bluuebunny/crossref_metadata_2025 huggingface dataset:
Electrocardiographic markers of atrial cardiomyopathy predict ineffective cardioversion: a FinCV2 cohort study
Authors: Relander A , Hellman T , Vasankari T , Nuotio I , Airaksinen K.E.J , Kiviniemi T
Published: November 2020

Background

Rhythm control using electrical cardioversion (CV) is a common treatment strategy for patients with symptomatic atrial fibrillation (AF). However, little is known about electrocardiographic (ECG) markers predicting CV failure and AF recurrence.

Methods

This study included 726 patients who underwent a CV for AF lasting >48h in a referral hospital. We analysed markers of atrial cardiomyopathy in post-CV sinus rhythm ECGs and compared them with CV failure and AF recurrence rates within 30 days after CV as well as their combination (ineffective CV). Of those with failed CV the most recent sinus rhythm ECG was used.

Results

CV was unsuccessful in 66 out of 726 patients (9.09%). Advanced interatrial block (IAB) defined as P-wave duration ≥120ms and biphasic morphology in inferior (II, III and aVF) leads (OR 3.96, 95%-CI 2.09–7.52, p<0.001) was an independent predictor for CV failure. Within 30 days after CV, AF recurred in 214 (32.4%) patients. Advanced IAB (OR 2.10, 95%-CI 1.19–3.72, p=0.011) was an independent predictor for AF recurrence. In total CV was ineffective (CV failure or AF recurrence) 280 of 726 times (38.6%). Advanced IAB (OR 2.72, 95%-CI 1.64–4.51, p<0.001) was an independent predictor for ineffective CV. Partial IAB categorized as P-wave duration ≥120ms with no biphasic morphology did not predict any end points.

Conclusions

Advanced IAB predicts CV inefficacy. This study identified ECG markers of atrial cardiomyopathy for clinical use in CV patient selection.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): This study research was funded by grants from the Finnish Medical Foundation, the Finnish Foundation for Cardiovascular Research, State Clinical Research Fund of Turku University Hospital, Turku, Finland, Finnish Cardiac Society, the Emil Aaltonen Foundation, and the Maud Kuistila Foundation.
Salvage DC ablation of ventricular tachycardia following failed RF attempts
Authors: Bailin S , Kaushik N , Kocherla C
Published: November 2020

Background

Ablation of ventricular tachycardia (VT) is a frequent clinical necessity. Modification of ventricular substrate can usually be achieved by radiofrequency ablation (RF). We present 4 cases of failed RF for recurrent VT. Two patients had multiple RF failures, one patient had in-procedure failure, and one patient had multiple RF attempts and a failed alcohol ablation (pt4).

Objective

To evaluate success of DC ablation after failed RF

Methods

A 6 Fr 4mm tip steerable ablation catheter, was placed at the site felt to be critical for the circuit following mapping (earliest activation, mid-diastolic, fractionated, site of concealed entrainment, or ventricular breakout). Two connection cables were utilized, one to the recording/mapping system, and one connected to an external biphasic defibrillator (DC). The DF was connected with one pad anterior chest and the other connected by the cable to electrode pins 1 and 2 folded within the second pad. The electrodes were secured by placing a hemostat on the pad. DC energy (360j) was delivered synchronized by electrodes 1–2

Results

During follow-up 3 months to 1 year, no recurrent VT was observed. 3 patients received a total of 4 DC pulses, while the pt4 received 16 (RV and LV septum), complicated by prolonged hypotension. No other complications were observed. Figure shows broad RV breakout from the septum in pt4.

Conclusion

In patients with RF refractory VT, DC ablation may be safely used and in this limited series, provides long-term success. Interestingly, biphasic energy did not induce transient hypotension in 3 of 4 pts. DC ablation should be considered following failed RF, especially when mid-myocardial origin suspected.

Funding Acknowledgement

Type of funding source: None
Fluoroless catheter ablation of supraventricular and ventricular arrhythmias in pregnancy: validation of a standard approach in a large multicenter registry
Authors: Stec S , Styczkiewicz K , Sledz J , Sledz A , Chrabaszcz M , Karbarz D , Wozniak I , Mlynarczyk K
Published: November 2020

Background

An increasing experience in zero- (ZF) or near-zero fluoroscopy catheter ablation (CA) supports the implementation of early, fluoroless approach for recurrent, symptomatic arrhythmias in pregnancy.

Purpose

The aim of the study was to evaluate the feasibility, efficacy, and safety of CA with a standardized ZF approach during pregnancy.

Methods

Data were derived from a large prospective multicenter registry (ELEKTRO-RARE-A-CAREgistry). Between 2012 and 2019, more than 2655 CA procedures were performed in women in intention-to-treat using a ZF fluoroscopy approach. The procedures were performer using: 1) femoral access, 2) double-catheter technique, without intracardiac echocardiography, 3) electroanatomic mapping system (Ensite, Abbott, USA) for mapping and navigation, 4) conscious, light sedation. Shared decision making approach was applied, including a pregnancy heart team consultations.

Results

The study group consisted of 18 pregnant women (mean age: 30.3±5.0 years; range: 19–38 years; mean gestational age during CA: 21.4±9.2 weeks; range: 7–36 weeks). All pregnant women had no overt structural heart disease. Among women in reproductive age, pregnant women referred for ZF-CA approach accounted for approximately 2% of procedures. In the study group, the major indications for

CA included: AVNRT (n=10); OAVRT/WPW (n=2); focal idiopathic ventricular arrhythmia (n=4), AT (n=1) and AF (n=1). Five women had double substrate for CA. In AF case general anesthesia and transesophageal echocardiography were used to monitor ZF-transseptal puncture and right-sided pulmonary vein isolation. All procedures were successfully completed without fluoroscopy, and without serious maternal or fetal complications. The procedure and ablation application times were 55.0±30.0 min and 394±338 s, respectively. In one patient second procedure for idiopathic ventricular arrhythmia was postponed after delivery.

Conclusion

Implementation of pregnancy heart team and a standard fluoroless protocol for CA in daily electrophysiological practice allowed an early, safe, and effective CA of maternal supraventricular tachycardia and idiopathic ventricular arrhythmias in pregnancy.

Funding Acknowledgement

Type of funding source: None
High incidence of left atrial dysfunction and low voltage zone in patients requiring multiple atrial fibrillation ablation
Authors: Oka T , Yoshimoto I , Koyama Y , Tanaka K , Hirao Y , Tanaka N , Okada M , Kitagaki R , Okamura A , Iwakura K , Fujii K , Inoue K
Published: November 2020

Background

While multiple catheter ablation for recurrent atrial fibrillation (AF) is effective for the maintenance of sinus rhythm, some of patients have ablation-refractory AF. Left atrial (LA) dysfunction and the presence of low voltage zone (LVZ) are associated with recurrence after AF ablation. The association between recurrence and LA dysfunction/ LVZ among patients undergoing multiple AF ablation remains unclear.

Purpose

We aimed to compare (i)LA function, (ii)the prevalence of LVZ among patients undergoing first, second and third or more AF ablation procedures. Further, we investigated whether LA dysfunction and LVZ are associated with recurrence after multiple procedures.

Methods

We retrospectively analyzed 460 patients undergoing AF ablation procedures including first, second and third or more sessions from January 2017 to October 2019 in our institute. Before each session, 256-slice MDCT was performed under sinus rhythm to measure pre-ablation LA emptying fraction (LAEF) as the representative of LA function. At the end of each session, we checked the presence of LVZ, which was defined as regions where bipolar peak-to-peak voltage was <0.5mV. All patients underwent pulmonary vein isolation (PVI). If necessary, additional ablation (e.g. linear ablation, non-PV foci ablation and LVZ ablation) was performed.

Results

Out of 460 sessions, 295 were first (follow-up years: 1.5 [0.8, 2.0]), 134 were second (1.0 [0.5, 1.8]), and 31 were third or more sessions (1.2 [0.7, 2.0]). As the number of sessions increased, the recurrence rate was increased (19% vs. 31% vs. 61%, first vs. second vs. ≥third, P<0.0001), LAEF decreased (39.7±10.5% vs. 32.6±10.1% vs. 25.3±11.8%, P<0.0001) and the incidence of LVZ increased (18% vs. 34% vs. 68%, P<0.0001) (Figure 1). In patients with recurrence (N=104) after multiple ablation (second or more sessions), LAEF was lower and the prevalence of LVZ was higher than those without recurrence (N=61) (LAEF: 27.3±10.3% vs. 33.5±10.5%, with vs. without, P=0.0003; LVZ: 57% vs. 31%, P=0.0014).

Conclusions

As the number of sessions increased, the recurrence rate was increased. The prevalence of LA dysfunction and LVZ was high in patients requiring multiple ablation procedure. LA dysfunction and LVZ possibly reflect arrhytmogenic substrate causing recurrence of ablation-refractory AF. We should carefully consider repeated AF ablation in patients with severe LA dysfunction and extensive LVZ.

Figure 1

Funding Acknowledgement

Type of funding source: None
Catheter ablation in adults with congenital heart disease: a 15-year perspective from a tertiary center
Authors: Waldmann V , Amet D , Zhao A , Ladouceur M , Karsenty C , Maltret A , Pontnau F , Legendre A , Soulat G , Lavergne T , Bonnet D , Jouven X , Vouhe P , Marijon E , Iserin L
Published: November 2020

Background

With the growing population of adults with congenital heart disease (ACHD), the number of catheter ablation procedures is expected to increase over time.

Purpose

We aimed to describe temporal trends in volume and outcomes of catheter ablation procedures in ACHD patients in a large tertiary center.

Methods

Retrospective observational study including all consecutive ACHD patients undergoing catheter ablation in a tertiary reference center over a 15-year period. Acute procedural success rate (including complete success in case of non-inducibility of any arrhythmia at the end of the procedure) as well as freedom from recurrence at 12 months were analyzed.

Results

From November 2004 to November 2019, 302 catheter ablations in 221 ACHD patients (43.6±15.0 years, 58.9% males) were performed. The annual number of catheter ablation increased progressively from 4 to 60 by year (p<0.001). Intra-atrial reentrant tachycardia/focal atrial tachycardia was the most common targeted arrhythmia (n=217, 71.9%). Over the study period, acute procedural success rate increased from 45.0% to 93.3% (p<0.001), including complete acute procedural success from 45.0% to 88.1% (p<0.001) (Figure 1). The use of irrigated catheters (30.0% to 94.8%, p<0.001), 3D-mapping systems (60.0% to 96.3%, p<0.001), contact force catheters (0.0% to 91.9%, <0.001), and high-density mapping (0.0% to 71.9%, p<0.01) increased significantly. Use of irrigated catheters (OR=3.96, 95% CI: 1.79–8.55), 3D-mapping system (OR=3.55, 95% CI: 1.62–7.55), contact force catheters (OR=3.46, 95% CI: 1.71–7.25), and high-density mapping (OR=3.85, 95% CI: 1.60–7.26) were associated with acute procedural success. The rate of freedom from any recurrence at 12 months increased from 29.4% to 66.2% (p=0.001). Seven (2.3%) non-fatal complications occurred.

Conclusions

The number of catheter ablation procedures in ACHD patients has considerably increased over the last 15 years. Advances in ablative technologies appear to be associated with a low rate of complications and a significant improvement in acute and midterm outcomes.

Evolution of acute procedural success

Funding Acknowledgement

Type of funding source: None
The Predictive Value of PRECISE-DAPT Score for the Thrombogenic Milieu in Left Atrium and Left Atrial Appendix in the Patients with Atrial Fibrillation Planned AF Ablation
Authors: Konte H.C , Cetin E.H , Ozbay M.B , Yaman N.M , Ozeke O , Cay S , Aras D
Published: November 2020

Introduction and aim

Atrial fibrillation (AF) is the most common arrhythmia in the clinical practice. In AF patients, the assessment of thromboembolic risk and the initiation of anticoagulant therapy to appropriate patients play critical role in management of these patients. Current guidelines recommend to use CHA2DS2VASC score in evaluation of thromboembolic risk. However, the effectiveness of this score has been questioned recently. This situation requires new risk indicators. Although PRECISE-DAPT score was initially constituted to determine the duration of dual antiplatelet therapy in patients with PCI, current studies have reported that this score may also predict thrombotic events. In this study, we aimed to evaluate the effectiveness of PRECISE-DAPT score to predict thrombogenic milieu by comparing with CHA2DS2VASC score in non valvular AF patients whom referred TEE before AF ablation procedure.

Method

428 patients were included in the study. The presence of grade 2–3 SEC and thrombus in left atrium and/or left atrial appendage were accepted as thrombogenic milieu. The patients were divided into two groups according to the presence of thrombogenic milieu. In addition, we constituted three groups as grade 0–1 SEC group, grade 2–3 SEC group and thrombus group to evaluate the parameters in detail.

Results

Grade 2–3 SEC was found in 36 patients and thrombus was detected in 24 patients. 60 patients was included to the thrombogenic positive (artı) group while 368 patients was included to thrombogenic milieu (−) group. PRECISE-DAPT and CHA2DS2VASC scores were higher in thrombogenic positive (artı) group In multivariate logistic regression analysis, PRECISE-DAPT score was found to be an independent predictor of thrombogenic milieu (OR: 1.145, CI:1.083–1.211, p<0,001). The comparison of ROC curves was shown that PRECISE DAPT score was higher area under curve than CHA2DS2VASC score, 0,753 and 0,649 respectively.

Conclusion

In our study, in patients performed TEE before AF ablation, PRECISE-DAPT score was found to be an independent predictor for thrombogenic milieu presented as high grade SEC and thrombus, there by thromboembolic risk. PRECISE-DAPT score seems to be more effective than CHA2DS2VASC score. In AF patients, PRECISE-DAPT score may provide additional benefit in assessment of thromboembolic risk, thus enabling a more individual and accurate anticoagulation decision in these patients.

Funding Acknowledgement

Type of funding source: None
Impact of catheter ablation for atrial flutter on mortality and hospital readmission rates in patients with heart failure and preserved ejection fraction
Authors: Thakkar S , Jani C , P Patel H , Arora S , Patel R , Kumar A , Gonzalez J , Deshmukh A , Rao M
Published: November 2020

Background

The availability of real-world data regarding the impact of the catheter ablation in patients with concomitant atrial flutter (AFL) and heart failure with preserved ejection fraction (HFpEF) is limited.

Methods

2016 and 2017 National Readmission Database (NRD) was subjected to appropriate ICD-10 codes to identify and extract patients having coexistent atrial flutter and heart failure with preserved ejection fraction including who had undergone ablation. At 1 year, all-cause mortality was utilized as the primary outcome while readmissions due to AFL, heart failure (HF) and any other causes were designated as secondary outcomes. Kaplan Meier curves were used for a time to event analysis. Cox proportional hazard regression was used to generate hazard ratios.

Results

Out of a total 6099 patients with AFL and HFpEF, 906 (14.85%) underwent catheter ablation. At 1 year all cause mortality (3%, vs. 4.4%, HR: 0.661, 95% CI: 0.444–0.985, p=0.042) and readmissions due to AFL (2.3% vs. 5.3%, HR: 0.424, 95% CI: 0.272–0.661, p<0.001) were significantly less among ablation group. Readmission due to HF (9.3% vs. 9.7%, HR: 0.938, 95% CI: 0.745–1.182, p=0.587) and other causes (37% vs.40.3%, HR: 0.926, 95% CI: 0.825–1.040, p=0.193) did not show any significant difference in outcomes at the end of 1 year.

Conclusion

The utilization of catheter ablation amongst AFL patients with concomitant HFpEF showed a significant reduction in all-cause mortality and readmission due to AFL. However, it did not show any significant changes in readmissions due to HF or other causes at the end of one year.

Outcomes of AFL and HFpEF

Funding Acknowledgement

Type of funding source: None
Conduction gaps after pulmonary vein isolation due to high contact force ablation in patients with atrial fibrillation
Authors: Takahashi S , Mine T , Kawai H , Takai K , Yoshikawa F , Takada M , Fujita K , Nishibori Y , Maruyama T
Published: November 2020

Background

Catheter ablation for atrial fibrillation (AF) with high contact force (CF) has been reported to lead to the gaps after pulmonary vein isolation (PVI), and the appearance of the gaps depends on the site in the left atrium (LA).

Purpose

The aim of this study is to clarify the relationship between the gaps appearance and high CF.

Methods

In the clinical study, 74 consecutive patients (39 males, age 71±9, 46 with paroxysmal AF) underwent conventional PVI with a point-by-point radiofrequency (RF) ablation using a CF sensing catheter (TactiCath SETM). RF energy (J), number of RF point, Lesion index (LSI), force-time integral (FTI), average CF (g), and the degree of LA depression with high CF were evaluated. In the experimental study (figure), the relationship between the ablation area and the degree of depression with high CF using bovine left ventricular wall.

Results

In the clinical study, the gaps were found in 175 of 1182 sites after first path PVI ablation. The CF in the gap sites was higher than without the gap sites in RPV roof, anterior RSPV and anterior RPV carina (18.9±6.8 vs 15.0±5.7g p=0.0262, 26.4±11.6 vs 19.5±6.0g p=0.0029, 22.7±6.4 vs 19.1±5.5g, p=0.0161). Meanwhile, there were no differences in RF energy, number of RF point, LSI, FTI. High CF (≥30g) showed a depression of 3 mm or more in only RPV roof and anterior RPV (figure). In the experimental study, the ablation range narrowed as the indentation deepened with more than 30g CF (r=0.6417, p=0.0625).

Conclusion

Catheter ablation for AF with high contact force might lead to the gaps in RPV roof and anterior RPV site by the reduction of the ablation area due to depression caused by the pressure.

Extension of each contact force

Funding Acknowledgement

Type of funding source: None
The effect of permanent pacemaker implantation following transcatheter aortic valve implantation upon survival
Authors: Soulaidopoulos S , Drakopoulou M , Stathogiannis K , Xanthopoulou M , Oikonomou G , Toskas P , Kouroutzoglou A , Synetos A , Papanikolaou A , Latsios G , Sideris S , Tousoulis D , Toutouzas K
Published: November 2020

Purpose

Transcatheter aortic valve implantation (TAVI) is often followed by conduction abnormalities, leading to a permanent pacemaker implantation (PPI). Data regarding the clinical impact of PPI following TAVI is yet to be established.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analyzed. Patients were stratified into two groups according to the need for PPI after TAVI and were followed up postoperatively with clinical and echocardiographic assessment. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium 2.

Results

In total, 292 patients were included (male: 50.2%, mean age: 80±7.6 years) in our study. Of these, 109 (37.5%) underwent PPI simultaneously or shortly after TAVI. The median follow-up period was 27.3 In this period, all-cause mortality showed no significant difference between patients with and those without PPI after TAVI (log-rank p=0.756), even after excluding patients with a pre-existing pacemaker from the analysis. Subgroup analysis also showed no difference in survival between patients with low ejection fraction (<50%) and those with preserved (≥50%) receiving a permanent pacemaker after TAVR (log-rank p=0.269). Taking into consideration factors that were found to associate to PPI in univariate analysis (pre TAVI - ejection fraction, pulmonary artery systolic pressure and New York Heart Association functional class) in a multivariate model, pre TAVI pulmonary artery systolic pressure was found to be an independent predictor of peri-procedural PPI [Exp(B): 0.977, 95% Confidence Interval: 0.957–0.998, B=−0.023, p=0.029]. Pre-TAVI conduction abnormalities and the degree of aortic annulus calcification, as assessed by computed-tomography, were not found to predict PPI after TAVI.

Conclusion

PPI following TAVI was not associated with survival at 27 months of follow-up, independently from the pre TAVI ejection fraction.

Figure 1

Funding Acknowledgement

Type of funding source: None
Abnormal coronary anatomy in patients with atrial switch: a predictor of serious cardiac adverse event?
Authors: Perreux Y.P , Chaix M.C , Fongeon F.P , Di Filippo S , Boussel L , Khairy P , Bessiere F
Published: November 2020

Introduction

Sudden death and heart failure are severe long-term complications after atrial switch for D-transposition of the great arteries (D-TGA). Mechanisms and factors of long-term complications are poorly known. Right ventricle ischemia may be involved in these complications. Since coronary malformations are present in about 30% of D-TGA, we aimed to look for an association between these complications and the presence of coronary anomalies.

Methods

The study is an observational international study in two tertiary centers. Adults with history of atrial switch and severe rhythmic or hemodynamic complications, history of heart transplantation or cardiovascular death were included. Patients under 18 years old and/or with corrected transposition of great arteries were excluded. A χ2 test was used to compare the proportion of coronary anomalies in this cohort to the one from population of D-TGA reported in previous studies.

Results

Forty-two patients were included: 11 women (26.2%) and mean age at the time of the study was 43.3±6.4 years. Eight patients (19.0%) died at a mean age 41.3±9.0 years. No ablation for ventricular tachycardia was reported while 15 (35.7%) patients underwent ablation for a SVT (supraventricular tachycardia). Thirty three patients (78.6%) suffered from heart failure and/or severe right ventricle dysfunction and 4 patients (9.5%) were transplanted at a mean age of 29.3±8.3 years. Ten (23.8%) patients suffered from both arrhythmic events and heart failure. Twelve patients (28,6%) had abnormal coronary anatomy. The χ2 test showed no significant difference of coronary anatomy between our population and a pooled population of 647 D-TGA from previous studies (28.7%, p=0.9804). By multivariate analysis, severe pulmonary hypertension and severe tricuspid regurgitation were significantly associated with cardiovascular death and/or heart transplantation (respectively: p=0.0323, OR= 2.5, and p=0.0494, OR= 4.0). SVT ablation tended to be associated to survival (p=0.0928 with OR= 2.2).

Conclusions

No difference of coronary anomalies ratio in complicated Mustard or Senning patients was seen in comparison with the coronary anomalies ratio of all D-TGA. These results plead against a role of abnormal coronary anatomy in right ventricle dysfunction. Ischemia may be more related with the alteration of micro vascularization and a mismatch between oxygen needs and supply.

Funding Acknowledgement

Type of funding source: None
Timing and degree of left atrial stunning and reverse functional remodeling following electrical cardioversion in patients with recent onset atrial fibrillation
Authors: Arvanitis P , Johansson A.K , Frick M , Malmborg H , Gerovasileiou S , Larsson E.M , Blomstrom Lundqvist C
Published: November 2020

Background

Atrial fibrillation (AF) results in left atrial electrical, structural and functional remodeling. Restoration of sinus rhythm hallmarks the beginning of reverse remodeling, the extent of which may depend on the type of AF.

Purpose

The aim of the study was to assess resumption of left atrial function after electric cardioversion in patients with recent onset AF and to explore the association between reverse remodeling and the type of atrial fibrillation.

Methods

Patients with AF duration <48 hours were prospectively included. Trans-thoracic echocardiography was performed prior, immediately after (2–4 hours) and 7–10 days following CV. Left atrial volume index (LAVI), left atrial global longitudinal strain during reservoir (LAGLS-res), conduit (LAGLS-cond) and contractile (LAGLS-contr) phases, left atrial ejection fraction (LAEF) and left ventricular ejection fraction (LVEF) were measured.

Results

Forty-three patients (84% males) aged 55±9.6 years, (mean±SD), with median CHA2DS2-VASc score 1 (interquartile range 0–1) were included. Repeated measure analysis of variance revealed a statistically significant overall change for LAGLS-res F(2,78)=55.4, p<0,001, LAGLS-cond F(2,78)=23.3, p<0,001, LAGLS-contr F(2,78)=39.7, p<0,001, LAEF F(2,80)=28.5, p<0.001 and LVEF F(2,80)=8.4, p<0.001. At 7–10 days, LAGLS-contr 12±4%, LAEF 53±9% and LVEF 60±6 (mean±SD) return within normal reference intervals. Notably left atrial recovery seems to precede left ventricular recovery. No statistical significant interaction with the type of atrial fibrillation could be shown.

Conclusion

Left atrial functional reverse remodeling occurs within ten days after successful electric cardioversion of patients with recent onset atrial fibrillation.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swedish Heart-Lung Foundation, Correvio International Sárl (Geneva Switzerland), Selanders Stiftelse
Epicardial adipose tissue and atrial fibrillation: guilty as charged or guilty by association?
Authors: Sousa J , Matos D , Ferreira A , Abecasis J , Saraiva C , Freitas P , Carmo J , Carvalho S , Rodrigues G , Durazzo A , Costa F.M , Carmo P , Morgado F , Cavaco D , Adragao P
Published: November 2020

Background

Epicardial adipose tissue (EAT) has been linked to the presence and burden of atrial fibrillation (AF). However, it is still unclear whether this relationship is causal or simply a surrogate marker of other risk factors commonly associated with AF.

Purpose

The purpose of this study was to assess the relationship between these factors and EAT, and to compare their performance in predicting AF recurrence after an ablation procedure.

Methods

We assessed 575 consecutive patients (mean age 61±11 years, 62% male) undergoing AF ablation preceded by cardiac CT in a high-volume ablation center. EAT was measured on cardiac CT using a modified simplified method. Patients were divided into 2 groups (above vs. below the median EAT volume). Cox regression was used to assess the relationship between epicardial fat, risk factors, and AF relapse.

Results

Patients with above-median EAT volume were older (p<0.001), more often male (OR 1.7, p=0.002), had higher body mass index, and higher prevalence of smoking, hypertension, diabetes and dyslipidemia (p<0.05). Non-paroxysmal AF was also more common in those with above-median EAT volume. During a median follow-up of 18 months, 232 patients (40.3%) suffered AF recurrence. After adjustment for BMI and other univariate predictors of relapse, three variables emerged independently associated with time to AF recurrence: non-paroxysmal AF (HR 2.1, 95% CI: 1.5–2.7, p<0.001), indexed left atrial (LA) volume (HR 1.006 per mL/m2, 95% CI: 1.002–1.011, p<0.001), and indexed epicardial fat volume (HR 1.87 per mL/m2, 95% CI: 1.66–2.1, p<0.001). None of the classic cardiovascular risk factors were an independent predictor of AF recurrence (all p>0.10).

Conclusion

Classic cardiovascular risk factors are more prevalent in patients with higher amounts of epicardial fat. However, unlike these risk factors, EAT is a powerful predictor of AF recurrence after ablation. These findings suggest that EAT is not merely a surrogate marker, but an important participant in the pathophysiology of AF.

EAT, cvrf and AF burden

Funding Acknowledgement

Type of funding source: None
Assessing endothelial function in patients with atrial fibrillation and hypertension using flow mediated dilatation: does atrial fibrillation add anything?
Authors: Khan A.A , Thomas G.N , Lip G.Y.H
Published: November 2020

Background

Atrial fibrillation (AF) and hypertension commonly co-exist and both are associated with endothelial dysfunction. A key consequence of normal endothelial function in vivo is the ability to release NO in response to physiological stimuli, such as increased flow, reflecting flow-dependent endothelium-mediated dilation (FMD). FMD measurement using a high-resolution ultrasound has become a reliable and reproducible technique for assessment of endothelial dysfunction.

Purpose

To investigate whether endothelium-dependent FMD is more abnormal in patients with AF and hypertension when compared to hypertension alone.

Design

In a cross-sectional comparison, we studied two patient groups: AF and hypertension (n=61) and hypertension control group (n=33). High-resolution ultrasound was used to measure brachial artery diameter at rest and during reactive hyperaemia (endothelium-dependent FMD). Data was analysed using SPSS software.

Results

Participants were matched for age, sex and BMI. There was no significant difference in FMD between permanent AF and hypertension group and hypertension control group (4.6%, 95% CI [2.6–5.9] vs 2.6%, 95% CI [1.9–5.3]; p=0.25). No variables were identified on univariate analysis and only heart rate was identified on multivariate analysis as an independent predictor of FMD (p=0.04).

Conclusion

First study investigating FMD in patients with permanent AF and hypertension together to assess whether presence of AF worsens the endothelial dysfunction seen in patients with hypertension. Endothelium-dependent FMD is impaired in patients with AF and hypertension. The presence of AF does not incrementally worsen endothelial dysfunction, nor was AF an independent predictor of endothelial dysfunction on multivariate analysis.

Funding Acknowledgement

Type of funding source: None
Factors affecting progression to permanent atrial fibrillation in an unselected population of patients with non-permanent form of atrial fibrillation
Authors: Malavasi V.L , Fantecchi E , Tordoni V , Melara L , Barbieri A , Valenti A.C , Menozzi M , Sgreccia D , Talarico M , Imberti J , Vitolo M , Boriani G
Published: November 2020

Background

Natural history of atrial fibrillation (AF) shows a progression of arrhythmia from non-permanent to permanent AF. Permanent AF was found associated with a worse prognosis than non-permanent one.

Aim

To assess the factors associated with progression to permanent AF in an unselected population of AF patients with non-permanent AF.

Methods

In this prospective study we enrolled in- as well as out-patients with non-permanent AF and age ≥18 years, with at least one episode of ECG-documented AF within 1 year. The patients were followed-up at 1 month and every 6 months thereafter.

Results

Out of 523 patients, 314 (60%) were in non-permanent AF (80 [25.5%] paroxysmal AF, 165 [52.5%] persistent AF, 69 [2%] first diagnosed AF), mostly male (188, 59.9%), median age 71 years (IQ range 62–77), median CHA2DS2VASc 3 (1–4), median HATCH score 1 (1–2). After a median follow-up of 701 (IQ range 437–902) days, 66 patients (21%) showed permanent AF.

CHA2DS2VASc and HATCH scores were incrementally associated to progression to permanent AF (CHA2DS2VASc χ2 p=0.001; HATCH χ2 p=0.017; p for trend CHA2DS2VASc <0.001, HATCH p=0.001).

At multivariable Cox proportional hazard regression the following variables were significantly associated with AF progression: age (hazard ratio [HR] 1.041; 95% CI: 1.004–1.079; p=0.028), at least moderate left atrial (LA) enlargement (>42 ml/m2) (HR 2.092; 95% CI: 1.132–3.866; p=0.018), antiarrhythmics drugs after the enrollment (HR 0.087; 95% CI: 0.011–0.662; p=0.018), EHRA score >2 (HR 0.351; 95% CI: 0.158–0.779; p=0.010) and Valvular HD (HR 2.161; 95% CI: 1.057–4.420; p=0.035). Adding LA dilation to HATCH score (HATCH-LA) and assigning 2 points based on multivariable Cox regression, HATCH-LA was statistically better in ROC curves in prediction of AF progression vs HATCH score (area under the curve 0.695 vs 0.636; DeLong p=0.0225). Survival-free curves on freedom from permanent AF using as discriminator HATCH-LA score ≤2 vs >2 led to a statistically significant difference (χ2=16.080 p<0.001), but the same was not found for HATCH score (χ2 =3.099; p=0.078).

Conclusions

In patients without permanent AF, progression of AF was independentely related to age, LA dilation, AF symptoms severity, antiarrhythmic drugs and Valvular HD. HATCH score predicted AF progression and adding to it LA dilation (at least moderate) improved patients stratification for the risk of evolution to permanent AF.

Funding Acknowledgement

Type of funding source: None
Paroxysmal and persistent atrial fibrillation; does the clinical classification match the substrate?
Authors: Van Der Does W.F.B , Heida A , Van Der Does L.J.M.E , Bogers A.J.J.C , De Groot N.M.S
Published: November 2020

Background/Introduction

The classification of atrial fibrillation (AF) currently is based on clinical characteristics, however classifying underlying electropathology would assist in selecting appropriate therapy. In this study, we measured atrial conduction parameters in sinus rhythm (SR) using an intra-operative high resolution epicardial mapping approach in paroxysmal (PAF) and persistent AF (persAF) patients.

Purpose

To study whether the clinical classification is related to the amount and severity of conduction disorders in SR.

Methods

We included 47 PAF and 24 persAF patients for intra-operative measurements of SR at the right atrium (RA), Bachmann's Bundle (BB), the left atrium (LA) and the pulmonary vein area (PV). Various conduction parameters were calculated, including number of continuous conduction delay and block (cCDCB) lines, total activation time (TAT), and orientation of conduction block (CB) lines at BB.

Results

After adjustment for confounders, only TAT of BB was significantly longer in persAF patients, 75 [53–92] ms vs 55 [40–76] ms. This can be attributed to more CB line parts orientated perpendicular to the conduction direction and a higher number of cCDCB lines. Other conduction characteristics at BB and other atrial areas showed no difference between PAF and persAF patients.

Conclusion(s)

Patients with persAF have a longer activation time at BB compared to patients with PAF. Other conduction parameters show significant overlap between these groups at BB and in other atrial areas, suggesting that, in SR, the clinical classification does not match the arrhythmogenic substrate.

Funding Acknowledgement

Type of funding source: None
Effect of prevalent atrial fibrillation on cardiovascular outcomes in patients with chronic kidney disease
Authors: Bhat A , Gan G , Chen H.H.L , Gu K , Denniss M , Burgess D.C , MacIntyre R , Tan T.C
Published: November 2020

Background

The global increase in incidence and prevalence of chronic kidney disease (CKD) is associated with a parallel rise in co-morbid atrial fibrillation (AF). Concurrent presence of both conditions increases clinical complexity and may portend poor outcomes in this population.

Purpose

The aim of our study was to assess the impact of prevalent AF on mortality and cardiovascular outcomes in patients with CKD.

Methods

Consecutive patients with CKD (Stages 2 to 5) attending the Nephrology outpatient clinics in our health district between Jan 2007-Dec 2017 were retrospectively evaluated. Detailed appraisal of patient demographics, anthropometrics, clinical co-morbidities (including aetiology, stage and management of CKD) and pharmacotherapeutics was undertaken. These patients were followed for up to ten years for the composite outcomes of all-cause death and major adverse cardiovascular events (MACE). We excluded patients with incomplete clinical data and patients with concomitant medical co-morbidity limiting lifespan to <6 months.

Results

2008 patients (63.61±17.17 yrs; 55.7% men) were assessed. The mean eGFR was 37.53±21.88 mL/min/m2. Patients with prevalent AF (n=440, 22%) were older (p<0.01), with lower eGFR (p<0.01) and higher rates of renal replacement therapy (p<0.01). They also had a greater burden of coronary disease (p<0.01), heart failure (p<0.01), stroke (p<0.01), obstructive sleep apnoea (p<0.01), chronic obstructive pulmonary disease (p<0.01), anaemia (p<0.01) and obesity (p<0.01). Over the mean follow-up period of 44.04±34.96 months, 832 patients met the composite outcome (410 all-cause death, 422 MACE). On log rank tests, prevalent AF was a predictor of the composite outcome (Figure 1; p<0.01) and remained an independent predictor of all-cause death and MACE on multivariate analysis (HR 1.65; 95% CI 1.24–2.21, p<0.01).

Conclusions

Prevalent AF is an independent predictor of all-cause death and MACE in patients with CKD.

Figure 1. Kaplan Meier Curve

Funding Acknowledgement

Type of funding source: None
New onset atrial fibrillation after dual chamber pacemaker implantation: long term predictors
Authors: Ferreira V , Portugal G , Viveiros Monteiro A , Oliveira M , Silva Cunha P , Cruz Coutinho M , Osorio P , Valente B , Covas S , Castelo A , Garcia Bras P , Mano T , Reis J , Cruz Ferreira R
Published: November 2020

Background

Preserving atrioventricular synchrony has been accepted as a significant advantage of atrial and dual-chamber (DDD) pacing. However, little is known about the incidence of atrial fibrillation (AF) after DDD implantation and its prognostic predictors in long term.

Purpose

To determine the incidence of new AF episodes and to identify risk factors and prognostic predictors for new-onset AF and all-cause mortality after implantation of dual-chamber pacemakers.

Population and methods

713 consecutive patients (P) who underwent colocation of DDD pacemaker, due to AV block (AVB) or sinus node disease (SND), with no prior history of AF, from 2011 to 2015. Through periodic PM interrogation, occurrence of AF (“automatic mode switch” episodes with documented AF), switch to ventricular pacing (VVIR), pacing site (apical or septal) and cumulative right ventricular (RV) pacing % were analysed.

Results

Follow-up data was available for 669 patients (93.8%) for a mean follow-up (FU) time of 47.8±22.7 months. Mean age was 72.9±10.8 years with 60.1% male. New occurrence of AF was observed in 345 P (51.6%) during the FU period; 45.7% of them were consequently anticoagulated (59.0% with NOACs). Median time to 1st AF episode since implantation was 21.6 months and in 50.9% of the cases it lasted ≥1h. In univariate analysis, 1st AF episode lasting more than 1 hour and existence of at least one episode longer than 24 hours were directly related to switch to VVIR (p<0.0005; p<0.0005; p<0.0005) as well as prescription of anticoagulation (p=0.001; p=0.011; p<0.0005).

Compared to non-AF P, those with AF were older (74.0±9.9 vs. 71.8±11.7 years; p=0.008), had higher prevalence of SND (50.0% vs 40.20%; p=0.015), had superior % of RV pacing (65.9±39.3% vs. 58.3±44.3%; p=0.021) and more frequently had RV apical pacing (70.1% vs 57.3%; p=0.001). The prevalence of hypertension, diabetes mellitus and dyslipidemia were similar in the two groups. With multivariable Cox-regression, age (HR 1.02; p=0.017), SND (HR 1.49; p=0.010), admission for HF (HR 1.55; p=0.012) and % RV pacing (HR 1.01; p=0.003) were significantly associated with the incidence of FA. Predictors of all-cause mortality in Cox regression were the occurrence of AF in 1st of FU (HR 1.67; p=0.018) and % RV pacing (HR 1.01; p=0.043).

Conclusions

New onset AF is a frequent finding after DDD pacemaker implantation and is associated with all-cause mortality in long term. Age, admission for heart failure, sinus node disease and % of RV pacing were independent predictors for AF during follow-up.

Funding Acknowledgement

Type of funding source: None
Sex-specific temporal trends in the incidence of atrial fibrillation in a large Norwegian population-based study 1986–2014
Authors: Sharashova E , Wilsgaard T , Ball J , Gerdts E , Rosengren A , Njolstad I , Mathiesen E.B , Schirmer H , Nyrnes A , Kildal S , Tiwari S , Espnes H , Stylidis M , Lochen M.L
Published: November 2020

Background

Due to population aging, increasing prevalence of obesity and enhanced detection, the prevalence of atrial fibrillation (AF) worldwide is increasing steadily. Considerable sex differences in the epidemiology of AF such as lower prevalence and later onset in women compared to men have been reported. However, little is known about sex-specific temporal trends in AF incidence within the general population.

Purpose

To explore sex-specific age-adjusted secular trends in the incidence of AF in a general population from Norway between 1986 and 2014.

Methods

A total of 16,865 men and 15,413 women aged 20 years or older and without AF were enrolled in a longitudinal population study between 1986 and 2008 and followed up for incident AF to the end of 2014. Follow-up was from the date of attendance to the date of AF, emigration or death, whichever came first. All AF cases were validated by an independent endpoint committee using hospital and death records. AF incidence rates were calculated for each calendar year by dividing the number of AF cases per year by the corresponding person-time at risk. To allow for non-linear time trends, calendar year was fitted using fractional polynomials. Poisson regression was used to estimate calendar year-specific AF incidence rates adjusted for age. All analyses were stratified by sex.

Results

A total of 911 AF events in women and 1,139 AF events in men occurred over 324,090 person-years and 294,531 person-years of follow-up, respectively. During the study period AF incidence rates in men were at least double that in women (Figure). Age-adjusted AF incidence rates in women increased from 1986, peaked at 0.87 per 1000 person-years in 1998 and then decreased slightly towards 2014. In men AF incidence rates increased up to 2.18 per 1000 person-years in 2005 and then steeply decreased.

Conclusion(s)

AF incidence rates decreased in both women and men towards the end of the study period. The decrease was more profound in men compared to that in women. One possible explanation is more pronounced reduction in incidence and better treatment of myocardial infarction in men compared to women given that the aetiology of AF in men is mainly ischemic heart disease-related. However, further epidemiological analyses should be undertaken to identify explanatory factors.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): University Hospital of North Norway, Northern Norway Regional Health Authority
Frequency of cardioversions for atrial fibrillation and the risk ischemic stroke
Authors: Jaakkola S , Kiviniemi T.O , Jaakkola J , Pouru J.P , Nuotio I , Vasankari T , Hartikainen J.E.K , Airaksinen K.E.J
Published: November 2020

Introduction

Patients with atrial fibrillation (AF) are selected for oral anticoagulation (OAC) therapy based on individual clinical characteristics collected in CHA2DS2-VASc -score. The characteristics of AF itself, however, are currently not included in stroke risk stratification schemes. Accumulating scientific evidence suggest that AF burden can be considered as an independent risk factor for cardiogenic stroke. So far, there are no studies evaluating the influence of AF burden measured by the frequency of symptomatic AF episodes on ischemic stroke risk.

Purpose

We sought to explore influence of symptomatic AF burden as determined by the frequency of acute cardioversions (CV) to the long-term ischemic stroke rate in AF patients.

Methods

This interim analysis of the multicenter, observational FinCV 4-study included 3867 CVs in 1521 non-anticoagulated patients. Clinical and laboratory data were collected manually through electronic patient records. Study follow-up started from the 1st CV of each patient and continued until one of the following events occurred: initiation of permanent OAC, non-CV related ischemic stroke, or death. Patients were divided in to three groups according to the individual frequency of CVs: high frequency (mean interval between CVs <12months), medium frequency (12–18months), low frequency (>18 months).

Results

A total of 113 (7.43% of patients) non-CV related (>30 days after CV) ischemic strokes occurred during the follow-up period (median 3.7 years [interquartile range 9.1 years]). The ischemic stroke rate per 100 patient-years was 7.5 in the high CV frequency group, 1.9 in the medium frequency group and 0.6 in the low frequency group. The mean CHA2DS2-VASc scores were 2.63±1.64, 2.46±1.63 and 2.20±1.68 in the three groups respectively. After adjusting for the CHA2DS2-VASc score, Cox regression analysis revealed CV frequency as an independent predictor for ischemic stroke (p<0.001). Kaplan-Meier analysis results are presented in Figure 1.

Conclusions

Determining the burden of AF based solely on the frequency of acute CVs seems to stratify the risk of ischemic stroke beyond CHA2DS2-VASc score.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): State clinical research fund (EVO) of Turku University Hospital
Exploring the temporal relationship between atrial fibrillation and heart failure development. Analysis from a nationwide database
Authors: Maalemben Messaoud B , Laurent G , Bisson A , Eicher J.C , Bodin A , Herbert J , Zeller M , Cottin Y , Fauchier L
Published: November 2020

Background

Atrial Fibrillation (AF) and Heart Failure (HF) often coexist and are closely intertwined, each condition worsening the other. Small cohorts studies have suggested a worse prognosis in patients who had developed HF first. However, the temporal relationships between these two pathologies have not been fully explored yet. We aimed to assess, at a nationwide scale, the prognosis of patients hospitalized with HF and AF, based on the timing of AF and HF development.

Methods

From the French administrative hospital-discharge PMSI database (Programme de Médicalisation des Systèmes d'Information), covering hospital care and representative of the whole french population. All consecutive patients with both diagnoses of AF and HF hospitalized between 2010 and 2018, whatever the order of occurrence for HF or AF, were included. From the database, 1,412,730 patients had inclusion criteria, of whom 403,934 developed AF First and 1,008,796 who developed HF First. Incidence rates (%/year) for the outcomes (all-cause death, cardiovascular (CV) death, or ischemic stroke) during follow-up were compared for each group using incidence rate ratios (RR) in the whole cohort and in a subgroup of 502,456 propensity-score matched patients (251,228 with AF first and 251,228 with HF first).

Results

In the whole population, most patients had developed HF before AF (n=1,008,796; 71.40%). At follow-up (median [IQR] 1.4 [0.1–3.7] years) patients with HF First had increased risk of all-cause death (yearly incidence: 18.9% vs 9.4%; [RR ([95% CI)]: [2.01 (2.00–2.02)]; p<0.00001), and CV death (7.0% vs 3.0%; [RR 2.31 (2.29–2.34)]; p<0.00001). In propensity score matched population, (follow-up median [IQR] 2.2 [0.5–4.4] years), patients with HF first had also worse outcomes than patients with AF first (all-cause death rates yearly incidence; 15.2% vs 9.4% [RR 1.63 (1.61–1.64)], p<0.00001; CV death rates: 5.6% vs 3.0% [RR 1.87 (1.84–1.90)], p<0,00001); ischemic stroke rate: 2.2% vs 1.3% [RR 1.71 (1.67–1.76)], p<0.00001).

Conclusion

In our large study from a nationwide database in patients hospitalized with both AF and HF, two distinct clinical entities were identified, based on the chronological sequence of AF and HF developments. Our results confirming that HF preceding AF is much worse than the opposite, and this might have therapeutics implications. However, further studies are needed to investigate the underlying mechanisms of the interplay of these dual conditions.

Funding Acknowledgement

Type of funding source: None