient selection for repeat ablations is sometimes difficult. Predicting factors of rhythm outcome might help with the decision.

Methods

Consecutive patients with recurrent atrial fibrillation (AF) or atrial tachycardia (AT) scheduled for repeat LA ablation were included in the prospective Bernau ablation registry between 2016 and 2020. All patients received a complete LA ultra-high-density map before ablation. Maps were analyzed for LA size, LVA percentage and distribution. The predictive value of demographic, anatomic and mapping variables on AF recurrence was analyzed in univariate logistic regression and integrated in a multivariate Cox regression if the p-value was <0.250.

Results

160 patients (50.6% male, 1.3 pre-ablations, 60% persistent AF) with complete LA voltage maps were included. Mean follow-up time was 16 ± 11 months. Mean recorded electrograms (EGMs) per map were 9754 ± 5808, mean LA volume was 176.1 ± 35.9 ml and mean rate of LVAs < 0.5 mV was 30.6% ± 23.1%. Baseline characteristics are depicted in table 1. During follow-up recurrence rate of AF or AT > 30 seconds was 55.6%. Patients with recurrence had a significant higher percentage of LVAs (40.0% vs. 18.8%, p<.001) but no relevant difference in LA volume (172 vs. 178 ml, p=.299). ROC curves revealed a cut-off of 22% LVAs with highest sensitivity (73.0%) and specificity (71.8%). Based on this cut-off event free survival was significantly higher in the Low LVA group (p<0.01), Figure 1. Other relevant clinical, anatomic or laboratory predictors could not be found in multivariate Cox regression analysis.

Conclusion

The amount of left atrial LVA is a good predictor for arrhythmia recurrence, even in a cohort of repeat ablations with progressively diseased atria. EAM derived left atrial volume has minor impact on recurrence in this group and should not solely guide the decision in favor or against further invasive treatment. Accomplishing a thorough 3D map of the left atrium to account for LVA should be mandatory in all repeat procedures.Baseline CharacteristicsKaplan-Meier for recurrence and voltage
One-year effectiveness and safety outcomes of edoxaban treatment in Chinese patients with atrial fibrillation: First snapshot of more than 4,800 patients from the ETNA-AF-China study
Authors: Guo X Y , Du J , Yin Y H , Heng Q , Jia Z S , Ji X J , Zhang Y Q , Liang X , Deng B , Liu J Y , Yi Y , Liu M Q , Chen C , Unverdorben M , Ma C S
Published: May 2024

Background

Direct oral anticoagulants (DOACs) have become the first-line therapy for ischaemic stroke prevention in atrial fibrillation (AF) patients. Data on the effectiveness and safety of single DOAC in large Chinese populations are scarce.

Purpose

We firstly present the one-year outcome data of edoxaban treatment in 5001 Chinese AF patients.

Methods

This is a multi-centre, prospective, observational study, ETNA-AF-China, conducted in 89 centres from four economic regions in Mainland of China with a follow-up of two years. Primary endpoint of safety [bleeding events including intracranial hemorrhage (ICH), all-cause and cardiovascular (CV) mortality] and efficacy endpoints [stroke, systemic embolic events (SEE), transient ischemic attack (TIA)] were adjudicated. Annualised event rates and Kaplan­Meier (KM) survival curves are given.

Results

A total of 4822 patients (57.1% male) using edoxaban (60 mg OD: n=2614, 30 mg OD: n=2208) who completed one-year follow-up were included in the full analysis set. The mean (SD) age of the overall patient population was 70.3 (9.5) years, CHA2DS2-VASc and HAS-BLED scores were 2.9 (1.4), 1.7 (1.0), with creatinine clearance (CrCl) of 71.2 (27.7) mL/min. Patients receiving 30 mg OD edoxaban at baseline were older (73.4 vs 67.7 years), with higher CHA2DS2-VASc score (3.3 vs 2.6), larger percentage of frail (9.9% vs 3.4%), and higher renal impairment (defined as CrCl ≤80 mL/min, 70.3% vs 42.9%). Annualised rates for all-cause and cardiovascular death in the overall population were very low with 2.22%/year and 0.41%/year, respectively. (Figure 1) The death rates were nearly three times lower in those receiving standard dose (60 mg) than reduction dose (30 mg) of edoxaban. Annualised event rates for all stroke/SEE (1.03%/year) and ischemic stroke (0.60%/year) were similar between two dose groups. Overall, annualised rates for major bleeding (1.03%/year), ICH (0.18%/year), major gastrointestinal (GI) bleeding (0.48%/year) events were relatively low, and those on 60 mg dose experienced less above bleeding events. Cumulative survival analysis demonstrated a slow increase in time-to-first event curve of all-cause death; and from baseline to 1-year follow-up, significant lower events of all-cause death (log-rank p<0.001), major bleeding (p=0.002) in 60 mg vs 30 mg edoxaban groups. (Figure 2).

Conclusion

Low incidences of major bleeding, notably ICH, major GI bleeding, and CV death were observed in unselected 4822 patients with AF during 1-year of edoxaban treatment. These findings confirm the effectiveness and safety of routine edoxaban use in China, consistent with other countries, and reinforce the results of the ENGAGE AF-TIMI 48 trial.Figure 1Figure 2
Effects of long-term continuous screening for atrial fibrillation on heart failure events - results from the randomized LOOP Study
Authors: Xing L Y , Hojberg S , Krieger D W , Graff C , Olesen M S , Healey J S , Mcintyre W F , Brandes A , Kober L , Haugan K J , Svendsen J H , Diederichsen S Z
Published: May 2024

Background

Previous research established a solid link between atrial fibrillation (AF) and heart failure (HF). However, while two landmark trials have assessed AF screening for stroke prevention, the potential impact of AF screening on HF remains unclear.

Purpose

This secondary analysis of the LOOP Study aimed to investigate the effects of AF screening on HF events.

Methods

The LOOP Study was a randomized clinical trial evaluating long-term continuous AF screening with implantable loop recorder (ILR) in individuals aged 70-90 years and with ≥1 of arterial hypertension, diabetes mellitus, HF, and/or prior stroke. At inclusion, study participants were randomized 1:3 to either ILR screening or usual care. Anticoagulation was recommended upon AF detection, whereas other treatment was left to the discretion of the treating physician. In this secondary analysis, a cause-specific Cox regression model was applied to explore the effects of AF screening vs usual care on 1) time-to-first HF event and 2) total HF events, with the latter performed using the Andersen-and-Gill extension. HF event was defined as newly diagnosed HF with left ventricular ejection fraction ≤40% or any HF hospitalization in participants with prior diagnosis of HF with reduced ejection fraction.

Results

In total, 6004 participants were enrolled in the LOOP Study: 1501 in the ILR group vs 4503 in the Control group. The study population had a mean age of 75 years and slightly more males than females (53% vs 47%), whereas 266 (4.4%) were previously diagnosed with HF at baseline. During a median follow-up of 5.4 years, a total of 208 HF events were reported in 175 (2.9%) participants: 37 events among 34 (2.3%) participants in the ILR group vs 171 events among 141 (3.1%) participants in the Control group. For time-to-first HF event, the annualized event rate was 0.44%/year [95% confidence interval (CI): 0.30-0.62] vs 0.61%/year [95% CI: 0.51-0.72] for ILR vs Control, corresponding to a hazard ratio (HR) of 0.72 [95% CI: 0.50-1.05]. When assessing total HF events, a significantly lower event rate was observed in the ILR group (0.47%/year [95% CI: 0.33-0.65]) compared with the Control group (0.73%/year [95% CI: 0.62-0.84]), resulting in a HR of 0.65 [95% CI: 0.44-0.97].

Conclusions

Among elderly individuals with additional stroke risk factors, long-term continuous AF screening led to a significantly reduced risk of total HF events, compared with usual care. This should be considered as hypothesis-generating and warrants further investigation.Cumulative incidence of HF event
Early rhythm control in patients with recently diagnosed atrial fibrillation: findings from the GLORIA-AF Registry Phase III
Authors: Corica B , Romiti G F , Proietti M , Mei D A , Boriani G , Ding W Y , Olshansky B , Huisman M V , Lip G Y H
Published: May 2024

Background

Early rhythm control (ERC) can improve outcomes in select patients with atrial fibrillation (AF) but real-world data are lacking.

Purpose

To evaluate the effectiveness of ERC in a real-world cohort of AF patients.

Methods

From the global, prospective GLORIA-AF Phase III Registry, adult patients with recent diagnosis (< 3 months and < 4.5 months in Latin America) of AF and CHA2DS2-VASc score ≥1 were included. ERC was defined as treatment with an antiarrhythmic drug, catheter ablation, or cardioversion at the baseline. Multivariable logistic regression analysis determined the odds of receiving ERC and an oral anticoagulant [OAC] with results reported as adjusted Odds Ratio (aOR) and 95% Confidence Intervals (95%CI). Risk of major outcomes was determined using multiple Cox regression analyses. The primary outcome was a composite of all-cause death and major adverse cardiovascular events (MACE). Secondary outcomes included all-cause death, thromboembolism and major bleeding. Results were reported as adjusted Hazard Ratio (aHR) and 95%CI.

Results

21,051 AF patients (age: 70.2±10.3, 45% female) were included. Of these, 6,932 (32.9%) received ERC, while 14,119 (67.1%) did not. Patients receiving ERC were younger with a higher prevalence of paroxysmal AF (62.8% vs. 53.2%) and heart failure (23.1% vs. 21.4%). They were less likely to have prior stroke/transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), and they had a lower mean CHA2DS2-VASc score (3.0±1.5 vs. 3.3±1.5). Age ≥75 [aOR: 0.53; 95%CI (0.0.49-0.57)] and age 65-75 [aOR: 0.76; 95%CI (0.70-0.82)] were associated with lower odds of receiving ERC. Those with prior stroke/TIA [aOR: 0.55; 95%CI (0.50-0.61)] and COPD [aOR: 0.82; 95%CI (0.71-0.94)], as well as patients with more sustained form of AF and patients recruited in North America were less likely to receive ERC. Conversely, female sex, higher symptom burden, hypertension and coronary artery disease were associated with higher odds of receiving ERC (Figure 1). Patients who received ERC were more likely to receive OACs [aOR: 1.36; 95%CI (1.25-1.48)].

Survival curve for the primary outcome according to ERC are shown in Figure 2. During a median follow-up of 3.0 [IQR: 2.9-3.1] years, ERC was associated with lower risk of the primary composite outcome (aHR: 0.88, 95% CI:0.80-0.96, p=0.006); Similar results were observed for the secondary outcomes.

Conclusions

In a real-world population with recently diagnosed AF, clinical risk factors and characteristics were associated with ERC. Patients who received ERC had a reduced risk of major outcomes. These findings suggest that in real-world patients with AF, ERC may provide beneficial effects on long-term outcome.Odds Ratios to be treated with ERC.Survival curve.
The effect of amiodarone given periprocedurally on the effectiveness of catheter ablation in patients with persistent atrial fibrillation refractory to cardioversion
Authors: Ehrenhalt G , Ciszewski J , Farkowski M , Baranowski R , Rymuza H , Jedrzejczyk B , Jankowska A , Kowalik I , Maciag A , Syska P , Lewandowski M , Kolakowski K , Zalewska J , Pytkowski M
Published: May 2024

Background

Rhythm control strategy in patients with persistent atrial fibrillation refractory to electrical cardioversion (AF-REC) poses an important clinical problem. Little is known about the effect of amiodarone therapy given periprocedurally with catheter ablation on maintaining sinus rhythm in this group of patients.

Purpose

This study aimed to determine whether initial amiodarone therapy introduced prior to AF ablation and continued for one month after the procedure affects the long-term effectiveness of the rhythm control strategy in patients with AF-REC.

Methods

We conducted a retrospective case-control study of medical records of AF-REC patients treated periprocedurally with amiodarone in addition to pulmonary vein isolation. Data on comorbidities, transthoracic echocardiogram results, and short- and long-term effectiveness of ablation was extracted. Patients were followed up in the out patient clinic with the use of a 72-hour Holter monitoring and telephone interviews. AF recurrence was defined as ≥ 30s episode of atrial tachyarrhythmia.

Results

The analysis comprised 56 patients: 37 in the amiodarone and 19 in the control group; 12 women, mean age 57 years, mean follow-up of 39.5 months. Amiodarone was discontinued after 1 month at the most after the ablation in all of the patients. The primary endpoint (AF-free survival) was achieved in 17 (45,9%) pts in the amiodarone group and 3 (15,8%) pts in the control group (p=0.026). On multivariable analysis, amiodarone therapy was the only variable correlating with the primary endpoint: OR 6.8 (95% CI: 1.4 - 33.9), p=0.019. Conversion of AF from persistent to paroxysmal or no AF in the follow-up was achieved in 32 pts (86,5%) in the amiodarone group and 9 pts (47,4%) in the control group: OR 8.0 (95% CI: 2.1 - 30.0), p=0.002. Patients in the amiodarone group experienced a borderline better increase of left ventricular ejection fraction: ∆ 5.2% (95% CI: -0.1 - 10.5), p= 0.054.

Conclusion

Periprocedural use of amiodarone in patients ablated due to persistent atrial fibrillation refractory to electrical cardioversion may lead to significantly better long-term efficacy of catheter ablation in this group of patients.
J-curved phenomenon between the prevalence of left atrial low-voltage areas and body mass index existed in patients with atrial fibrillation ablation
Authors: Matsuda Y , Masuda M , Uematsu H , Sugino A , Ooka H , Kudo S , Fujii S , Asai M , Okamoto S , Ishihara T , Nanto K , Tsujimura T , Hata Y , Higashino N , Mano T
Published: May 2024

Background

Left atrial low-voltage areas (LVAs) were known to be associated with atrial fibrosis and atrial fibrillation (AF) recurrence after catheter ablation. However, the association between body mass index (BMI) and prevalence of LVAs has not been fully elucidated. We hypothesized that LVAs were more frequently found in patients with abnormal BMI than in those with normal BMI.

Purpose

The purpose of this study was to clarify the association between body mass index (BMI) and the prevalence of LVAs in patients with AF ablation.

Methods

Between December 2014 and March 2022, 1,479 (age, 68±10 years; female, 500 [34%]) consecutive patients who underwent initial AF ablation were enrolled. BMI was divided into four groups, namely <18.5 kg/m², 18.5-25 kg/m², 25-30 kg/m², ≥30 kg/m². LVAs was defined as areas with bipolar voltage of <0.5 mV covered ≥5 cm² of left atrium. Rhythm outcome following the catheter ablation procedure was also followed for 24 months.

Results

LVAs were found in 349 (24%) patients. J-curved phenomenon existed between BMI and the prevalence of LVAs (Figure 1). In particular, BMI <18.5 kg/m² was an independent predictor of LVAs on multivariate analysis (odds ratio, 1.9; 95% confidence interval: 1.01–3.5; p=0.046). As for rhythm outcome, there was significant difference in freedom from AF recurrence among groups stratified by BMI (Figure 2).

Conclusions

Between BMI and the prevalence of LVAs, J-curved phenomenon existed in patients with AF ablation. There was significant difference in rhythm outcome following AF ablation among groups stratified by BMI.Figure 1Figure 2
Efficacy of laser balloon left atrial roof ablation for patients with atrial fibrillation
Authors: Yamasaki T , Kakita K , Pak M , Hattori T
Published: May 2024

Background

The roof area ablation beyond pulmonary vein (PV) isolation (PVI) using a cryoballoon has been described as an effective therapy for patients with atrial fibrillation (AF). However, the effect of roof area ablation performed with a visually guided laser balloon (VGLB) remains to be elucidated.

Purpose

This study aims to investigate the efficacy of roof area ablation using VGLB.

Methods

A total of 325 patients with AF (paroxysmal AF=199, persistent AF=126) who underwent VGLB ablation from July 2018 to May 2022 were analyzed retrospectively. After initial circular isolation, VGLB was inflated to a larger size on both sides of superior PVs, and the isolation areas were extended to the roof portion. At the end of the procedure, left atrial (LA) voltage mapping was obtained to assess the LA roof scar area, and differential pacing was performed to confirm the complete conduction block. Our study population was divided into the PVI group (LB-PVI, n=228) and the roof line block beyond PVI group (LB-Roof, n=97). The efficacy endpoint was defined as freedom from atrial tachyarrhythmia (ATa) between months 3 and 12.

Results

One-year clinical follow-up could be obtained in 170 patients with LB-PVI and 81 patients with LB-Roof. The Kaplan-Meier survival curves are shown in Figure. At the end of the 12 months of follow-up, freedom from ATa was 80.8% in patients with LB-PVI and 91.2% in LB-Roof. The ATa freedom rate was significantly higher in the LB-Roof than in the LB-PVI (P=0.03).

Conclusion

The roof area ablation using VGLB was proved to be effective for patients with AF.The Kaplan-Meier survival curves
Direct epicardial validation of posterior wall isolation in persistent atrial fibrillation: pulsed field versus radiofrequency ablation
Authors: Compagnucci P , Solimene F , Tondo C , La Fazia V M , Schillaci V , Mohanty S , Cipolletta L , Fassini G M , Chiariello P , Mottola G , Schiavone M , Casella M , Dello Russo A , Natale A
Published: May 2024

Background

Lesion transmurality is an important determinant of durable effectiveness of catheter ablation (CA) for atrial fibrillation (AF). The impact of different energy sources on the achievement of transmural left atrial (LA) ablation has not been explored so far.

Purpose

We sought to compare the transmurality associated with pulsed field ablation (PFA) and radiofrequency (RF) ablation of LA posterior wall (PW) among patients with persistent AF.

Methods

Eight patients (mean age, 70±7 years; 88% male) undergoing CA for persistent AF with PW ablation and adjunctive high-density epicardial mapping were included in a multicenter international registry. In four patients, PW ablation was performed using PFA, while in the remaining four, RF energy was used with high/very-high-power short-duration settings. The primary study outcome was transmural PW isolation (PWI) with endocardial-only ablation.

Results

A trend towards shorter times required to complete endocardial PW ablation was observed with PFA compared to RF (9±1 vs 11±2min, p=0.065). At endocardial mapping, apparent PWI was observed in all cases. However, transmural PWI after endocardial-only ablation was demonstrated in each patient in the PFA group, but only in one RF case, in whom 50 Watt/≥10 sec settings were used (100% vs 25%, p=0.143). Interestingly, in three patients in the RF group, endocardial ablation resulted in conversion of AF into atypical flutter, which could be successfully terminated by epicardial ablation.

Conclusions

We observed a trend towards greater transmurality with PFA compared to high/very-high power RF ablation in the region of septopulmonary bundle. This observation may have potential implications on clinical outcomes after endocardial AF CA.
Impact of restoration of sinus rhythm after catheter ablation of atrial fibrillation on reverse cardiac remodelling
Authors: Alatic J , Suran D , Pirnat M , Vokac D , Naji H F
Published: May 2024

Introduction

Catheter ablation (CA) with pulmonary vein isolation (PVI) has become widely used for the treatment of atrial fibrillation (AF). Restoration of sinus rhythm in patients with AF is of vital importance, because AF induces the development of heart failure (HF) through various pathophysiological mechanisms, one of them is epicardial adipose tissue (EAT). EAT is a type of visceral adipose tissue that is in direct contact with the myocardium. Under pathological conditions it serves as a direct and indirect factor in pathogenesis of AF. It is also an established prognostic factor after CA of AF recurrence. Since cardiac magnetic resonance (CMR) represent the gold standard for the measurement of volume and muscle mass, it has been used more and more for the assessment of EAT volume lately.

Purpose

The aim of our study was to investigate the impact of restoration of sinus rhythm on EAT volume, and cardiac function and morphology evaluated by the CMR.

Methods

We prospectively included 17 patients with paroxysmal and persistent AF that were referred for CA. All patients underwent cardiac magnetic CMR prior to radiofrequency CA with PVI and 6 months thereafter in order to quantify periatrial EAT volumes and evaluate cardiac morphological and functional characteristics. AF recurrence rate was diagnosed by serial ECG recordings, Holter ECG monitoring and AF suggestive symptoms within 6 months of follow-up period.

Results

17 patients, mainly male (76.5 %) with an average age of 62.35 ± 12.10 years were included in our study. The average body mass index (BMI) was 29.0 ± 4.71 kg/m2. Most patients had paroxysmal AF prior to CA (88.2 %). The recurrence rate of AF was 35.3 % after 6 months of follow-up. By performing CMR after 6 months of CA we observed lower median periatrial EAT volume (36.00 mL (IQR 38.25 mL) vs. 27.45 mL (IQR 30.94 mL); p= 0.004) and lower median left ventricular mass (LVM) (104.0 g/m2 (IQR 38 g/m2) vs. 100.0 g/m2 (IQR 42 g/m2); p= 0.019). Furthermore, when patients were stratified based on the AF status after the follow-up period, we observed that the patients who remained AF-free had significantly lower median periatrial EAT volumes (38.90 mL (IQR 43.84 mL) vs. 26.83 mL (IQR 33.25 mL); p= 0.003) and median LVM (96 g/m2 (IQR 35 g/m2) vs. 90 g/m2 (IQR 29.8 g/m2); p= 0.041) compared to the group of patients who relapsed where we did not observe a significant change in periatrial EAT volume (23.76 mL (IQR 26.84 mL) vs. 31.28 mL (IQR 27.84); p= 0.345) or LVM (117.5 g/m2 (IQR 34 g/m2) vs. 112 g/m2 (IQR 28.6 g/m2); p= 1.0). Significant correlation was observed between BMI and periatrial EAT volume (p= 0.029).

Conclusions

Restoration of sinus rhythm after CA of AF is associated to lower periatrial EAT volume and LVM. Patients who relapsed did not show reverse cardiac remodelling. Periatrial EAT volume significantly correlates with BMI.
Weight change does not impact the long-term outcomes following pulmonary vein isolation in obese patients with atrial fibrillation
Authors: Musat D , Milstein N S , Park L S , Bhatt A , Habibi M , Kochav S , Preminger M , Sichrovsky T , Shaw R , Mittal S
Published: May 2024

Background

Weight loss has been shown to reduce the burden of atrial fibrillation (AF) in obese patients. However, there are limited data on the impact of weight loss on long-term outcomes in patients with atrial fibrillation (AF) who undergo pulmonary vein isolation (PVI).

Objective

To understand the impact of weight change, as assessed by freedom from recurrent AF, in obese patients undergoing cryoballoon (CB) PVI.

Methods

We enrolled consecutive obese (BMI ≥ 30 kg/m2) patients with AF who underwent CB PVI; all patients had an implantable loop recorder (ILR) for long-term ECG monitoring. The cohort was divided into 3 groups based on their weight change 1-year after ablation: (1) weight loss (WL) > 3% weight decrease; (2) no weight change (NWC) - weight change < 3%, (3) weight gain (WG) > 3% weight increase. We assessed long-term AF recurrences, after excluding an initial 3-month post-ablation blanking period.

Results

Out of total of 137 pts with obesity, 61 pts had weight available at the ablation and at 1-year follow-up (65 ± 9 years; 41 [67%] male; 23 [38%] PAF; CHA2DS2-VASc 2.9 ± 1.7). There were no differences in baseline characteristics. At follow-up, 24 (39%), 26 (43%), and 11 (18%) pts lost, had no change, or gained weight, respectively. Of the 24 pts who lost weight, 3 pts lost > 10% body weight. During a follow-up of 964 ± 512 days, 41 (67%) pts had recurrent AF; the change in weight did not impact outcomes (Figure), including those who lost > 10% body weight.

Conclusions

During 3-years of follow-up, 2/3 of obese patients had objective evidence of AF recurrence following CB PVI. Weight change in the first-year post ablation did not alter long-term outcomes. Other strategies may be needed in these patients to improve outcomes.
Real-world multicenter registry on a novel focal lattice tip catheter toggling between pulsed electric field and radiofrequency for atrial tachyarrhythmia ablation
Authors: Della Rocca D , Vetta G , Mene R , Pannone L , Betancur A , Sorgente A , Almorad A , La Meir M , Del Monte A , Marcon L , Combes S , Boveda S , De Asmundis C , Sarkozy A , Chierchia G B
Published: May 2024

Background

Pulsed field ablation (PFA) has emerged as a novel non-thermal energy source for cardiac tissue ablation. A novel focal 9mm lattice tip catheter, namely Sphere-9 (Affera Inc), has recently received regulatory approval; the technology is part of a technology that allows the delivery of either pulsed electric field or radiofrequency energy and incorporates a proprietary 3D electroanatomical mapping system.

Purpose

To describe the first real-world, multicenter experience with the AfferaTM system.

Methods

Consecutive AF patients undergoing first-time or redo atrial tachyarrhythmia ablation with the AfferaTM system in two different centres between August and November 2023 were prospectively enrolled. PFA was always used to ablate the posterior left atrium, whereas anterior applications were performed using either radiofrequency energy (RF/PF strategy) or PFA (PF/PF strategy) based on operator's discretion. Data on first-pass pulmonary vein isolation (PVI) and posterior wall isolation (PWI), as well as success rate of extrapulmonary ablation were reported. Primary safety endpoint included any technology-related periprocedural complications.

Results

46 patients (mean age: 67±10; 41.3% males, 60.8% non-paroxysmal AF) were included.

5 (10.8%) patients were in atrial flutter (AFlu) at the beginning of the procedure, whereas AF was the rhythm at presentation in 19 (41.3%) others.

First-time PVI was performed in 37 (80.4%) patients, 68.4% of whom received concomitant PWI. PVI was performed with PFA-only in 27% of them. First-pass isolation was achieved in 97.3% and 100% of PVI and PWI cases, respectively.

Additional lesions included an anterior or posterior mitral line (6 and 15 patients), CTI (4 patients) or substrate ablation in 3 patients. Evidence of first-pass line block was documented in 96.4% of patients.

The remaining 9 (19.6%) patients had already undergone a previous ablation; remapping showed 27.7% of PVs requiring reisolation. PWI was performed in 88.9% of them, for the first time (75%) or due to reconnection (25%). Additional lesions included an anterior or posterior mitral line (3 and 3 patients) or CTI in 2 patients. Evidence of first-pass line block was documented in 100% of patients.

In 3 AFlu patients, the arrhythmia was mapped and termination was achieved while performing an AML (2 patients) and CTI (1 patient).

Procedural duration was 96.5±15.6 min for first time and 97.8±12.6 min for redo procedures. Mean left atrial dwelling and fluoroscopy times were 75.4±17.6 min and 7.36±2.1 min, respectively.

No technology-related complications were documented.

Conclusions

AF ablation with the focal 9-mm lattice tip catheter Sphere-9 confirmed high efficacy and safety in a real-world population.
Advanced pulsed field ablation: comprehensive analysis of safety and efficacy in a real-world cohort
Authors: Parwani A , Mahrous N , Rozados Da Conceicao C , Baehr F , Schoeppenthau D , Blaschke F , Dagres N , Hindricks G , Boldt L H
Published: May 2024

Background

Pulsed field ablation (PFA) represents a novel energy modality for catheter ablation of atrial fibrillation (AF). Initial preclinical and clinical studies indicate a higher safety profile with promising efficacy outcomes as well as shorter procedure times. Real world data are sparce and methods to improve clinical success rates are under development.

Methods

In this observational study 124 patients underwent pulmonary vein isolation with PFA (Farapulse, Boston) for paroxysmal and persistent AF. For anatomical visualization and optimal positioning of the PFA catheter a 3D mapping system was used (Ensite X, Abbott). Patients were followed over a 15-month period to evaluate both efficacy and safety of PFA in a real-world cohort using an advanced mapping technology.

Results

The patient cohort had a mean age of 67 ± 11 years, 38% females (n= 47), paroxysmal AF 53% (n = 66), persistent AF 47% (n = 58). Acute pulmonary vein isolation (PVI) rate was 100%. After a median FU of 6 months, 17 patients (14%) had a recurrence of AF.

In our study population no esophageal complications, pulmonary vein stenosis, or persistent phrenic palsy occurred. Major complications were observed in 2.4% of the cases (3/124), involving two pericardial tamponades (1.6%) and one vascular complication with intervention (0.8%). There were no stroke events and no occurrences of death. Noteworthy was the absence of complications such as coronary arterial spasm or hemolysis-related acute renal failure. The average dose-area product and average procedure time were 9.54 ± 7.68 µGym² and 57.94 ± 18 minutes, respectively.

Conclusion

PVI with PFA in a real world cohort demonstrates a high safety profile. Furthermore, high clinical success rates can be achieved also in mixed paroxysmal/persistent AF populations. The use of 3D mapping systems might even improve clinical outcomes of PVI with PFA and will also help to guide more complex ablation strategies in the future. These findings pave the way for further exploration into the long-term benefits and broader applicability of PFA in AF ablation.
LINAC-Based STereotactic Arrhythmia Radioablation (STAR) for paroxysmal atrial fibrillation in elderly: a prospective phase II trial
Authors: Romanazzi I , Di Monaco A , Valenti N , Grimaldi M
Published: May 2024

Background and aims

Stereotactic arrhythmia radioablation (STAR) is a novel therapeutic approach for cardiac arrhythmias. The aim of this trial is to investigate the feasibility of STAR for the treatment of paroxysmal atrial fibrillation (AF) in elderly patients.

Method

inclusion criteria were: age > 70 years, symptomatic AF, antiarrhythmic drugs failure or intolerance. All patients underwent to 4D cardiac Computed Tomography simulation. The clinical target volume was identified in the area around pulmonary veins (PV). STAR was performed with a total dose of 25 Gy (single fraction) delivered in 3 minutes.

Results

Twenty patients were enrolled and 18 underwent STAR. One patient withdrew informed consent before treatment and 1 patient was excluded due to unfavorable esophagus position. With a median follow-up (FU) of 16 months (range 12-23), no acute toxicity more than grade 3 was reported. Five patients had a grade 1 esophagitis 24 hours after STAR; eight patients had an asymptomatic grade 1 pericardial effusion, one patient had a torsade de pointes treated effectively by electrical cardioversion and subsequent cardiac ICD implantation. Most patients had a significant reduction in AF episodes. Five patients, due to arrhythmias recurrences after STAR, performed electrophysiological study documenting successful PV isolation. Finally, a significant improvement of quality of life was documented (48 ± 15 at enrollment vs 75 ± 15 at 12 months FU; p < 0.001).

Conclusion

The present phase II trial demonstrated the feasibility of STAR in paroxysmal AF elderly patients and its potential role in increasing the quality of life. Surely, more robust data are needed about safety and efficacy.
Predicting bleeding risk in frail older patients with atrial fibrillation using data from the FRAIL-AF trial
Authors: Van Doorn S , Joosten L P T , Kohlen B T G , Nierman M C , Koek H L , Hemels M E W , Huisman M V , Kruip M , Faber L M , Wiersma N M , Buding W F , Adriaansen H J , Rutten F H , Geersing G J
Published: May 2024

Background

Bleeding remains an important complication in anticoagulated patients with atrial fibrillation (AF). Hereto, multiple scores have been developed to predict bleeding risk and subsequently identify a subset of patients in whom additional effort may be warranted to lower the risk of bleeding. Bleeding risk is particularly high in frail older individuals with AF. Yet to what extent existing scores can accurately identify patients at high risk in this population is unknown.

Purpose

To validate existing bleeding risk scores for predicting bleeding in frail older AF patients using oral anticoagulants.

Methods

We used data from the FRAIL-AF trial that randomized frail AF patients ≥75 years of age between continuing vitamin K antagonist (VKA) treatment or switching to non-VKA oral anticoagulant (NOAC) treatment. The outcome was major or clinically relevant non-major bleeding. We validated 4 existing bleeding risk scores: ORBIT, ATRIA, AF-BLEED and (the recently derived) DOAC-score. We used cause specific cox proportional hazard models with all-cause mortality as a competing risk, with the number of points on each score as a univariate variable to calculate discrimination by means of the c-statistic for each score. Next, to assess clinical utility, we estimated the incidence bleeding rates for patients classified as low-risk and high-risk by each respective score.

Results

In total 661 patients continued VKA treatment, and 663 switched to any NOAC. An additional 66 patients, originally excluded from randomization due to an estimated glomerular filtration rate (eGFR) ≤30 ml/min/1.73 m2 but followed observationally were included in the current analysis. The median age was 82.3 years (interquartile range (IQR) 78.7 – 86.6), 61.4% were male. Median eGFR was 61 (IQR 49 – 57), 54% had hypertension, 14% a previous bleeding, and 1.2% liver disease. In total 172 first bleedings occurred. Discrimination of all risk scores was poor, both in VKA and in NOAC users. Table 1 shows the c-statistics across the different risk scores; ranging from 0.54 to 0.56. The observed risk of bleeding in the low-risk category varied widely, see Table 2.

Conclusion

Existing bleeding risk scores are unable to accurately predict the bleeding risk in frail older patients with AF. Novel risk tools are needed for this growing population of vulnerable AF patients at high risk of bleeding.
Dynamic change, not tonic activation, of the heart rate variability predicts onset of postoperative atrial fibrillation
Authors: Zhang Y , Wang H
Published: May 2024

Background and Aims

Post-operative autonomic disturbances contribute to susceptibility to post-operative atrial fibrillation (POAF) but the nature of the autonomic disturbances and whether they precede POAF and can signal POAF onset is unclear.

Methods

In this prospective observational study, patients undergoing cardiac surgery were consecutively enrolled. Holter monitoring was undertaken 7 days before and after surgery with continuous heart rate variability (HRV) measurement. Cox regression was used to evaluate autonomic changes, and analyzed by restricted cubic spline (RCS) to explore individual risk levels. For the first episode of POAF, HRV indexes captured an hour before the onset of POAF were divided into six 10-minute epochs and analyzed by Friedman's Two-Way Analysis of Variance by Ranks.

Results

A total of 2306 patients known to have been without prior AF were enrolled and completed the study; POAF occurred in 718 (31.14%) patients. Based on univariate and multivariate analysis preoperative, tonic activation and perioperative HRV change were not significantly related to new POAF. However, in the postoperative phase, a marked increase or decrease of Δ Lg (LF/HF), Δ Lg (HF) and Δ Lg (LF) were associated with increased POAF risk. Further, examination of 10-minute epochs in the 30 minutes before the onset of POAF, revealed that progressive increase of HRV indexes.

Conclusions

POAF susceptibility is associated with postoperative dynamic HRV changes but not tonic autonomic state. Potentially the observation that POAF was preceded by progressive rise of HRV indexes may offer a promising signal for early warning of POAF, and permit preventive intervention.
Evaluating the efficacy of pre-ablation algorithms in WPW syndrome localization: a retrospective study
Authors: Coteli C , Kara S C , Aygun S , Yorgun H , Aytemir K
Published: May 2024

Background and Objective

Wolf-Parkinson-White (WPW) syndrome is a congenital condition that can be diagnosed at any age and may lead to dysrhythmias, most notably atrioventricular reentrant tachycardia (AVRT). Ablation of the accessory pathway responsible for the disorder has become a standard treatment approach. The success of ablation therapy is closely linked to accurately localizing the accessory pathway. Consequently, algorithms have been developed to predict the location of the accessory pathway using pre-ablation electrocardiography (ECG) parameters. This study aims to evaluate the predictive values of previously published algorithms.

Method

This study included 122 patients diagnosed with WPW syndrome who underwent successful ablation of a manifest accessory pathway at our university's cardiac electrophysiology laboratory between 2019 and 2023. We retrospectively examined these patients' baseline characteristics and their procedures' features. Additionally, a team analyzed their baseline electrocardiograms (ECGs) using the EASY-WPW, Pambrun, and St. George algorithms. The sensitivity, specificity, PPV, and NPV of these algorithms were then calculated based on the location of the accessory pathways identified during the patients’ ablation treatments.

Results

The median age of the patients in this study was 33 years (18 - 79). Among them, 65 patients (53.3%) were male (Table 1). Ablation treatment was conducted using a 3D mapping system for all included patients, considering only those who achieved acute procedural success for analysis. The most frequently observed accessory pathway localization was the posteroseptal region of the tricuspid annulus, found in 48 patients (39.3%). Regarding the accuracy of accessory pathway prediction, the EASY-WPW, Pambrun, and St. George algorithms demonstrated correct localization rates of 81%, 72%, and 62%, respectively. The efficacy of these predictions varied according to the specific localization of the accessory pathways (Table 2).

Conclusion

This study highlights the limitations of previously published algorithms in predicting the localization of accessory pathways in WPW syndrome. The notably lower success rates observed in our research, as compared to earlier studies, might be attributed to variations in how localization is defined across studies, differences in the interpretation of these algorithms by users, or evolving definitions of localization resulting from advancements in 3-dimensional mapping systems. Given these findings, there is a clear need for the development of new algorithms that incorporate current localization definitions and are validated in larger patient cohorts.
Prognostic significance of beat-to-beat variability of spatial heterogeneity of repolarisation analysed from 5-minute resting electrocardiogram in coronary artery disease
Authors: Perkiomaki J , Rahola J T , Mattila S M , Kiviniemi A M , Ukkola O H , Tulppo M P , Junttila M J , Huikuri H V , Kentta T V
Published: May 2024

Background

Data on the prognostic significance of temporal variability of spatial heterogeneity of electrocardiographic repolarisation in coronary artery disease (CAD) are limited.

Purpose

To evaluate the prognostic value of temporal variability of T-wave morphology analysed from 5-minute resting ECG in CAD.

Methods

The standard deviation (SD) of T-wave morphology dispersion (TMD-SD), the SD of T-wave heterogeneity (TWH-SD), and the SD of total cosine R-to-T (TCRT-SD) were analysed on beat-to-beat basis from a 5-minute period of resting 12-lead ECG obtained before a clinical stress test in 1702 patients with angiographically verified CAD and well-preserved left ventricular function.

Results

During an average of 8.7±2.2 years of follow-up, 60 (3.5 %) patients experienced sudden cardiac death (SCD) or were resuscitated from a sudden cardiac arrest (SCA), 69 (4.1 %) patients experienced non-sudden cardiac death (NSCD), and 161 (9.5 %) patients died due to non-cardiac death (NCD). TMD-SD was significantly higher in patients who experienced SCD/SCA compared with those without such an event (1.72 ± 2.00 vs. 1.12 ± 1.75, p= 0.01, respectively) and in patients who succumbed to NSCD compared with those without such an event (1.57 ± 1.74 vs. 1.12 ± 1.76, p=0.04, respectively), but did not differ significantly between patients who experienced NCD and those without such an event (1.16 ± 1.42 vs. 1.14 ± 1.79, p=0.86, respectively). After adjusting for relevant clinical risk factors in the Cox multivariate hazards model, TMD-SD retained its significant association with the risk of SCD/SCA (HR 1.119, 95 % CIs 1.015–1.233, p=0.024), but not with the risk of NSCD (HR 1.089, 95 % CIs 0.983–1.206, p=0.103).

Conclusion

TMD-SD, representing temporal variability of spatial heterogeneity of electrocardiographic repolarisation, is independently associated with the long-term risk of SCD/SCA in CAD patients with well-preserved left ventricular function.
Real life experience with point by point pulsed field ablation for recurrent ventricular arrhythmias
Authors: Ene E , Nentwich K , Berkowitz A , Deaconu A , Deneke T
Published: May 2024

Introduction

The safety and effectiveness of electroporation/point by point pulsed field ablation (PP PFA) as emerging technoloy for catheter ablation (CA) of ventricular arrhythmias (VAs) has been described till now only in case reports.

Purpose

The aim of this observational retrospective study is to present real life data concerning the overall performance of PP PFA for CA of recurrent VA.

Methods

A total number of 13 consecutive patients (11 VTs and 2 PVCs), in whom recurrent VTs after RF ablation documented, were included. In all patients the substrate location was documented beforehand based on cardiac MRI or CT with myocardial thinning. For substrate mapping a high resolution multipoint mapping catheter was used. A complete success was defined as non inducibility of any arrhythmia at the end of procedure respectively lack of VA recurrence at follow – up.

Results

Excepting 2 patients, all other had a non ischemic cardiomyopathy as underlying heart disease (mean age 63 ± 8 y/o, mean LVEF 42 % ± 9 %). In every patient at least one conventional RF CA has been performed previously (mean 2 ± 1) and 38 % of patients had a previous epicardial RF VT ablation. The PP PFA VT ablation was performed endocardialy in 11 patients (84 %), respectively epicardialy in 2 patients. The ablation sites had a septal location in 53 % of patients and other localisation in 47 % of patients. The applied energy was 25 A. The overall acute complete success was achieved in 77 % patients. At medium 6 ± 3 months follow up a complete success was present in 46 % cases. Most frequently a VT recurrence after PP PFA ablation was encountered in patients with combined septal and nonseptal substrate distrubution. After PP PFA, the RF CA strategy due to recurrent VAs was endocardial in 2 patients, respectively epicardial 2 in cases and bipolar in 1 case. No PP PFA redos were undergone. Three major complications have been documented (1 tamponade, 1 AV block III° and 1 complete LBBB).

Conclusion

As bailout strategy in patients with failed conventional CA, PP PFA represents a safe strategy. Specific complications like temporary atrioventricular or intraventricular conduction disturbancies are extremely rare, reversible but not life threathening. The midterm success is satisfactory but still limited in patients with intramural substrate.