bluuebunny/crossref_metadata_2025 huggingface dataset:
Long-term efficacy and safety of ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy
Authors: Wang Gottlieb A , Edner J , Gottlieb-Vedi E , Yacoub N , Shahim A , Schwieler J , Bastani H , Drca N , Saluveer O , Jensen-Urstad M , Braunschweig F , Haugaa K , Shahim B
Published: October 2024

Background

Hypertrophic cardiomyopathy (HCM) is often accompanied by atrial fibrillation (AF) but data on safety and long-term outcomes after catheter ablation for AF in HCM are scarce.

Purpose

To investigate safety, long-term efficacy and clinical outcomes following AF ablation in patients with HCM and in matched controls.

Methods

Patients with HCM (n=76) undergoing a first catheter ablation for AF or atrial flutter between 1999 and 2022 at a University Hospital in Sweden were included (age 64±12 years, 43% female). Diagnosis of HCM was based on the European Society of Cardiology definition (left ventricular wall thickness ≥15 mm or ≥13 mm not solely explained by abnormal loading conditions, and combined with family history, genetic components and/or electrocardiogram abnormalities). Patients with HCM were matched with controls (n=152) based on age, gender, ablation type and intervention-year. Patients were followed for a mean of 5 years and study endpoints included heart failure hospitalization (HFH), stroke and mortality. Cox regression analyses were performed for the association between HCM and the endpoints.

Results

Among the overall population, 121 (53%) underwent pulmonary vein isolation (PVI), 62 (27%) isthmus ablation and 45 (20%) His-Bundle ablation. Patients with HCM had a shorter mean duration of AF before ablation (48 months vs. 66 months; p=0.047) and more severe symptoms as indicated by a higher EHRA class (EHRA class IV: 30% vs. 10%; p<0.01). Procedural success rate of PVI and isthmus ablation was lower in patients with versus without HCM (88% vs. 97%; p=0.02). Procedure related complications (vascular complications, tamponade) were overall similar in both groups (9% in HCM vs. 5% in controls, p=0.17) except for higher rates of pulmonary oedema in patients with HCM (7% vs 1%, p=0.03). There was a nearly two-fold increase in risk of AF recurrence after PVI or isthmus ablation in patients with HCM compared to controls (OR 1.95; 95% CI 1.06-3.58; p=0.03). During follow-up, patients with HCM had an increased risk of HFH (HR 2.55, 95% CI 1.21-5.36, p=0.01) but not of stroke or mortality (Figure 1).

Conclusion

AF ablation was overall safe in patients with HCM but less effective. Patients with HCM had an increased risk of the individual endpoint of HFH after AF ablation but not stroke or mortality during long-term follow-up.
Effect of selective renal denervation guided by renal nerve stimulation on atrial remodeling
Authors: Li D , Long Y X , Zhou H , Yin Y H
Published: October 2024

Background

The renal nerves play a crucial role in regulating blood pressure (BP), and the parasympathetic nervous has been confirmed as one of the components of the renal nerves, with close connections to the central solitary nucleus. Renal nerve stimulation (RNS) can activate not only the sympathetic nerves, leading to an elevation in BP, but also the parasympathetic nerves, resulting in a reduction in BP. Multiple clinical studies have demonstrated that compared to pulmonary vein isolation (PVI), renal denervation (RDN) combined with PVI significantly increased the likelihood of freedom from atrial fibrillation, but its mechanism remains unclear.

Purpose

Exploring the effects of renal sympathetic denervation and renal parasympathetic denervation on atrial neural remodeling and structural remodeling from a histological perspective of atrial myocardium.

Methods

24 adult healthy Kunming dogs were randomly divided into three groups: (1) RNS-guided reduced BP response sites ablation (RRA group, n=8), (2) RNS-guided elevated BP response sites ablation (ERA group, n=8), and (3) RNS only, no ablation (RSC group, n=8). Left atrial samples were obtained after a 4-week follow-up period.

Results

Compared to the RSC group, the ERA group showed a significant decrease in tyrosine hydroxylase (TH), while the RRA group showed a significant decrease in choline acetyltransferase (CHAT) and muscarinic acetylcholine receptor 2 (CM2) (Fig. 1A-1C). Histological results indicated that compared to the RSC group, the ERA group exhibited orderly arrangement of myocardial cells, with a significant reduction in the degree of mitochondrial swelling and a decrease in average myocardial cell area. In contrast, the RRA group showed disordered arrangement of myocardial cells, with some myofibril dissolution, noticeable swelling of cell nuclei and mitochondria, and an increase in average myocardial cell area (Fig. 1D). Further evaluation of left atrial fibrosis degree revealed that compared to the RSC group, the ERA group showed a significant decrease in Collagen I, with a reduction in interstitial fibrosis degree, while the RRA group showed a significant increase in Collagen I expression, with an increase in myocardial interstitial fibrosis degree (Fig.2).

Conclusion

Renal sympathetic denervation can reduce atrial sympathetic nerve, improve atrial macrostructure, ultrastructure, and fibrosis levels, which may be one of the reasons why RDN combined with PVI is more effective in maintaining sinus rhythm compared to PVI. Renal parasympathetic denervation can decrease atrial parasympathetic nerve, leading to deterioration of atrial tissue structure and exacerbation of fibrosis. This emphasizes the importance of electrical stimulation guidance during the RDN procedure to avoid "side effects" caused by renal parasympathetic nerves ablation.Figure 1Figure 2
Significant reduction of complications applying an optimized vascular access and post-interventional groin-site management during electrophysiology procedures
Authors: Obergassel J , Schenker N , Asbeck C , Lemoine M D , Ismaili D , My I , Moser F , Riess J , Nies M , Kirchhof P , Ouyang F , Reissmann B , Rillig A , Metzner A , Rottner L
Published: October 2024

Background

Catheter ablation of cardiac arrhythmias is an established treatment strategy. However, the optimal femoral vascular access strategy and post-interventional management in the electrophysiology (EP) setting is still under debate.

Purpose

To assess the impact of ultrasound-guided versus conventional femoral vascular puncture and of a modified post-interventional groin-site management strategy on complication rates.

Method

Patients undergoing EP procedures at the our university heart and vascular center are included in an institutional prospective registry. Conventional vascular access as well as post-interventional groin site pressure-bandage and bed rest of 6 hours (group I) was compared to a new strategy including ultrasound-guided vascular access, venous closure by a Z-suture and groin site pressure-bandage for only 2 hours plus additional 4 hours bed rest (group II). Incidences of minor and major groin site complications for both groups were compared. Hematoma, bleeding, arteriovenous fistula or pseudoaneurysm of the femoral artery without need for intervention (e.g. transfusion, thrombin injection, surgery) were classified as minor complications. Complications requiring intervention or retroperitoneal hematoma were defined as major complications.

Results

A total of 1535 procedures in 1381 patients (779 (51 %) procedures in 705 (51%) patients in group I and 756 (49%) procedures in 676 (49%) patients in group II) were analyzed. In group I and group II, respectively, 39%/44% procedures were index pulmonary vein isolations, 30%/29% repeat atrial fibrillation, 16 %/15% supraventricular tachycardia, 12%/11% PVC or VT ablations, and 4%/2% left atrial appendage occlusions. The total groin site complication rate was 9% (70/779 procedures) for group I, and 5% (38/756 procedures) for group II (OR 0.54 [95%-CI 0.35-0.82], p=0.003). Major groin site complications occurred in 2% (19/779 procedures) in group I and were reduced to 1% (10/756 procedures) in group II (OR 0.53 [95%-CI 0.22-1.22], p=0.156).

Conclusion

The overall groin site complication rate in EP-procedures was significantly reduced by implementing a novel institutional standard for vascular access management including ultrasound-guided puncture and a modified post-interventional groin site management.
Improved clinical outcome by means of three-dimensional electroanatomically- guided slow pathway elimination with irrigated, contact- force sensing catheter
Authors: Doundoulakis I , Tsiachris D , Antoniou C K , Kordalis A , Tsioufis P , Laina A , Botis M , Bartsioka L I , Kotoulas S , Sakalidis A , Gatzoulis K , Tsioufis K
Published: October 2024

Background

Slow pathway (SP) ablation, in the context of atrioventricular node reentrant tachycardia (AVNRT) treatment could result in either complete elimination or only modification of the SP with ambiguity regarding associated benefits.

Purpose

Three-dimensional electroanatomical mapping (3D-EAM) with irrigated, contact-force sensing may be used adjunctively aiming to complete SP elimination. Our purpose was to compare a 3D-EAM based strategy targeting SP elimination to the conventional fluoroscopic approach with respect to clinical outcome.

Methods

Eighty-four consecutive AVNRT patients (33 males, mean age 50.1±11.7 years) underwent a conventional fluoroscopic ablation approach (N=42) or a 3D-EAM-guided ablation irrigated, contact-force sensing catheter (ThermoCool SmartTouch ST, Biosense Webster, Inc.) focusing on complete SP elimination (N=42).

Results

Several procedural parameters improved with 3D-EAM use, including fluoroscopy time (2.0±4.3min vs 11±4.0min) and slow pathway elimination frequency (100% vs 50%, all p<0.001). Altogether, over a mean follow-up of approximately 2.0 years, recurrence occurred in 6 of 42 (14.3%) in the conventional group as compared to 1 of 42 (2.4%) in the EAM-based group (P =0.04).

Conclusions

The present study showed that an EAM-based SP elimination strategy is not only feasible and safe but it is also accompanied by improved clinical outcome in the setting of AVNRT ablation.
Digital health in the EP lab: routine implementation of remote access and technical support for complex ablation procedures
Authors: Popescu S S , Heeger C H , Vogler J , Eitel C , Botezat B I , Duta A I , Feher M , Phan H L , Mamaev R , Kuck K H , Tilz R R
Published: October 2024

Background

Complex electrophysiological procedures are performed using three-dimensional (3D) electroanatomical mapping (EAM) systems, which are usually operated on site, by field technical engineers (FTE). Due to a lack of skilled personnel, the engineers usually must travel between different hospitals and the procedures have to be planed in advance. Remote access (RA) technologies were recently implemented in clinical practice, aiming to increase the flexibility in the EP lab and maximise healthcare resources use.

Methods

Electroanatomical mapping was performed remotely by means of an integrated audio-visual solution for RA. The operator and the FTE communicated exclusively using the RA system, while the latter worked only in home office. Consecutive procedures were prospectively enrolled and analysed in terms of indication, procedural characteristics, feasibility and saved travelled time by the FTA.

Results

Between September 2022 and July 2023, a total of 133 EP procedures were performed in a high volume, tertiary electrophysiological centre in Germany. The mean age was 67 (57.5, 75.5) years. Women represented 39.8% of the population. The median BMI was 26.2 (23.1, 30.3) Kg/m2. A total of 56 (42.1%) patients underwent an atrial fibrillation ablation procedure (37.5% paroxysmal), 22 (16.5%) an atrial tachycardia ablation, 13 (9.8%) cavotricuspid isthmus ablation, 15 (11.3%) supraventricular tachycardia ablation, 14 (10.5%) a premature ventricular contraction ablation, 12 (9%) ventricular tachycardia ablations and 1 patient an electrophysiological diagnostic study. The median time length of procedure was 130 (96.5, 168) minutes. The median number of radiofrequency applications was 63.5 (22.3, 109.5), while the median RF time was 14.2 (6.9, 25.1) minutes. The fluoroscopy time was 9.2 (6.5, 12.6) minutes, with a median radiation dose of 408.5 (233.0, 631.8) cGy x cm2. The median amount of contrast media was 40 (8.75, 50.0) ml and the median amount of heparin administered was 12000 (8000, 16000) UI. Protamine was used in 9 cases, with a median of 7000 (5000, 7000) UI.

Except for one supraventricular procedure, where no arrhythmia induction was possible, all procedures were successful. One major complication was observed. In one case, the internet-based headphone connection was not stable. Therefore, the communication was established via a conventional smartphone. No change to on-site support was needed.

The travel time reduction was available in 130 cases. In total, 290 travel hours could be saved.

Conclusion

The routine implementation of RA for complex EP procedures proved to be safe and efficient. This approach has the potential to increase the feasibility in case of emergency procedures, reduce travel times for FTE and streamline healthcare resources allocation.
Sex differences in shocks and device-related complications in subcutaneous implantable-cardioverter defibrillator patients
Authors: De Veld J , Sivanesan S , Pepplinkhuizen S , Smeding L , Knops R E
Published: October 2024

Background

The use of implantable cardioverter-defibrillators (ICDs) improves the life expectancy of patients at risk of sudden cardiac death. However, ICD treatment comes with the risk of device-related complications. As the lead is the Achilles heel of the transvenous ICD (TV-ICD), the subcutaneous ICD (S-ICD) was developed to overcome the risk of lead-related complications. It is reported for TV-ICDs that women receive less appropriate therapy, but are more likely to experience ICD-related complications than men. It is unclear whether these differences also exist among S-ICD recipients.

Purpose

This study investigates the differences in appropriate shocks (AS) and device-related complications in men and women implanted with an S-ICD.

Methods

Retrospective data was collected of all patients implanted with an S-ICD between 2009 and 2022 in our tertiary center. Propensity score matching was used to create two comparable groups that differed by sex. The numbers of patients with an AS and device related-complication requiring intervention were compared between men and women. Differences between the groups were tested using a Fisher’s exact or X2-test.

Results

A total of 108 men and 108 women were included in this analysis. The median age was 40 years in men and 41 years in women (p=0.747), 61% had a primary prevention indication, and the median follow-up duration was 8 years. AS were seen in 15 women versus 24 men (p=0.156). There were 6 women versus 12 men with a device-related complication requiring intervention (p=0.218) (figure). The most common complication in men was infection (4/12) whereas in women erosion of the pocket occurred most frequently (2/6).

Conclusions

In this study, there was no significant difference in the number of patients with AS or complication between men and women with an S-ICD. However, a trend was seen towards more shocks and complications in men. The S-ICD may be a more suitable device for women, but further research with a larger sample size is needed.sex differences in S-ICD recipients
Intracardiac leadless pacemaker: long term safety over traditional pacemakers. a systematic review and meta-analysis
Authors: Gharehdaghi S , Engh M , Veres B , Vigh N , Fehervari P , Hegyi P , Zima E , Duray G
Published: October 2024

Introduction

Leadless pacemaker (LP) is a novel technology designed to reduce lead-related, including pocket infections, associated with traditional pacemakers. LP can be used in patients with high-degree AV block, sinus node dysfunction, and bradycardia with syncope. We conducted a systematic review and meta-analysis to examine the long-term safety of intra-cardiac leadless pacemakers compared with traditional pacemakers.

Methods

Our protocol was registered in advance on PROSPERO. Studies were eligible if they compared complications, revision, cardiac perforation, infections, and all-cause mortality between patients who received leadless pacemakers versus traditional pacemakers. The systematic search was conducted in five databases (MEDLINE, EMBASE, CENTRAL, Web of Science, Scopus) without restriction. The random-effect model was implemented to calculate pooled odds ratio (OR) with a 95% confidence interval (CI). Also, the Mantel-Haenszel method, Paule-Mandel estimator for tau^2, Q-Profile method for the confidence interval of tau^2 and tau, and Hartung-Knapp adjustment for random effects model methods were used for the prediction of data extracted directly from the curves. ROBINS-I tool was used for the risk of bias assessment, and the certainty of the evidence was evaluated with the GRADE approach.

Results

Of 6450 studies screened, we identified 21 observational studies of Nanostim and Micra leadless pacemakers. The pooled incidence of complications of leadless versus traditional pacemakers at 1, 6, 12-24 months show the odds are clinically and statistically different (OR=0.66, 95% CI: 0.42–1.02; OR=0.44, 95% CI: 0.22–0.86; OR=0.41, 95% CI: 0.32–0.53 respectively). The pooled incidence of infection rate at 6, 12-24 months is lower in patients with LP (OR=0.37, 95% CI: 0.31–0.44; OR=0.20, 95% CI: 0.00–97.31). The studies comparing all-cause mortality during 6, 12-24 months in leadless versus traditional pacemakers did not show statistically significant differences in these outcomes (OR=1.26, 95% CI: 0.88–1.81; OR=0.86, 95% CI: 0.25–2.92 respectively.

Conclusion

Our results show that complications and infections occur less frequently in patients with leadless pacemakers than in patients with conventional pacemakers with no difference in all-cause mortality. However, there is a need for high-quality randomized clinical trials and propensity score-matched studies focusing on this clinically relevant question.Complication Forest plotsInfection Forest plots
Clinical outcomes of atrial high-rate episodes: an updated meta-analysis
Authors: Ahmed H , Mahmoud Ismayl M I , Manvir Mangat M M , Anirudh Palicherla A P , Anthony Kashou A K , Jalal Dufani J D , Andrew Goldsweig A G , Nandan Anavekar N A , Ahmed Aboeata A A
Published: October 2024

Background

Atrial high-rate episodes (AHRE) are commonly detected in individuals with cardiac implantable electronic devices. Outcomes of atrial high-rate episodes remain unclear in those without a prior history of atrial fibrillation.

Purpose

This study aims to evaluate clinical outcomes of atrial high-rate episodes in patients who have no prior history of atrial fibrillation.

Methods

PubMed, EMBASE, and Cochrane databases were searched through February 2024 for studies evaluating clinical outcomes in individuals with cardiac implantable electronic devices who experienced atrial high-rate episodes, compared to those who did not. Individuals who had a prior history of atrial fibrillation were excluded. Outcomes assessed were clinical atrial fibrillation, thromboembolic events, and all-cause mortality. A fixed-effects model was used to calculate risk ratios (RRs) with 95% confidence intervals (CI). A subgroup analysis of thromboembolic events was conducted based on the duration of atrial high-rate episodes.

Results

A total of 9 studies met inclusion criteria with a combined enrollment of 7440 patients. Compared to those who did not experience atrial high-rate episodes, those who did had significantly increased risks of clinical atrial fibrillation (RR 3.33; 95% CI 1.99 - 5.57; P < 0.0001) and thromboembolic events (RR 2.21; 95% CI 1.72 -2.85; P < 0.0001). The risk of all-cause mortality was similar between both groups (RR 1.19; 95% CI 0.95 – 1.49; P = 0.13). Subgroup analysis revealed an increased risk of thromboembolic events among atrial high-rate episodes ≥ 24 hours (RR 12.34; 95% CI 2.70 – 56.36) while atrial high-rate episodes lasting < 24 hours were insignificantly associated with thromboembolic events (RR 0.83; 95% CI 0.12 – 5.58).

Conclusions

Our study indicates a heightened risk of clinical atrial fibrillation and thromboembolic events among patients with atrial high-rate episodes, with no observed increase in mortality risk. Furthermore, our findings suggest that the duration of atrial high-rate episodes influences the risk of thromboembolism. Further studies are warranted to confirm our findings.
Impact of adjacent thoracic structures in negative left atrial remodelling in atrial fibrillation
Authors: Sharp A J , Pope M T B , Briosa E. Gala A , Varini R , Betts T R , Banerjee A
Published: October 2024

Background

Previous work has suggested that compression from external structures can promote negative atrial remodelling in atrial fibrillation (AF) [1]. This is mechanistically plausible, with many recognised risk factors in developing AF (age, hypertension, obesity, obstructive sleep apnoea, etc.) related through activation of the autonomic nervous system with an associated increase in atrial pressure and chronic elevation in wall stress [2,3]. Such negative remodelling contributes to the existence of arrhythmogenic atrial substrate [4]. This is highly significant when we consider catheter ablation of extrapulmonary vein targets.

Purpose

This study aims to investigate the relationship between abnormal conduction patterns indicative of potential AF drivers and their proximity to structures adjacent to the left atrium (LA).

Methods

Eight patients with paroxysmal or persistent AF, scheduled for an elective catheter ablation procedure using a charge density mapping (CDM) system [5] underwent pre-procedural cardiac MRI. 3D surface mesh reconstructions of individuals’ LA and adjacent structures (ascending aorta [AoA], descending aorta [AoD], and spine) were produced from 2D MRI slices using a proprietary graphical interface tool developed in MATLAB (Figure 1A & B) [6].

MRI derived LA geometries were registered with their CDM counterparts by the Iterative Closest Point algorithm (Figure 1C); this enabled integration of MRI LA geometries into the CDM system. Subsequently, non-contact intrachamber voltage measurements from individuals’ procedures were used to derive cardiac activation directly onto MRI LA geometries.

Abnormal conduction patterns representing possible AF drivers (focal firing, rotational propagation, and pivoting propagation) [5] were quantified as occurrences per second at each vertex of MRI LA geometries (Figure 1D). These conduction patterns could then be visualised and assessed in the context of adjacent structures (Figure 1E), with the Euclidean distance between each vertex of the MRI LA geometries and the closest point to their adjacent structures being calculated.

Results

Mean age was 65±9 years; 4 patients (50%) were male; AF was paroxysmal in 3 (37%) and persistent in 5 (63%); median time since AF diagnosis was 1 (1-3.8) years; ablation type was de novo in 5 (63%) and retreatment in 3 (38%).

Frequencies of pivoting and rotational propagation were notably higher in regions of the LA closer to the AoA, and lower near the AoD and spine (Figure 2A & B). Conversely, focal firing showed a less prominent trend, being more frequent in LA regions nearer the AoD and distant from the AoA (Figure 2C).

Conclusions

Compression from the ascending aorta may promote anterior LA remodelling in AF, leading to increased pivoting and rotational AF drivers. Clinically, this suggests a potential target for ablation therapy with an anterior seatbelt line connecting the right superior pulmonary vein to the mitral annulus.
Quo vadis, the leading arrhythmia? Projecting the prevalence of atrial fibrillation up to 2070
Authors: Lehto M , Haukka J , Halminen O , Teppo K , Putaala J , Linna M , Mustonen P , Aro A L , Hartikainen J , Airaksinen K E J
Published: October 2024

Introduction

The prevalence of atrial fibrillation (AF) is strongly associated with age, and with increasing life expectancy worldwide, the number of AF patients has been steadily rising. However, long-term projections of AF prevalence are scarse.

Purpose

To predict the prevalence and the number of patients with AF in Finland from 2021 until 2070.

Methods

In the Finnish Anticoagulation in Atrial Fibrillation (FinACAF) study we gathered data of all AF patients from all national health care registers (hospitalizations and outpatient specialist visits, primary health care contacts, and reimbursements for prescription medicines) from 2004 to 2018. The prevalence of AF on December 31st 2018 was calculated as the number of patients alive with AF divided by the number of Finnish population. We utilized age- and sex-specific prevalences on year 2018 to predict the prevalence by sex and 5-year age groups, using a 1-year time interval of AF in Finland between years 2021 and 2070. We obtained the projection for population structure in Finland between 2021 and 2070 from Statistics Finland. The prevalences in 2070 are provided for population ≥20 years as well as for populations ≥65 years, ≥75 years, and ≥85 years.

Results

In 2018, a total of 226 847 patients with the diagnosis of AF were documented in Finland. The number of adult patients with AF is predicted to increase strongly up to 2040 with a slower increase from 2040 to 2060, and again a faster increase is estimated from 2060 up to our final estimation of 2070. In total, the number of AF patients will increase with 60% until the year 2070.

In 2021, prevalence of AF was 5.5% in adults and prevalence rate will increase to 8.6% in 2070. Proportion of men will be from 54.7 % to 56.0%, and the prevalence will be higher in men compared to women in all age groups with the exception in the age group ≥85 years. Among the population ≥65 years the prevalence in 2070 will be 19.7 %, and in the elderly, ≥75 years, the prevalence of AF will 25.6% and in the oldest, ≥85 years, 31.7%. In 2070 73.3 % of patients with AF are over 75 years, and 38.8% are over 85 years old.

Conclusions

Drawing upon extensive nationwide data covering all levels of care, our estimates indicate a continual rise in the number of AF patients in Finland until the year 2070. Notably, throughout the projected period, there is a discernible increase in the proportion of older and the oldest patients, highlighting the demographic shift in AF prevalence.Patients with AF 2021-2070 in Finland
Direct synchronized cardioversion not independently associated with infarcts on cerebral magnetic resonance imaging and clinical outcomes in patients with atrial fibrillation
Authors: Bernheim A , Mueller A , Rommers N , Aeschbacher S , Bonati L , Conen D , Reichlin T , Ammann P , Beer H , Jeger R , Kurz D , Liedtke C , Kuehne M , Osswald S , Stauber A
Published: October 2024

Background

Direct synchronized cardioversion (DCV) is frequently performed in atrial fibrillation (AF). In general, DCV is considered a safe procedure. A rare, but feared complication following DCV is an overt ischemic stroke resulting from embolization of a left atrial clot to the cerebral circulation.

Purpose

The aim of the present study was to assess the association of DCV with infarcts on brain magnetic resonance imaging (bMRI) and clinical outcomes.

Methods

2386 patients of the Swiss AF cohort were included. 1731 patients were evaluated by bMRI. DCVs were recorded by questionnaire. Patients were categorized by number of DCVs performed before enrollment (0,1,≥2). BMRI were conducted at baseline and after 2 years (n=1227) and analyzed for large noncortical or cortical infarcts (LNCCI) and small noncortical infarcts (SNCI). Clinical outcomes were recorded during follow-up. Associations of DCV and outcome-measures were assessed by multivariate analyses.

Results

There was no independent association between the number of DCV and infarct prevalence (LNCCI + SNCI) on baseline bMRI (DCV 1 vs. 0: OR 0.95 [95% CI 0.73-1.26]; DCV ≥2 vs. 0: OR 1.04 [0.73-1.51]) or between DCV performed during follow-up and new infarcts on bMRI at 2 years (OR 1.46 [0.54-3.31]). DCVs were not associated with overt stroke or transient ischemic attack (DCV 1 vs. 0: HR 1.35 [0.87-2.03]; DCV ≥2 vs. 0: HR 1.54 [0.95-2.49]), hospitalization for heart failure (DCV 1 vs. 0: HR 1.03 [0.80-1.33]; DCV ≥2 vs. 0: HR 1.03 [0.77-1.37]), or death (DCV 1 vs. 0: HR 0.85 [0.67-1.09]; DCV ≥2 vs. 0: HR 0.92 [0.70-1.22]).

Conclusions

There was no association between DCV performed before enrollment and cerebral infarcts on baseline bMRI or between DCV performed during follow-up and new infarcts at 2 years. Moreover, DCV were not associated with clinical events.
Proteomic and genomic evaluation of plasma protein biomarkers for atrial fibrillation
Authors: Vad O B , Paludan-Muller C , Diederichsen S Z , Svendsen J H , Olesen M S
Published: October 2024

Background

Atrial fibrillation (AF) is a common arrhythmia and an important cause of ischemic stroke. Several plasma proteins have been suggested as biomarkers for the risk of AF and subsequent stroke in previous studies, but validation in independent cohorts is needed. Large-scale integration of proteomics with genetic and clinical data holds potential for refinement of disease prediction and risk stratification.

Purpose

This study aimed to evaluate previously suggested plasma protein biomarkers of AF and ischemic stroke using plasma protein measurements in a large cohort.

Methods

Ten tentative protein biomarkers previously associated with AF or ischemic stroke in AF patients, were evaluated in a nested case-control study comprising 49,757 individuals from the UK biobank (UKB). Plasma proteins were measured by normalized protein expression on the Olink platform. Outcomes were incident AF and ischemic stroke. The proteins were evaluated in Cox regression models adjusted for sex, age, and clinical risk factors. To assess whether the proteins were independent predictors, they were evaluated in sensitivity analyses with additional adjustment for NT-proBNP levels. Polygenic risk scores were calculated for plasma protein concentrations using the PRS-CS-auto algorithm and tested for association with AF or ischemic stroke in an independent subset of the UKB cohort without plasma protein measurements (n=379,392).

Results

All ten plasma proteins were associated with incident AF in the primary model, and eight were associated with incident ischemic stroke (P-values < 0.0025 for all). Adjusted for NT-proBNP levels, the proteins interleukin-6, GDF15, angiopoietin 2, and Troponin-I remained independently associated with AF, and the proteins GDF15, Cystatin-C, interleukin-6, ADAMTS13, and FGF23 remained independently associated with ischemic stroke. Polygenic risk scores for NT-proBNP and angiopoietin 2 were associated with increased rates of AF. No polygenic scores were significantly associated with ischemic stroke.

Conclusion

Large-scale proteomic evaluation validated ten plasma proteins associated AF and found eight to be associated with ischemic stroke. Seven proteins were associated with AF or ischemic stroke independently of NT-proBNP levels. Additional genomic evaluation provided evidence of associations between incident AF and genetically predicted plasma levels of angiopoietin 2 and NT-proBNP. As proteomic analyses of the plasma proteome become cheaper and more readily available, these findings could contribute to future risk stratification and selection of individuals for AF screening programs.Proteins associated with AFProteins associated with ischemic stroke
Cluster-specific predictors of early rhythm control in contemporary European cohort of patients with atrial fibrillation: The EHRA-PATHS Project
Authors: Potpara T , Mihajlovic M , Linz D , Dagres N , Dabrowski R , Sterlinski M , Heidbuchel H
Published: October 2024

Background

Early rhythm control (ERC) using antiarrhytmic drugs, electrical cardioversion or catheter ablation for AF within a year from first diagnosis of atrial fibrillation (AF) has been shown to reduce the risk of major adverse outcomes compared to usual care, and the effects of ERC have been suggested to be consistent across all AF subgroups with different risk profiles. We aimed to identify cluster-specific predictors of ERC in pre-defined AF clusters in contemporary European EHRA-PATHS AF cohort.

Methods

The EHRA-PATHS AF cohort was derived from the three prospective EurObservational Research Programme (EORP) AF registries - General Pilot, General Long-term, and AF III registry. A two-step cluster analysis was performed. A hierarchical cluster analysis with 18 variables was used to identify the optimal number of clusters, followed by a K-means cluster analysis to determine variable cluster association. Cluster-specific predictors of ERC were identified using univariate and multivariate logistic regression analyses.

Results

Of 18,799 patients, AF was diagnosed within 1 year in 8088 (43.0%), and 3913/8088 patients (48.4%) were treated with ERC. Among the three clusters - Cluster 1 (younger healthier AF patients) compared with Cluster 2 (Elderly with less comorbidity, mostly non-cardiovascular) and Cluster 3 (Elderly with more comorbidity, mostly cardiovascular), see Table, ERC was significantly more often used in Cluster 1 compared with Cluster 2 and Cluster 3 (both P<0.001), and in Cluster 2 compared with Cluster 3.

Cluster-specific multivariable predictors of ERC are shown in Table. In all three clusters, asymptomatic AF (EHRA score I) and Northern Europe residence were inversely associated with ERC, while Western Europe residence was positively associated with ERC in Cluster 2 and 3. In Cluster 1, low stroke risk and hypertension were positively associated with ERC, while dilated left atrium (LA) and reduced left ventricular ejection fraction (LV EF) were negative predictors of ERC. In Cluster 2, age ≥80 years, enlarged LA, and CHA2DS2-VASc ≥2 for males and ≥3 for females were negatively associated with ERC. In Cluster 3, age ≥75 years, cardiomyopathy, liver disease, dementia and reduced LV EF were negative predictors of ERC.

Conclusion

Our study of a large European AF cohort showed that likelihood for ERC was greater in younger and healthier AF patients, as well as in elderly from Western Europe, while ERC was significantly less likely with increasing age and comorbidity (especially cardiovascular diseases). These findings likely reflect the lack of high-quality evidence supporting aggressive ERC in high-risk patients with AF. With increasing body of evidence favouring ERC such patients, a shift towards less selective consideration of ERC in daily practice may be expected.
Combined SK and K2P channel block cardioverts atrial fibrillation in 82% of cases, doubling the efficacy of single channel block
Authors: Dasi A , Bueno-Orovio A , Rodriguez B
Published: October 2024

Background

Inhibiting the atrial-selective SK and K2P channels represents a promising strategy for cardioverting atrial fibrillation (AF), but its efficacy has not been evaluated in a large human cohort.

Objectives

This study employed in-silico trials in 1000 virtual patients (i.e., clinical trials conducted in a population of virtual human subjects through modelling and simulation) to estimate the efficacy and safety of three pharmacological interventions: single and combined SK and K2P channel block.

Methods

A large cohort of 1000 virtual patients was developed based on human data, to cover the electrophysiological, anatomical and structural variability encountered in clinical practice. The subset of virtual patients with AF maintenance underwent pharmacological cardioversion (Figure).

Results

Sustained AF was observed in 654 (65%) virtual patients. In this cohort, cardioversion efficacies of 33% (213 of 654), 43% (278 of 654) and 82% (534 of 654) were obtained for single SK, single K2P and combined channel block, respectively (Figure). The cardioversion efficacy was proportional to an increase in tissue refractoriness (increase of 45.2±43.0, 71.0±55.3 and 133.0±48.4 ms in the atrial refractory period) and depended on the ionic current profile. Virtual patients cardioverted by SK channel block presented lower K2P densities (0.008±0.002 vs. 0.006±0.002 S/mF; non-cardioverted vs. cardioverted virtual patients, respectively). Similarly, a lower SK density favoured the success of K2P channel inhibition (1.87±0.24 vs. 1.46±0.5 S/mF; non-cardioverted vs. cardioverted virtual patients, respectively). Both ionic currents had a crucial role on atrial repolarization, and thus, a synergism resulted from the polypharmacological strategy (i.e., higher efficacy than the additive effects of single channel block). All three interventions, including the multi-channel block, preserved the atrial electrophysiological function (i.e., conduction velocity and calcium transient dynamics) and thus, the atrial contractile properties (safety).

Conclusion

In-silico trials identify the polypharmacological SK+K2P channel block as an effective and safe strategy for AF management.
Atrial fibrillation recurrence rates in patients with transthyretin cardiac amyloidosis undergoing pulmonary vein isolation: a comparative retrospective study with propensity score matching
Authors: Addeo L , Valeriano C , Valcher S , Viscusi M M , Buytaert D , Storozhenko T , Shumkova M , Geelen P , Peytchev P , De Schouwer K , Al Zand B , De Potter T
Published: October 2024

Background

Atrial fibrillation (AF) affects up to 70% of individuals diagnosed with transthyretin cardiac amyloidosis (ATTR CA) [1]. AF ablation is frequently considered in the management of these patients, but there is a lack of data about outcomes of the procedure in this population.

Purpose

This study aims to evaluate AF recurrence rates and long-term AF recurrence-free survival in patients with ATTR CA undergoing pulmonary vein isolation (PVI).

Methods

A single-center retrospective study was conducted, including all patients diagnosed with ATTR CA who underwent PVI from 2016 to 2023. We compared patients with amyloidosis (cases) to those without (controls), employing propensity score matching for age, gender, AF type (paroxysmal vs. persistent), BMI, diabetes, arterial hypertension diagnosis, antiarrhythmic drug therapy post-index ablation, and left atrium (LA) volume assessed by 3D rotational angiography (3DRA).

Results

16 patients with CA were matched to 16 patients without (32 patients in total). After matching, the populations demonstrated comparable baseline characteristics (figure 1). The study consistently revealed a higher AF recurrence rate, after PVI, in the CA group (81.3%) compared to the control group (37.5%) at the last follow-up (p-value 0.01) (median follow-up 1255 ± 1055 days in CA and 1491 ± 464 days in control group), as well as a significantly lower long-term AF-recurrence free survival (log-rank p = 0.01 – figure 2). Additionally, the recurrence rate at 1-year post-procedure was 56.25% in the CA group and 18.75% in the control group (p-value 0.03).

Conclusions

Pulmonary vein isolation remains a viable treatment option for individuals with ATTR CA. However, it proved less effective (or less durable) than in the general population without the disease, both at 1-year follow-up and for longer periods, as shown also with recurrence-free survival rate. Further studies are warranted to determine the optimal treatment strategy for this specific population.Baseline Characteristics fig. 1Kaplan Meyer fig. 2
Timing of early recurrence of atrial fibrillation during the blanking period after catheter ablation for persistent atrial fibrillation and implications for long-term success: a multicentre study
Authors: Tang P T , Betts T R , Pedersen M E F , Rajappan K , Bashir Y , Wijesurendra R S , Ginks M R
Published: October 2024

Background

After catheter ablation (CA) for atrial fibrillation (AF), early recurrences of AF (ERAF) that occur within a 90-day post-ablation "blanking period" are considered to represent transient post-ablation pro-arrhythmia.

Purpose

To determine if the timing of early recurrence of AF during the traditional 90-day post-CA blanking period is associated with long-term AF recurrence after CA for persistent AF (PsAF).

Methods

We performed a multicentre retrospective study of patients undergoing first-time CA for PsAF between 2015-2018. All patients had undergone pre-CA DCCV. Incidences of ERAF during the post-CA blanking period were reviewed, and patients were categorised into three groups based on the timing of last episode of ERAF during the blanking period: (1) no ERAF (reference population); (2) last ERAF <30 days post-CA; (3) last ERAF 31-90 days post-CA. The primary outcome was long-term recurrence of atrial arrhythmia, i.e. time to first recurrence of atrial arrhythmia occurring beyond the first 90 days after CA. Patients who had ERAF and exited the blanking period in AF (i.e. those with immediate recurrence at 90 days) were excluded from this analysis.

Results

331 patients were identified from five centres. 206 patients had no ERAF during follow-up, 124 patients had ERAF during the blanking period, and in one patient the presence of ERAF was not documented. Of the 124 patients experiencing ERAF during the 90-day post-CA blanking period, the timing of the last episode was known in 122 patients (Table 1). Of these, 58 patients exited the 90-day blanking period in AF and were excluded. Over median post-CA follow-up of 590 days, 147 patients (54%) experienced the primary outcome. Compared with Group 1 (no ERAF), ERAF within each of the time periods was associated with a statistically significant progressively increased risk of long-term recurrence (Group 2, last ERAF <30 days post-CA: hazard ratio [HR] 1.95 [95% CI 1.15-3.31]; Group 3, last ERAF 31-90 days post-CA: HR 4.86 [95% CI 2.13-11.08]; Figure 1).

Conclusion

ERAF during the traditional 90-day post-CA blanking period is associated with long-term AF recurrence, with later recurrence within the 90-day period conferring greater risk. Patients with ERAF during the blanking period may need to be considered for earlier repeat intervention where clinically appropriate.
Procedural outcomes of fluoroscopy-less catheter ablation for atrial fibrillation
Authors: Rajkumar S , Alfraih A , Vivekanantham H , Dadon Z , Acosta G , Roberts J , Divakara Menon S , Amit G , Wong J
Published: October 2024

Background

Radiofrequency catheter ablation is superior therapy to antiarrhythmic drugs for maintaining sinus rhythm in atrial fibrillation (AF) patients. Traditional fluoroscopy-guided AF ablation poses risks of prolonged radiation exposure for both patients and medical staff. Recent advancements in fluoroscopy-less catheter ablation techniques offer potential solutions, but comprehensive data on their effectiveness and safety are lacking.

Purpose

To evaluate the procedural outcomes and safety of fluoroscopy-less catheter ablation for AF compared to fluoroscopy-guided ablation.

Methods

Retrospective observational study of consecutive AF ablations (N=881) conducted at a university teaching hospital (Hamilton Health Sciences, Hamilton, Ontario) from November 2017 to September 2022. An electro-anatomical mapping system and ICE was used in all cases. Baseline characteristics and procedural outcomes between the fluoroscopy-less and fluoroscopy-guided groups were compared. Cases that used <60 seconds of fluoroscopy (occasionally used by operators during the placement of an esophageal probe) were included in the fluoroscopy-less group (N= 68).

Results

Mean age of individuals was 60.6 ± 11 years, 71.7% were male, 72.6% had paroxysmal AF, mean CHA2DS2-VASc score was 1.6 ± 1.4, 11.1% had prior heart failure, and mean left ventricular ejection fraction was 57.5 ± 15%. There were no significant differences in patient baseline characteristics between the fluoroscopy-less and fluoroscopy groups. Total procedure and fluoroscopy times were lower in the fluoroscopy-less group compared to the fluoroscopy-guided group (169.3 ±42 minutes vs. 192.1 ±54 minutes, p<0.0001 and 0.024 ±0.10 vs. 10.0 ±7.4 minutes , p<0.0001). Fluoroscopy-less AF ablation remained an independent predictor of lower procedure times following adjusting for the use of general anesthesia, high-power short-duration, presence of trainees, AF pattern, redo cases, and type of mapping system. Complication rates were similar between fluoroscopy-less and fluoroscopy-guided ablation (1.9% vs. 3.8%, p=0.11).

Conclusion

Fluoroscopy-less catheter ablation for AF appears to have similar procedural outcomes and safety than fluoroscopy-guided AF ablation.
Pulsed-field ablation for atrial fibrillation with a novel simplified protocol: the Swiss PFA dose multicenter study
Authors: Badertscher P , Breitenstein A , Spreen D , Isenegger C , Siemer D , Knecht S , Krisai P , Osswald S , Sticherling C , Kuehne M
Published: October 2024

Introduction

Pulsed-field ablation (PFA) has emerged as a novel treatment technology for patients with atrial fibrillation (AF). So far, little is known about the optimal number of PFA applications per pulmonary vein (PV). The standard protocol for PFA, as per manufacturer’s recommendation, entails 8 applications per PV.

Purpose

To assess the optimal pulsed-field ablation dosing (simplified versus standard protocol vs. extended protocol).

Method

We prospectively enrolled patients undergoing their first PVI using PFA in three tertiary referral centers. The following PFA dose protocols were applied: In the simple PFA group, a novel simplified protocol for PFA was performed with only 4 applications per PV (2x in basket and 2x in flower configuration). In the standard PFA group, a standard protocol with 8 applications per PV (4x basket and 4x flower configuration) was applied and in the extended PFA protocol, an extended protocol with 12 applications per PV (4x basket and 8x flower configuration) was applied.

Results

364 patients were included (32% female, median age 66 [IQR 58 – 73] years). Among these, 100 patients (36%) were in the simple PFA group, 180 patients (50%) in the standard PFA group and 84 (24%) patients in the extended PFA group. The median procedure duration, left atrial dwell time and the fluoroscopic time for the simple PFA, standard PFA and extended PFA group were 45 [interquartile range (IQR) 28 – 57] min vs. 54 [IQR 41 – 67] min vs. 63 [55 – 76] min (p < 0.001), 25 [IQR 12 – 38] min vs. 37 [IQR 27 – 50] min vs. 39 [29 – 55] min (p < 0.001), 9 [IQR 8 – 12] min vs. 11 [IQR 9 – 14] min vs. 9 [8 – 10] min (p < 0.001), respectively. A total of four procedural complications (two tamponades, one stroke, one temporary ST elevation) were observed for the standard PFA group and none for the simple or extended PFA group (p = 0.382). The recurrence rate of atrial arrythmias was 41 (23%) for the standard protocol, 11 (11%) for the simple protocol and 12 (14) % for the extended protocol over a median follow-up of 285 [IQR 173 – 478] days (p = 0.065).

Conclusion

A novel simplified PFA protocol resulted in significantly shorter procedure duration, left atrial dwell time and fluoroscopic time, without compromising procedural efficacy compared to the standard or extended protocol.Figure 1