bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of atrial fibrillation ablation in heart failure with reduced ejection fraction
Authors: Massa M P , Arias R M , Spaccavento A , Ballari F N , Burgos L M , Diez M , Espinoza J C , Gil Ramirez A J , Mondragon L I , Albina G , Scazzuso F
Published: November 2023

Introduction

Atrial fibrillation (AF) is the most common supraventricular arrhythmia in patients with heart failure (HF) and is associated with a significant increase in morbidity and mortality. Some studies have shown evidence in favor of ablation over pharmacological treatment in patients with AF and reduced ejection fraction (HFrEF). However, little is known about the generalizability of the trial results to routine clinical practice, particularly in a low- and middle-income country.

Objective

To evaluate whether catheter ablation (CA) of AF reduces morbidity and mortality compared to medical therapy alone in patients with HFrEF and AF in a real-word contemporary cohort from Argentina.

Methods

We consecutively identified patients with HF with ejection fraction less than 40% associated with paroxysmal or persistent AF who presented to our hospital, either as outpatients or inpatients, between February 2018 and June 2020. Baseline characteristics and outcomes were compared among patients undergoing CA or medical therapy alone. The primary outcome was all-cause mortality and first HF hospitalization until completing a 3-year follow-up. Propensity score overlap weighting was used to balance ablated and drug-treated patients on sex, age, body mass index, hypertension, diabetes, dyslipidemia, smoking, previous atrial fibrillation ablation, use of antiarrhythmic drugs, cardiac resynchronization, cardiac defibrillator, left ventricular ejection fraction, cardiovascular surgery, infarction, stroke, peripheral vascular disease, etiology of heart failure, respiratory disease and renal disease baseline characteristics.

Results

Data from 6297 patients with AF were analyzed, of whom 430 had ejection fraction ≤ 40%. We excluded 20 patients who were ablated for atrial flutter. 53 patients in the ablation and 357 patients in the medical therapy group were identified.

After PS matching, the primary outcome occurred in 9 patients (23,7%) in the ablation group and in 19 patients (50%) in the control group. Catheter ablation was associated with a statistically significant reduction of the primary outcome in a 3-year follow up (Hazard ratio [HR] 0.33 [95%CI, 0.12-0.93]).

Conclusion

Catheter ablation for atrial fibrillation in patients with HFrEF was associated with decreased risk of mortality and heart failure hospitalisations relative to medical therapy.Kaplan-Meier survival estimates
Zero x-ray pulmonary vein isolation with heliostar radiofrequency balloon: efficacy and safety
Authors: Martinez Gomez E , Salgado Aranda R , Calvo Cuervo D , Gonzalez Ferrer J J , Canadas Godoy V , Filgueiras Rama D , Chavez Ortiz I , La Rosa G , Sanchez Vallejo C , Perez-Villacastin Dominguez J , Perez Castellano N
Published: November 2023

Introduction

Single shot pulmonary vein isolation techniques are currently an attractive and effective alternative to point-by-point ablation. The Heliostar® radiofrequency balloon is capable of producing single shot isolation with reduced procedure times and high efficacy and safety. A particular feature of this new balloon is its ability to be visualized on the Carto 3® navigation system, which makes it possible to reduce or even eliminate the use of X-rays (XR) in this type of procedure.

Objectives

Our objective was to demonstrate the efficacy and safety of pulmonary vein isolation with Heliostar® radiofrequency balloon without the use of XR.

Methods

Twenty-five patients with paroxysmal (68%) or persistent (32%) atrial fibrillation were prospectively included in our centre and underwent pulmonary vein isolation with radiofrequency balloon. Ten cases were performed without XR (40%), and the remaining 15 (60%) using fluoroscopy. All cases were performed under general anaesthesia and using the Carto 3® navigation system. Electroanatomical mapping was performed pre and post ablation in all cases. Mapping was performed in sinus rhythm. In cases without XR, intracardiac echocardiography was used to guide the transseptal puncture and the rest of the procedure. Technical and clinical data were collected. Cases with and without XR were compared.

Results

There were no complications in either group. All veins were successfully isolated, with 56% first pass isolation in the non-XR group versus 68% in the XR group (non-significant difference). The vein with the highest percentage of first pass isolations was the left inferior vein in both groups. Procedure times were similar (median left atrial dwell time of 34 minutes in the non-XR group and 36 minutes in the XR group, non-significant difference). There was also no difference in the median time to isolation from the start of radiofrequency application in each vein (10 seconds in both groups). Left atrial size was normal in most patients, and ventricular function was preserved, with no differences between the two groups. The non-XR group had a higher number of patients with left main trunk, but the XR group had a higher percentage of patients with persistent forms of atrial fibrillation.

Conclusion

Zero-XR pulmonary vein isolation with Heliostar® balloon is possible and safe, with similar efficacy and first pass isolation rate, similar procedure time and no relevant complications in our series.
Predicting success of atrial fibrillation ablation: comparing machine learning approaches of intracardiac electrograms
Authors: Feng R , Ganesan P , Deb B , Ruiperez-Campillo S , Chang H J , Clopton P , Rogers A J , Rodrigo M , Tjong F V Y , Zaharia M , Narayan S M
Published: November 2023

Introduction

Machine learning (ML) and Deep learning (DL) neural networks have been used to predict which patients will respond to atrial fibrillation (AF) ablation. However, the predictive results of DL are modest compared to traditional statistical models of clinical features with or without intracardiac electrograms.

Purpose

To test the hypothesis that optimized ML architectures will better identify patients who respond to AF ablation using intracardiac EGM than other DL architectures in our large registry of 320 consecutive patients.

Methods

Our patients had age 65.1±10.4Y, were 25% women, 61.6% non-paroxysmal, with intracardiac EGM recorded from multipolar catheters and 64-pole baskets (Fig A). Patients were propensity matched into those in whom ablation terminated by ablation (N=160, "Term") and those without termination (N=160, "Non-Term"). Using a proven DL architecture, ResNet, we systematically varied the depth (i.e., number of residual layers (D)) and width (i.e., number of nodes per layer (W)). We predicted termination (Fig C), presenting EGMs to training cohorts and testing in separate cohorts in a 6-fold cross-validation which we repeated 10 times for each fold with different randomization.

Results

Fig B illustrates that the prediction accuracy is generally negatively correlated with the network depth but positively correlated with the width. Specifically, the deep architecture (D=4, W=256, with 265M trainable parameters, blue-circled in Fig B) predicted with AUC = 0.61±0.08. However, a shallow-narrow architecture (D=1, W=16, green-circled in Fig B) achieved same AUC (0.61±0.09, p=0.65), while reducing the number of parameters by 97% compared to the DL architecture (79K vs. 265M). Additionally, a shallow-wide architecture (D=1, W=2048, red-circled in Fig B) achieved higher AUC (0.74±0.08; p<0.0001), while saving 44% of the parameters (148M vs 265M) and 26% training time compared to the deep architecture.

Conclusion

Shallow neural network classification of raw EGMs predicted ablation response with better accuracy than other architectures. Future work should determine if deep architectures ultimately ‘overfit’ detailed EGM data, which may explain their lower success.Figure
Revisiting pulmonary vein stenosis after high-power short-duration radiofrequency ablation in patients with atrial fibrillation
Authors: Kim J , Kim D , Park J , Yu H , Kim T , Uhm J , Joung B , Lee M , Park H
Published: November 2023

Background

High-power short-duration atrial fibrillation catheter ablation (HPSD-AFCA) of pulmonary vein (PV) isolation reduces the procedure time without a difference in the efficacy as compared to conventional power AFCA (ConvP-AFCA). PV stenosis (PVS) after AFCA is a rare complication.

Purpose

We compared the frequency of symptomatic PVS as a long-term complication between the ConvP-AFCA and HPSD-AFCA groups.

Methods

We included 3,851 patients undergoing AFCA between 2009 and 2022 prospectively. We evaluated the characteristics of patients diagnosed with clinically symptomatic PVS, ascertained using computed tomography during the follow-up period. The risk of PVS was compared between the ConvP-AFCA and HPSD-AFCA groups using propensity overlap weighting.

Results

Symptomatic PVS was diagnosed in 14 (0.4%) patients at a mean of 342.9 days after the procedure. After overlap weighting, PVS was significantly more frequent in the HPSD-AFCA group (incidence: HPSD-AFCA, 0.8% vs. ConvP-AFCA, 0.2%; weighted hazard ratio [HR] 6.27, 95% confidence interval [CI] 2.15-18.28; P<0.001). In the multivariable Cox regression analyses, repeat AFCA procedures (HR 3.52, 95% CI 1.18-10.55; P=0.024) and paroxysmal AF (HR 8.29, 95% CI 1.08-63.82; P=0.042) were also independently associated with PVS after AFCA. Among the PVs of patients with PVS, stenotic PVs had shorter antral diameters and a smaller cross-sectional area than non-stenotic PVs on preprocedural computed tomographic evaluations.

Conclusion

HPSD-AFCA, compared to ConvP-AFCA, was associated with a 6-fold increased risk of symptomatic PVS. Caution is required, especially in patients with plans for a repeated AFCA, paroxysmal AF, or small PV antrum.
High efficacy and safety of pulsed electrical field ablation via contact force-controlled radiofrequency catheters for atrial fibrillation ablation with linear lesions in the left atrium
Authors: Schreieck J , Scheckenbach C , Kranert M , Gawaz M , Heinzmann D
Published: November 2023

Background

Pulsed Field Ablation have been shown to be efficient and safe for Pulmonary vein isolation (PVI) in catheter ablation of atrial fibrillation (AF). The bipolar application of pulsed electrical energy for electroporation of myocardium has been established with specially designed catheters, which are not used for linear ablation.

Purpose

We evaluated a novel monophasic PEF ablation technique applied by commercially available CF-controlled catheters for linear ablation lines beyond PVI for treatment of complex AF patients.

Methods

Patients (n=31, age 64±12 years, 29% females, BMI 29±4) referred for re-ablation of AF and presented with recurrence of persistent AF (n=13) or atypical atrial flutter (n=14) after a PVI procedure, or patients with longstanding persistent AF and severe enlarged atrium (n=4) were included in our patient cohort for additional AF substrate ablation with PEF applications. After high density voltage mapping of the left atrium with multipolar microelectrode catheters, and PVI, or re-PVI was completed (8 patients), additional left atrial linear lesions were performed according to the atrial flutter mechanism or as fibrosis-guided substrate ablation. All but one patient showed low voltage areas (bipolar electrograms <0.5mV) in 35±31% of the left atrial surface. Using contact force sensing catheters, maximal PEF energy pulses were applied with a minimum of 5g contact force and an interlesion distance ≤6mm. Performed linear lesions were left atrial roof line, lateral mitral isthmus line, anterior mitral line, left posterior wall isolation, and cavotricuspid isthmus (CTI) line. Before PEF application close-by a coronary artery (lateral mitral line, CTI) nitroglycerie 0.2mg i.v. was injected.

Results

Complete lines with exclusively PEF applications and proofed bidirectional conduction block were 100% for roof lines (n=20), posterior wall isolation (n=8), anterior mitral lines (n=10). Exclusively endocardial PEF applications blocked the lateral mitral line in 14 out of 16 cases (88%). Only in two cases additional epicardial RF applications via coronary sinus and endocardial additional RF applications were necessary to complete the mitral isthmus block. In 7 out of 8 cases CTI were blocked by linear PEF applications (88%), however, in one case additional RF applications became necessary. No ECG ST segment elevation was recorded. No serious complications occurred throughout all procedures.

Follow up will be available at presentation time.

Conclusion

Catheter ablation of complex AF patients with linear lesions is performd very efficient and safe with PEF applications by CF-sensing RF ablation catheters. Especially the high efficacy of exclusively endocardial PEF applications for creation of a lateral mitral isthmus block is very promising. However, the long term permanence of the linear lines have to be awaited.
Development and validation of the DOAC Score: a novel bleeding risk prediction tool for patients with atrial fibrillation
Authors: Aggarwal R , Ruff C , Virdone S , Perreault S , Kakkar A , Palazzolo M , Dorais M , Kayani G , Singer D , Secemsky E , Piccini J , Tahir U , Shen C , Yeh R
Published: November 2023

Background

Clinicians and patients must balance the ischemic benefits and bleeding risks when deciding to anticoagulate patients with atrial fibrillation (AF). Current clinical decision tools for assessing bleeding risk have limited performance and were developed for individuals anticoagulated with warfarin.

Purpose

This study develops and validates a clinical risk score to personalize estimates of bleeding risk for individuals with AF taking direct-acting oral anticoagulants (DOACs).

Methods

Among individuals taking dabigatran 150mg twice per day from 44 countries and 951 centers in this secondary analysis of the RE-LY trial, a risk score was developed to determine the probability for bleeding, based on covariates derived in a Cox proportional hazards model. The risk prediction model was internally validated with bootstrapping. We then refined the model in the GARFIELD-AF registry, with individuals taking dabigatran, edoxaban, rivaroxaban, and apixaban. To determine generalizability in external cohorts and among individuals on different DOACS, the risk prediction model was validated in the COMBINE-AF pooled clinical trial cohort and the RAMQ administrative database. The primary outcome was major bleeding. The risk score, termed the DOAC Score, was compared to the HAS-BLED score.

Results

Of the 5684 patients in RE-LY, 386 experienced a major bleeding event, within a median follow-up of 1.74-years. The prediction model was well-calibrated (goodness-of-fit P = 0.57) and had an optimism-corrected C statistic of 0.73 after internal validation with bootstrapping. The DOAC Score assigned points for age, creatinine clearance/glomerular filtration rate, underweight status, stroke/transient ischemic attack/embolism history, diabetes, hypertension, antiplatelet use, non-steroidal anti-inflammatory use, liver disease, and bleeding history, with each additional point scored associated with a 48.7% (95% CI: 38.9%-59.3%, P<0.001) increase in major bleeding in RE-LY. The score had superior performance to the HAS-BLED score in RE-LY (C Statistic: 0.73 vs 0.60, P for difference <0.001) and among 12,296 individuals in GARFIELD-AF (C statistic: 0.71 vs 0.66, P for Difference = 0.025). The DOAC Score had stronger predictive performance than the HAS-BLED score in both validation cohorts, including 25,586 individuals in COMBINE-AF (C statistic: 0.67 vs 0.63, P for Difference <0.001) and 11,945 individuals in RAMQ (C statistic: 0.65 vs 0.58, P for Difference <0.001).

Conclusion

In individuals with AF on DOAC therapy, the DOAC Score can help stratify patients based on expected bleeding risk.
Anticoagulation-associated bleeding in patients randomised to screening for atrial fibrillation or usual care
Authors: Kongebro E , Diederichsen S , Xing L , Haugan K , Graff C , Hoejberg S , Olesen M , Brandes A , Koeber L , Svendsen J
Published: November 2023

Background

Atrial fibrillation (AF) prevalence is rising, strongly aided by population ageing and increased awareness. Detection and treatment of subclinical AF may help mitigate stroke risk, but could increase iatrogenic complications.

Purpose

To evaluate whether detection of subclinical AF using implantable loop recorder (ILR) and subsequent initiation of oral anticoagulant (OAC) enhances the risk of major bleeding in elderly individuals with stroke risk factors.

Methods

This was a post-hoc analysis of a trial which randomised 6004 participants without known AF but with stroke risk factors in a 1:3 ratio to either ILR-screening for AF and OAC initiation upon AF episodes lasting ≥6 minutes or usual care (Control group). We examined the risk of major bleeding using OAC initiation as a time-varying exposure (figure 1) in Cox regression models, and similarly for the use of antiplatelets. Further, we estimated the incidence rates of OAC/antiplatelet initiation and discontinuation along with the distribution of major bleeding events according to drug exposure and subgroups.

Results

A total of 1019 participants (17%) initiated OAC; 578 (12.8%) in Control group vs. 441 (29.4%) in ILR group, with a mean age of 78.8 (±4.7) years in Control vs. 77.0 (±4.8) in ILR group, p<0.0001. Major bleeding events totalled 221 (3.7%) with 47 of these occurring after OAC initiation (4.6% of all OAC-users); 26 (4.5%) vs. 21 (4.8%) in Control and ILR group, respectively. Without the use of OAC or antiplatelets the overall rate of major bleeding was 0.44 (0.33-0.57) per 100-perosn years compared to 1.54 (1.13-2.05) after OAC initiation. For the individual person, the hazard ratio for major bleeding after OAC initiation was 2.08 (1.50-2.90) p<0.0001 compared to before initiation (Control: 2.81 (1.82-4.34) p<0.0001, ILR: 1.32 (0.78-2.23) p=0.31, p=0.07 for interaction)(table 1), similarly was usage of antiplatelet associated with a hazard ratio of 1.3 (0.96-1.75) p=0.09. For OAC users ≥75 years, the rate of major bleeding was 1.96 (1.30-2.83)(Control: 2.20 (1.23-3.63), ILR: 1.73 (0.92-2.96)), compared to 1.17 (0.70-1.83) among users <75 years (Control: 1.64 (0.82-2.93), ILR: 0.84 (0.36-1.66)). After OAC initiation, the discontinuation rate in the Control and ILR group was 9.60 (7.9-11.6) and 6.15 (4.95-7.55), respectively, while the rate of antiplatelet discontinuation was 7.44 (6.92-7.99) and 12.24 (10.9-13.4) in the Control and ILR group.

Conclusion

This post-hoc study of a randomised study found a two-fold risk increase of major bleeding after OAC initiation on individual basis compared with before, but this increase did not seem augmented by AF screening and treatment. A weaker signal was seen for antiplatelets. The OAC-associated bleeding risk was markedly higher in the elderly population. Finally, discontinuations of OAC and antiplatelets were common throughout follow-up.
Safety and efficacy of anticoagulation for atrial fibrillation in cirrhotic patients
Authors: Song J J , Boulier K , Shang H , Jackson N J , Shetty A , Xia V , Honda H M
Published: November 2023

Introduction

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia and increases thromboembolism risk. AF is more prevalent in patients with cirrhosis and cirrhotics are at higher risk for ischemic stroke from thromboembolic mechanisms such as AF. Cirrhotics have complex pathophysiology of coagulation which can lead to bleeding diathesis or hypercoagulability. Cirrhotics have been excluded from major trials of anticoagulants (AC), thus there are currently no guidelines for AC in cirrhotics with AF. We aim to investigate how the incidence of ischemic stroke, major bleeding, hospitalizations, and mortality vary in patients with AF and cirrhosis between AC choices including no AC.

Methods

De-identified electronic health records from a U.S. health system between March 2013 and December 2022 were reviewed to identify patients with International Classification of Diseases (ICD) diagnoses of both AF and cirrhosis and who also had Creatinine, Bilirubin, and INR values within 6 months of their second diagnosis (either AF or cirrhosis). Model for End-stage Liver Disease (MELD) scores were calculated from these values and patients were followed from the first date of their second diagnosis. Incidences of ICD-coded ischemic stroke, ICD-coded bleeds, Current Procedural Terminology (CPT) coded transfusions, all-cause mortality, and hospitalizations were recorded. Propensity score weighting between AC and non-AC groups balanced covariates (Table 1). Bivariate analyses for outcomes were conducted between AC and non-AC groups and among warfarin, DOAC, and injectable AC subgroups.

Results

1,205 patients with AF and cirrhosis were included. 605 patients were prescribed AC (50.2%), 384 were prescribed DOACs (63.5%), 275 were prescribed Warfarin (45.4%), and 131 (21.7%) were prescribed injectable AC. After propensity weighting, patients prescribed AC had similar rates of bleed (p=0.607), transfusion (p=0.225), and death (p=0.779) but decreased rates of ischemic stroke (p=0.001) and number of hospitalizations (p<0.001) compared to non-AC patients. Patients prescribed DOACs had similar rates of bleed (p=0.529), ischemic stroke (p=0.108), number of hospitalizations (p=0.870), and death (p=0.230) but decreased rates of transfusion (p<0.001) compared to patients on other forms of AC. Patients prescribed warfarin had similar rates of death (p=0.230) and decreased rates of bleed (p=0.013) but increased rates of transfusion (p<0.001), ischemic stroke (p<0.001), and number of hospitalizations (p = 0.024) (Table 2).

Conclusions

Patients with AF and cirrhosis receiving AC experienced decreased rates of ischemic stroke and number of hospitalizations compared to patients who did not receive AC. Among AC subgroups, patients prescribed DOACs had lower rates of transfusion compared to other AC therapies while patients prescribed warfarin had increased rates of transfusion, ischemic stroke, and number of hospitalizations compared to other AC therapies.
Impact of oral anticoagulants in frail atrial fibrillation patients: a report from an observational registry of european patients
Authors: Proietti M , Romiti G F , Corica B , Mei D A , Bonini N , Vitolo M , Fawzy A M , Ding W Y , Imberti J F , Boriani G , Lip G Y H
Published: November 2023

Background

The last years showed a substantial increase of interest about the clinical issue of frailty among patients with cardiovascular diseases. Impact of frailty in atrial fibrillation (AF) has been examined in terms of management, quality of life and increased risk of outcomes; nonetheless, the impact of treatment with oral anticoagulants (OAC) remains suboptimally understood.

Purpose

To analyse the impact of OAC in a cohort of frail AF patients.

Methods

We used data from a European-wide prospective observational AF registry. Frailty was evaluated with a 40-items frailty index (FI) built according to the cumulative deficit method proposed by Rockwood and Mitnitski. OAC treatment was evaluated at baseline. A net clinical outcome (NCO) of all-cause death, major adverse cardiovascular outcomes, and major bleeding, as well as the single components were the study outcomes.

Results

Among 10,172 patients available for this analysis, 2,171 (21.3%) were frail. AF frail patients had a mean (SD) age of 71.7 (9.8) years and were 1,073 (49.4%) females. Overall, 1,801 (83.0%) were treated with OAC, of which 1,232 (68.4%) prescribed with vitamin K antagonist (VKA) and 569 (31.6%) prescribed with non-vitamin K antagonist oral anticoagulants (NOACs). Over a mean (SD) follow-up time of 1.56 (0.74) years there were 571 (26.3%) NCO events. Frail patients prescribed with OAC had a lower rate of NCO compared to those not prescribed (27.1% vs. 44.6%, p<0.001). After adjustments, use of OAC was associated with lower risk of NCO and all the other secondary outcomes (Table 1). Regarding the type of OAC, patients prescribed with NOACs reported a lower rate of NCO compared to those prescribed with VKAs (22.7% vs. 29.1%). After adjustments, use of NOACs was associated with a lower risk of NCO and all the other secondary outcomes, except for major bleeding (Table 1). When comparing patients with FI <80th percentile with those with FI ≥80th percentile, adjusted analysis showed that in the FI <80th group the use of OAC was consistently associated with lower risk of all outcomes (except for major bleeding), with a non-statistically significant trend seen in those with FI ≥80th percentile treated with OAC (Table 1).

Conclusions

In frail AF patients, use of OAC was associated with a lower risk of outcomes, as well as the use of NOACs compared with VKAs. In patients with a very high frailty burden the benefits of OAC may be attenuated.
The predictive value of compression rate on residual leak after left atrial appendage occlusion with watchman FLX
Authors: La Fazia V , Gianni C , Pierucci N , Della Rocca D G , Mohanty S , Macdonald B , Mayedo A , Torlapati G , Bassiouny M , Al-Ahmad A , Gallinghouse G J , Burkhardt J D , Horton R , Di Biase L , Natale A
Published: November 2023

Background

Incomplete left atrial appendage (LAA) occlusion due to residual leaks may occur after percutaneous closure procedure with Watchman FLX. Before release of device PASS (position, anchor, size and seal) criteria must be verified. Optimal compression rate for watchman FLX device is between 10-30% according to company recommendations.

Purpose

The aim of this study is to evaluate the correlation between compression rate and leak presence after left atrial appendage closure.

Methods

This is an observational retrospective study including patients that underwent LAA closure under transesophageal echocardiography (TEE) with at least one follow-up where complete LAA closure was assessed by TEE in our center between January 2021 and August 2022. TEE images were reviewed by the first author. Compression rate was calculated based on intraprocedural TEE images using the following formula: (original device size—size after deployment)/original device size*100. Patients were divided into 2 groups based on the compression rate: group 1: 10-30%; group 2: >30%. The rate of leak between groups was compared using the Chi-square test.

Results

203 patients (mean age 79± 8 years) were included in the study. The implanted device size was 20 mm in 7 (3.4%), 24 mm in 30 (14.8%), 27 mm in 49 (24.1%), 31 mm in 75 (36.9%) and 35 mm in 42 (20.7%) patients.

Based on the compression rate, patients were classified into group 1: >30% [n=37 (18.2%)] and group 2: ≤30% [n=166 (81.8%)]. Mean compression rate was 38.5% and 21.3% in group 1 and 2 respectively. At follow-up TEE, 1 (2.7%) patient in group 1 and 32 (19.3%) patients in group 2 were found to have a residual leak of >1 mm.

When comparing leaks between the two groups, there was 1 leak in group 1 whereas in group 2 there were 32 leaks (1/37 vs 32/166, p value 0.01, RR 0.14, 95% CI, 0.02-0.74).

Conclusion

Devices with compression rate ≤30% were associated with significantly higher risk of residual leak.
Gastrointestinal bleeding and cardiovascular events in patients with atrial fibrillation: results from the SAKURA AF registry and RAFFINE registry
Authors: Abe K , Wada H W , Miyauchi K M , Suwa S S , Miyazaki S M , Hayashi H H , Nishizaki Y N , Sumiyoshi M S , Nakazato Y N , Minamino T M , Okumura Y O , Daida H D
Published: November 2023

Background

Anticoagulants for patients with atrial fibrillation (AF) reduce cardiovascular events but increase gastrointestinal bleeding. However, the association between gastrointestinal bleeding and cardiovascular events is unclear. The present study aimed to evaluate the association between bleeding and major adverse cardiac and cerebrovascular events (MACCE) among patients with AF.

Methods

We analyzed the data of 2 Japanese multicenter registries (the SAKURA AF registry and RAFFINE registry). Primary endpoint was MACCE, which was defined as a composite of death, myocardial infarction and stroke. The association of gastrointestinal bleeding with subsequent MACCE risk was investigated using time-adjusted Cox multivariate analysis after adjusting for baseline characteristics and time from bleeding.

Results

Among 7,133 AF patients, 192 (2.7%) had gastrointestinal bleeding events during follow-up. Multivariate logistic regression analysis showed that age (Odds ratio (OR) 1.02, 95% CI 1.00-1.05, p=0.046), hypertension (OR 1.52, 95% CI 1.04-2.21, p=0.03), diabetes mellitus (OR 1.38, 95% CI 1.02-1.88, p=0.04) and lower hemoglobin level (OR 0.84, 95% CI 0.76-0.92, p=0.0002) were independent predictors of gastrointestinal bleeding. Incidence of MACCE was significantly higher in patients with gastrointestinal bleeding than those without (13.93% versus 3.54% per patient-year; p<0.0001, Figure). Even after adjusted for other risk factors, patients who experienced gastrointestinal bleeding had significantly higher risk of MACCE (hazard ratio, 3.09; 95% CI, 2.20-4.33; p<0.0001).

Conclusions

In patients with AF, gastrointestinal bleeding was strongly associated with incidence of MACCE. Thus, it is important to prevent gastrointestinal bleeding to avoid adverse cardiovascular events.Figure
Association between left atrial strain and peri-operative stroke in catheter ablation for atrial fibrillation
Authors: Tajima A , Yoshimoto I , Hamamoto Y , Ichiki H , Ninomiya Y , Kamada H , Uchiyama Y , Yasuda H , Iriki Y , Horizoe Y , Ikeda Y , Miyata M , Ohishi M
Published: November 2023

Background

It has been reported that left atrial (LA) phasic function, evaluated by LA strain, is associated with cardiogenic stroke in patients with atrial fibrillation (AF). There are no well-established echocardiographic findings to predict peri-operative stroke in AF ablation.

Purpose

The aim is to evaluate between LA strain and peri-operative stroke in AF ablation.

Methods

This study included 103 consecutive AF patients (90 paroxysmal and 13 non-paroxysmal AF cases) who underwent initial cryo-ablation without interruption of peri-operative anticoagulation from January 2019 to August 2022. Pre-operative echocardiography was used to measure the LA strain items: LA reservoir strain, contractile strain, and conduit strain in sinus rhythm. Twenty-three patients were excluded due to AF rhythm and atrial septal defect. Peri-operative stroke was detected by using magnetic resonance imaging on the day after ablation.

Results

Peri-operative stroke occurred in 9 patients (11.3%), and there was no symptomatic stroke. In univariate analysis, age (69.6 ± 4.8 years vs. 64.2 ± 10.9 years, p<0.05) and log brain natriuretic peptide (1.61 ± 0.26 vs. 1.32 ± 0.42 p<0.05) were significantly higher in the stroke group. On the other hand, LA reservoir strain (20.9 ± 5.6% vs. 29.8 ± 8.3%, p<0.01) and LA conduit strain (10.9 ± 2.3% vs. 15.9 ± 7.0%, p<0.01) in the stroke group was significantly lower compared with the non-stroke group. There were no significant differences in the rate of intra-operative electrical cardioversion and other clinical parameters between both groups. Receiver operating characteristic curve analysis revealed that LA reservoir strain cut-off value of 22.7% provided a c-statistic of 0.82 for predicting peri-operative stroke in AF ablation.

Conclusions

LA reservoir strain is closely associated with peri-operative stroke in AF ablation.ROC curve analysis
The association of vasoactive agents with postoperative atrial fibrillation after cardiac surgery
Authors: Hammer A , Hofer F , Kazem N , Schnaubelt S , Steinacher E , Baumer U , Koller L , Steinlechner B , Laufer G , Niessner A , Sulzgruber P
Published: November 2023

Background

Postoperative atrial fibrillation (POAF) constitutes a common complication after cardiac surgery, that is associated with major adverse cardiac events and prolonged hospital stay. Causes for developing POAF are multifactorial. While there are non-modifiable predisposing characteristics such as higher age or comorbidities, several factors of postoperative patient management could be modulated in order to lower the individual risk of POAF. In this regard, inotropic agents (i.e. norepinephrine, dobutamine) in postoperative care are known to possess arrhythmogenic potential. It is unknown, however, to what extent this postoperative catecholamine therapy influences the emergence of POAF.

Methods

Within this prospective observational study 514 patients were included who underwent elective coronary artery bypass graft (CABG), heart valve, or combined valve/CABG surgery. In total, 438 patients received vasoactive drugs during the postoperative course. These participants were subsequently followed for the occurrence of POAF.

Results

Overall, 43.4% (n=190) of all catecholamine-receiving patients developed POAF. Interestingly, participants who developed POAF had received significantly higher median doses of norepinephrine as compared to non-POAF individuals (POAF: 0.083μg/kg/min vs. non-POAF: 0.062μg/kg/min; p=0.001), while the median dobutamine dose did not significantly differ between groups (POAF: 3.332 μg/kg/min vs. non-POAF 3.289μg/kg/min; p=0.254). Moreover, regression analysis identified norepinephrine with an adjusted hazard ratio (HR) per standard deviation (1-SD) of 1.388 (95% CI:1.114-1.728; p=0.003) as an independent risk factor for the occurrence of POAF. In addition, a norepinephrine dose of 0.18μg/kg/min was determined as the cut-off value, from which the POAF risk increased significantly. Notably, no association between dobutamine and POAF was found (adjusted HR 1.140 [95% CI:0.773-1.683; p=0.508]).

Conclusion

Within this prospective observational study, we were able to demonstrate that the postoperative use of norepinephrine, in contrast to dobutamine, represents an independent risk factor for the development of POAF. Furthermore, a dose dependency was found for norepinephrine from which the risk for POAF substantially increased. To prevent POAF episodes and thus prolonged intensive care unit stay it may be suggested to further promote rapid norepinephrine weaning if feasible.
Epidemiology and clinical impact of chronic obstructive pulmonary disease in patients with atrial fibrillation: findings from an european prospective observational registry
Authors: Romiti G F , Proietti M , Corica B , Mei D A , Vitolo M , Frost F , Boriani G , Lip G Y H
Published: November 2023

Background

The interplay between atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) has been poorly investigated and understood, with previous studies reporting unsatisfactory management and poor prognosis of patients with AF and COPD.

Purpose

To describe the epidemiology, management and natural history of AF patients with COPD using a contemporary European prospective cohort.

Methods

From a European-wide prospective observational AF registry, we identified patients with COPD as reported by the investigators. We analysed the association between COPD and the odds of receiving oral anticoagulants (OAC) and other pharmacological treatments using multivariable logistic regression models. We also assessed the associations between COPD and risk of major outcomes using multivariable Cox-regression models. Our primary outcome was all-cause mortality; secondary outcome was the risk of major adverse cardiovascular events (MACE). We finally evaluated the interaction between disease-specific treatments for COPD and the risk of major outcomes in AF-COPD patients.

Results

A total of 10,219 AF patients were included in this analysis (mean age 69.2 ± 11.4 years; 40.3% females); COPD was found in 909 patients (8.9%). Patients with COPD were older, more likely males, and had a higher burden of thromboembolic and bleeding risk factors. No differences were observed in the likelihood of receiving OAC or non-vitamin K antagonist oral anticoagulants (NOAC) in COPD vs. no COPD patients (OR: 1.00, 95%CI: 0.81-1.24, and OR: 0.91, 95%CI: 0.77-1.06, respectively for OAC vs. non OAC and NOAC vs. VKA prescription). Patients with COPD were less likely treated with ACE inhibitors, beta-blockers, amiodarone and class IC antiarrhythmics, while they showed higher odds of receiving diuretic, digoxin, and non-dihydropyridinic calcium channel blockers (Figure 1). Over a median follow-up of 24.3 [IQR: 23.0-25.0] months, the risk of all-cause death was higher among COPD patients (HR: 1.52, 95%CI: 1.28-1.80), as well as the risk of MACE (HR: 1.49, 95%CI: 1.22-1.83) and the composite outcome of ‘all-cause death and MACE’ (HR: 1.50, 95%CI: 1.29-1.74) (Figure 2). No statistically significant interactions were observed between the use of beta-blockers, beta-2 agonists and anticholinergic drugs, and the risk of death in COPD patients.

Conclusions

COPD was common in AF patients and was associated with higher prescription of rate-control (except for beta-blockers) and lower prescription of rhythm control drugs, with no differences in OAC treatment. COPD was associated with worse prognosis, without significant interaction observed for beta-blockers or other COPD-specific treatment.Figure 1Figure 2
Role of liver disease in management and outcomes of european and asian patients with atrial fibrillation: a report from two regional prospective observational AF registries
Authors: Mei D A , Bucci T , Romiti G F , Shantsila A , Tse H F , Chao T F , Boriani G , Proietti M , Lip G Y H
Published: November 2023

Background

In patients with atrial fibrillation (AF), the impact of liver disease (LD) on prescription of oral anticoagulant (OAC) therapy and risk of outcomes remains unclear, as well as possible differences between ethnicities.

Objective

To examine the impact of LD in a large cohort of European and Asian AF patients on OAC prescriptions and the risks of adverse outcomes.

Methods

AF patients derived from from two large prospective observational AF registries, conducted in Europe and Asia, on the basis of the same electronic case report form. OAC prescription and risk of outcomes was analyzed according to LD at baseline. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). Logistic and Cox regression analyses were used to determine associations with LD, and interaction analyses were performed to examine possible differences between European and Asian patients.

Results

15,681 patients (mean age 69.0, SD 11.6 years; 38.7% female) were included, with 517 (3.3%) reporting LD. AF patients with LD were more likely permanent AF, symptomatic, higher thromboembolic and bleeding risks, and had higher multimorbidity, frailty and polypharmacy than those without LD. At baseline, AF patients with LD were less prescribed OAC, as well as with NOACs, than those without [Figure 1].

After adjustments, LD was associated with lower OAC prescription (OR 0.67, 95% CI 0.53-0.84) overall. OAC was less likely prescribed in European (OR 0.54, 95% CI 0.40-0.71) than in Asian (OR 0.95, 95% CI 0.66-1.39) patients (pint=0.015). No differences were found regarding prescription of NOACs vs. VKAs [Figure 1].

Adjusted Cox regression found that LD was associated with a higher risk of composite outcome (HR 1.42, 95% CI 1.11-1.81) and MACEs (HR 1.47, 95% CI 1.07-2.02), with no ethnic differences (Pint=0.631 and Pint= 0.495 for composite outcome and MACEs respectively). LD patients not receiving OAC were at higher risk for MACEs occurrence than those prescribed (pint=0.050). No differences were found regarding major bleeding.

Conclusions

Presence of LD in AF is associated with a lower prescription of OAC, especially amongst European patients. LD is associated with a higher risk for adverse outcomes, especially in those not prescribed with OAC.Figure 1
Pulmonary hypertension is an adverse risk factor for patients admitted with atrial fibrillation
Authors: Kodali M , Atluri R , Shoura S , Vardar U , Yalamanchili S
Published: November 2023

Background

Atrial Fibrillation (AF) poses a significant burden on the resources of the American Healthcare system. Heart failure and AF commonly coexist in patients. Elevated left ventricular and atrial pressures result in progressive left atrial dilation and remodeling which in turn predisposes to the generation of AF. Many of these patients develop pulmonary hypertension (PHT) due to the remodeling and elevated left-sided pressures. Since many who have AF could have PHT, we aimed to assess outcomes in this population.

Methods

We utilized the National Inpatient Sample from 2016-2019 to identify roughly 16,500,000 hospitalized adults who had AF. These hospitalizations were further stratified based on the presence of PHT. A multivariate regression model was used to adjust for confounders and analyze the variables.

Results

Of those with AF, 1,855,020 (11.2%) had PHT. In-hospital mortality was higher in those with PHT (5.6% vs 4.9%; p<0.001). Figure 1 shows the Forrest plot for multivariate analysis of in-hospital outcomes when adjusted for patient demographics, comorbidities, and hospital characteristics. When adjusted similarly, patients with AF and PHT had longer length of stay (LOS) by 0.92 days (p<0.001) and had additional hospital costs (HC) of $9,463 (p<0.001).

Conclusion

In this study, patients admitted with AF with co-existing PHT had significantly worse outcomes in terms of in-hospital mortality, LOS, HC, cardiac arrest, pulmonary embolism, atrial flutter, AKI, blood transfusions, pneumonia, and endotracheal intubation. One major limitation of our study is the lack of outpatient follow up. Given that overall outcomes are worse in the setting of PHT, potential strategies for early rhythm control for AF should be pursued to avoid negative cardiac remodeling that would predispose to the development of PHT. AF patients with co-existing PHT should be aggressively monitored during hospitalizations as they have the potential to have worse outcomes.
Epicardial fat can predict the in-atrial thrombus in patients with atrial fibrillation
Authors: Shi T A O , Yan Y , Li M J , Guo J X , Wang H , Tang M Y
Published: November 2023

Background

Thromboprophylaxis is important in the management of patients with atrial fibrillation. Epicardial adipose tissue (EAT) is involved in the formation of the pre-thrombotic state. However, the potential of EAT in predicting the risk of thromboembolism in atrial fibrillation remains unknown.

Objective

To study the imaging features of EAT and its potential in predicting the risk of in-atrial thrombus in atrial fibrillation.

Methods

Patients were divided into the group with (thrombus group) and without (non-thrombus group) intra-atrial thrombosis according to the results of transesophageal echocardiography (TEE). The EAT volume, mean EAT density and EAT volume/whole heart volume ratio measured on coronary artery CT angiography (CA-CTA) were compared between the two groups.

Result

A total of 347 atrial fibrillation patients undergoing both TEE and CA-CTA were included and 38 cases were complicated with in-atrial thrombus. Using quartile values, EAT volume, mean EAT density, the ratio of EAT volume/whole heart volume are divided into four grades according to the values. By analyzing the ROC curve and comparing the area under the curve of AUC, EAT volume and EAT volume/whole heart volume ratio show potential diagnostic value in predicting the risk of in-atrial thrombus in atrial fibrillation. In addition, 38 cases without in-atrial thrombus were included in the non-thrombotic group after matching the propensity score by age and gender. On multivariate analysis, patients in the thrombus group had the larger EAT volume (P=0.000, P<0.05) and higher ratio of EAT volume/whole heart volume ratio (P=0.004, P<0.05) when compared with patients in the non-thrombotic group, but there was no difference of mean EAT density (P=0.224, P>0.05) between the two groups. On logistic regression analysis, patients in the thrombus group had the larger EAT volume when compared with patients in the non-thrombotic group (P=0.003, P<0.05).

Conclusions

EAT may be a potential marker in predicting the risk of in-atrial thrombus in atrial fibrillation. However, much more efforts and testing would be needed before our conclusion could be tried in other people and to elucidate pathogenic mechanisms of EAT.Figure 1Epicardial fat measuremeFigure 2ROC curve
High-sensitivity cardiac troponin-T concentrations and their prognostic implications in paroxysmal supraventricular tachycardia: A nationwide study
Authors: Laursen S B , Pareek M , Polcwiartek C B , Kragholm K H , Kristensen A M D , Tofig B J , Hansen M L , Riahi S , Biering-Sorensen T , Byrne C
Published: November 2023

Introduction

Paroxysmal supraventricular tachycardia (PSVT) may mimic symptoms and electrocardiographic findings compatible with acute coronary syndromes. As a result, cardiac troponin concentrations are frequently measured upon presentation. Although PSVT may increase troponin concentrations, the expected magnitude and prognostic clinical value of high-sensitivity troponin (hs-TnT) concentrations remain uncertain.

Purpose

The purpose of this study was to examine whether elevated hs-TnT concentrations in PSVT patients were associated with a higher risk of death from any cause.

Methods

We used Danish nationwide registry data from January 2013 through December 2019. PSVT was defined as all supraventricular tachycardias except atrial fibrillation and atrial flutter. The inclusion criteria were de novo PSVT and at least one measured hs-TnT level during hospitalization. Exclusion criteria were a history of cardiovascular disease (coronary artery disease, atrial fibrillation or flutter, or heart failure) or absence of hemoglobin or creatinine measurement within one day of the hs-TnT measurement. Elevated hs-TnT was defined as a value of ≥14 ng/l (the conventional 99th percentile upper reference limit). The primary outcome was death from any cause evaluated at 0-30 and 31-365 days, using multivariable Cox regression with average treatment effect, rendering standardized absolute and relative risks.

Results

A total of 1029 patients were included. Median age was 58 years (25th to 75th percentile: 45-71), and 45% were male. Elevated hs-TnT level was observed in 674 (65.5%) patients, who also had a higher prevalence of cardiovascular comorbidities. The median hs-TnT level was 16 ng/l (25th to 75th percentile: 10-35). The standardized mortality risk at 30 days was significantly higher in patients with elevated hs-TnT compared with patients with normal hs-TnT concentrations (2.38% [95% confidence interval (CI): 1.38 to 3.37] versus <0.01% [95% CI: <0.01 to <0.01]) (Figure 1). The relative risk was 58722906 (95% CI: 23126570 to 94319242), p = 0.001. At 31-365 days, the standardized risk of death was 1.51% (95% CI: 0 to 3.28) in individuals with a normal hs-TnT and 4.23% (95% CI: 2.81 to 5.66) in those with an elevated hs-TnT (Figure 2), resulting in a relative risk of 2.81 (95% CI: 0 to 6.32), p = 0.31.

Conclusion

In patients without prior cardiovascular disease, an elevated hs-TnT concentration during the first episode of PSVT was only associated with an increased early mortality risk. Long-term mortality was not affected by elevated hs-TnT.Figure 1Figure 2