bluuebunny/crossref_metadata_2025 huggingface dataset:
The safety of catheter ablation of atrial fibrillation in elderly patients -analysis of the nationwide database in Japan, JROAD-DPC-
Authors: Yokoyama Y , Miyamoto K , Nakai M , Sumita Y , Ueda N , Nakajima K , Kamakura T , Wada M , Yamagata K , Ishibashi K , Inoue Y , Nagase S , Noda T , Aiba T , Kusano K
Published: November 2020

Background

“Age” is one of the major concerns and determinants of the indications for catheter ablation (CA) of atrial fibrillation (AF). There are little safety data on CA of AF according to the age. This study aimed to assess the safety of CA in elderly patients undergoing CA of AF.

Methods and results

We investigated the complication rate of CA of AF for the different age groups (<60 years, 60–65, 65–70, 70–75, 75–80, 80–85, and ≥85) by a nationwide database (Japanese Registry Of All cardiac and vascular Diseases [JROAD]-DPC). The JROAD-DPC included 73,296 patients (65±11 years, 52,883 men) who underwent CA of AF from 516 hospitals in Japan. Aged patients had more comorbidities and a significantly increased CHADS2 score and higher rate of female according to a higher age. The overall complication rate was 2.6% and in-hospital mortality was 0.05%. By comparing each age group, complications occurred more frequently in higher aged groups. A multivariate adjusted hazard ratio revealed an increased age was independently and significantly associated with the overall complications (odds ratio was 1.25, 1.35, 1.72, 1.86, 2.76 and 3.13 respectively; reference <60 years).

Conclusions

The frequency of complications was significantly higher according to a higher age. We should take note of the indications and procedure for CA of AF in aged patients.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Intramural Research Fund 17 (Kusano) for Cardiovascular Diseases of the National Cerebral and Cardiovascular Center
Electrophysiological findings after bilateral thoracoscopic atrial fibrillation ablation using irrigated bipolar radiofrequency energy
Authors: Skala T , Moravec O , Santavy P , Steriovsky A , Taborsky M
Published: November 2020

Background

Thoracoscopic atrial fibrillation (AF) ablation (TARAFS) using irrigated bipolar radiofrequency energy should result in posterior left atrial (LA) wall isolation.

Purpose

To assess the long-term durability of this “box” lesion and the extent of additional ablation needed to achieve AF non-inducibility.

Methods

22 patients with AF recurrence after bilateral TARAFS for persistent AF had a radiofrequency catheter ablation (RFA) at least three months after TARAFS. Electroanatomical voltage map was done in all patients prior to any ablation.

Results

Out of 22 patients, the box lesion was not completed in 15 (68.2%). In these 15 patients, 12 had no signs of any prior ablation in endocardium (voltage >0.5mV), 2 had right pulmonary veins (PVs) isolated and 1 had left PVs isolated.

At the end of RFA, box lesion was finished in all 15 patients and AF non-inducibility was achieved in 18 patients. For this endpoint, besides box lesion, mitral line and extensive coronary sinus ablation was necessary in 14, extensive CFAE ablation in 7 patients. Cavotricuspid isthmus line block was done in all patients.

Conclusion

A minimally invasive thoracoscopic box-lesion ablation is considered to be a safe and effective method of stand-alone AF treatment. However, in a considerable amount of patients no signs of prior ablation are found on electroanatomical voltage map. Gaps thus cannot be found and a completely new complex ablation must be done. In a lot of patients, additional ablation is needed besides box lesion to achieve non-inducibility.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): University Hospital Olomouc
Relationship of aging and incident comorbidities to stroke risk in 594,169 Patients with atrial fibrillation: a nationwide analysis
Authors: Fauchier L , Bisson A , Bodin A , Herbert J , Spiesser P , Clementy N , Pierre B , Angoulvant D , Babuty D , Chao T.F , Lip G
Published: November 2020

Background

When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA2DS2-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities. This study hypothesized that the “Delta CHA2DS2-VASc score”, which reflects the change in score between baseline and follow-up, may be predictive of ischemic stroke compared with the baseline or follow-up assessments of the CHA2DS2-VASc score.

Methods

Based on the France nationwide administrative hospital-discharge database, we collected information for all patients treated with AF between 2010 and 2019 in France. Adverse outcomes were investigated during follow-up. A total of 594,169 patients with AF who did not have comorbidities of the CHA2DS2-VASc score except for age and sex, were studied. The Delta CHA2DS2-VASc score was defined as the change/difference between the baseline and follow-up CHA2DS2-VASc scores. During 1,290,721 person-years, 19,492 patients experienced ischemic stroke. The accuracies of baseline, follow-up, and Delta CHA2DS2-VASc scores in predicting ischemic stroke were analysed and compared.

Results

The mean baseline CHA2DS2-VASc score was 1.69, which increased to 2.33 during the follow-up, with a mean Delta CHA2DS2-VASc score of 0.64. The CHA2DS2-VASc score increased in 39.8% of patients. Among 19,492 patients who experienced ischemic stroke, 66.0% had a Delta CHA2DS2-VASc score ≥1 compared with only 38.9% in patients without ischemic stroke, and 5,811 (29.8%) patients had ≥2 new-onset comorbidity, the most common being hypertension. The follow-up CHA2DS2-VASc score and Delta CHA2DS2-VASc score were significant predictors of ischemic stroke (C-index 0.670 95% CI 0.667–0.674 and 0.637 95% CI 634–641 respectively) that performed better than baseline CHA2DS2-VASc score (C-index 0.613 95% CI 0.609–0.616, p<0.0001 for DeLong test).

Conclusions

In this AF cohort, we found that stroke risk (CHA2DS2-VASc score) was non-static, and that many patients developed ≥1 new stroke risk factor(s) before presentation with ischemic stroke. The follow-up CHA2DS2-VASc score and its change (ie Delta CHA2DS2-VASc, reflecting the change in stroke risk profile between baseline and follow-up) were better predictors of ischemic stroke than relying on the baseline CHA2DS2-VASc score. This emphasises how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities, and regular re-assessment of risk is needed.

Funding Acknowledgement

Type of funding source: None
Still using “aspirin or nothing” for AF patients with frailty? ETNA-AF-Europe shows frailty corresponds to higher mortality but not neurological bleeding with edoxaban anticoagulation in routine care
Authors: Bakhai A , Fumagalli S , Mazzone A , Diemberger I , Kirchhof P , De Caterina R
Published: November 2020

Background

Clinicians are encouraged to anticoagulate frail and older patients. Both groups were underrepresented in pivotal AF stroke prevention trials. Large, more geographically generalizable data are needed for safety and treatment efficacy in these groups. Aim: ETNA-AF-Europe registry assessed key clinical outcomes and risk scores in frail and older patients compared to their counterparts.

Methods

ETNA-AF-Europe is a large, prospective, post-authorisation, observational study of patients with AF being prescribed edoxaban. The registry captured frailty as a single, mandatory field as perceived by physicians. Baseline characteristics evaluation and 1-year outcomes of patients were extracted by presence of frailty and age (≥ vs. <80 years) using descriptive analyses.

Results

Of, 13,090 enrolled patients, 10.6% were considered frail with coding complete for 12,212 patients. Whilst 27.9% of patients were aged ≥80, of these only 25.3% were frail. Frail patients differed from non-frail and had similar baseline characteristics to those aged ≥80 years. Frail patients were more frequently female, with lower BMI and higher HAS-BLED risk score (Table), and incurred the highest rates of overall and cardiovascular deaths and major bleeding, even more than those aged ≥80 (Figure). Despite this, intracranial haemorrhage (ICH) was surprisingly low and comparable.

Conclusions

In this large, Europe wide group of patients with AF anticoagulated with edoxaban, patients considered frail by physicians are not always older. A clinical frailty perception is associated with a 4-fold higher short-term mortality. Whilst major bleeding is higher in this frail cohort, ICH is comparably low. The HAS-BLED score in frail patients prescribed edoxaban, appears to predict non-neurological bleeding. These data provide confidence for prescribing edoxaban in frail AF patients to prevent stroke.

One-year outcomes

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH, Munich, Germany
Baseline characteristics and follow-up outcomes in routine clinical practice patients categorised by renal function in the ETNA-AF-Europe registry
Authors: De Caterina R , Gwechenberger M , Bakhai A , Monteiro P , Kelly P , Levy P , Kirchhof P
Published: November 2020

Background

Edoxaban is an oral factor Xa inhibitor anticoagulant with 50% renal clearance, and proven efficacy and safety in patients (pts) with atrial fibrillation (AF). The post-authorisation, observational, ETNA-AF-Europe registry (NCT02944019) assessed the risks and benefits of edoxaban in pts with AF from 10 European countries.

Purpose

Evaluate baseline characteristics and event rates in pts categorised by creatinine clearance (CrCl) at 1-year follow-up of the ETNA-AF-Europe registry.

Methods

In this analysis, pts were divided into three groups according to CrCl: ≤50 ml/min (I), 50–80 mL/min (II) and ≥80 mL/min (III) (calculated using Cockcroft-Gault). Outcomes were descriptively analysed.

Results

Pts with the lowest CrCl (Group I) were mostly females, and had a higher mean age, lower body weight, higher stroke and bleeding risk scores and were considered more frail than those with higher CrCl (Groups II and III) (Table). Group I experienced higher rates of stroke or SEE, major or CRNM bleeding, cardiovascular death, and had a higher total mortality (Figure). Rates of intracranial haemorrhage (ICH) and haemorrhagic stroke (intracerebral and subarachnoid haemorrhage) were low and similar in pts across the range of CrCl.

Conclusions

Those with lower CrCl had more comorbidities and higher event rates than those with higher CrCl, with the exception of ICH and haemorrhagic stroke. A steep rise in the proportion of pts perceived as frail and in overall mortality in the lowest renal function tertile, raises the question whether low renal function is a determinant or a correlate of mortality.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH, Munich, Germany
Risks and outcomes of gastrointestinal malignancies in anticoagulated atrial fibrillation patients experiencing gastrointestinal bleeding
Authors: Chao T.F , Lip G.Y.H , Chen S.A
Published: November 2020

Background

Oral anticoagulants (OACs) may serve as a type of “screening test” for the diagnosis of occult gastrointestinal (GI) tract malignancies through a clinical presentation with bleeding.

Objective

We aimed to investigate the 1-year incidence and predictors of GI cancers after GI bleeeding events among patients with atrial fibrillation (AF) treated with warfarin or NOACs. Second, we aimed to compare the risk of mortality after GI cancers between patients treated with warfarin or NOACs.

Methods

A total of 10,845 anticoagulated AF patients who experienced hospitalizations due to GI bleeding without prior history of GI cancers were identified from the Taiwan National Health Insurance Research Database. Patients were followed up for incident GI cancers for up to 1 year.

Results

Within 1 year after GI bleeding, 290 (2.67%) patients were diagnosed to have GI tract cancers. More patients treated with NOACs were diagnosed to have GI cancers than those receiving warfarin (68/1,759; 3.87% [NOACs] versus 222/9,086; 2.44% [warfarin], p<0.001) with an odds ratio (OR) 1.606 (95% CI: 1.208–2.117, p<0.001). Age (OR 1.025 [95% CI: 1.012–1.037] per 1 year increment) and male sex (1.356 [95% CI: 1.050–1.700]) were independently associated with the diagnosis of GI cancers within 1 year after GI bleeding. Among 290 patients diagnosed to have GI cancers, 131 (45.2%) experienced mortality within 1 year. The risk of mortality was lower for patients treated with NOACs compared to those receiving warfarin (23.5% versus 51.8%) with an adjusted hazard ratio (aHR) 0.441 (95% CI: 0.262–0.744, p<0.001) (Figure).

Conclusions

Incident GI cancers were diagnosed in 1 in 37 AF patients at 1 year after OAC-related GI bleeding, which were more common among patients treated with NOACs (1 in 26) compared to warfarin (1 in 41). Detailed surveys for occult GI cancers were necessary for these patients, especially for the elderly males.

Survival curves

Funding Acknowledgement

Type of funding source: None
Pulmonary artery injury in left atrial appendage closure device implantation: a systematic review of a potentially fatal complication
Authors: Hanna B , Desai R , Sachdeva S , Singh S , Gangani K , Taha Y , Echols M , Paul T.K , Berman A , Bloom H , Kumar G , Sachdeva R
Published: November 2020

Background

Pulmonary artery (PA) injury is a rarely reported complication following percutaneous left atrial appendage closure (LAAC). This study aims to systematically review all reported cases of PA injury associated with LAAC.

Methods

PubMed/Medline, SCOPUS, EMBASE, Google Scholar and the MAUDE databases were searched to find studies reporting PA injury during or after LAAC with the Amplatzer Amulet (AA), Amplatzer Cardiac Plug (ACP) or Watchman device through October 2019. Categorical data were reported in terms of numbers and/or percentages (%).

Results

We found 13 cases (mean age 71.4 yrs) with reported PA injury associated with LAAC. Of these, 9 were case reports, 3 were reported in observational studies, and 1 was in the MAUDE database. Most cases (n=8) were reported in Europe followed by Australia (n=2) and Asia (n=2). The indication for device implantation in all patients was a high bleeding risk with anticoagulation for atrial fibrillation. Five cases were reported with the ACP (1/5 patients died), 5 with AA (2/5 patients died), and 3 with the Watchman (1/2 patients died). Acute and late presentations following implantation were reported for all three devices. 69.2% of cases (9/13) occurred acutely (during or within 24 hours of intervention). Of these, 3/9 occurred during device implantation. 2/4 of the delayed cases occurred >2 weeks following implantation. The mortality rate for acute and delayed cases was 22% (2/9 patients) and 50% (2/4 patients), respectively. A majority of the cases were attributable to barb/strut/hook injury of the PA. PA injury was associated with a mortality rate of approximately 31%. All surviving patients were managed with surgical intervention.

Conclusion

PA injury is an infrequently reported complication following LAAC and is associated with high mortality. Cases can present acutely (intra-procedurally or within 24 hours) or delayed (>24 hours post-implantation). A majority of cases are due to direct injury of the PA by the struts/hooks/barbs of the device. Practitioners should be cognizant of this life-threatening complication, which requires a high index of suspicion for diagnosis and can occur weeks after device implantation.

Funding Acknowledgement

Type of funding source: None
Unravelling the black box of machine learning for atrial fibrillation forecast: role of heart rate variability and of premature beats
Authors: Gregoire J.M , Gilon C , Carlier S , Bersini H
Published: November 2020

Background

The identification of patients still in sinus rhythm who will present one month later an atrial fibrillation episode is possible using machine learning (ML) techniques. However, these new ML algorithms do not provide any relevant information about the underlying pathophysiology.

Purpose

To compare the predictive performance for forecasting AF between a machine learning algorithm and other parameters whose pathophysiological mechanisms are known to play a role in the triggering of arrhythmias (i.e. the count of premature beats (PB) and heart rate variability (HRV) parameters)

Material and methods

We conducted a retrospective study from an outpatient clinic. 10484 Holter ECG recordings were screened. 250 analysable AF onsets were labelled. We developed a deep neural network model composed of convolutional neural network layers and bidirectional gated recurrent units as recurrent neural network layers that was trained for the forecast of paroxysmal AF episodes, using RR intervals variations. This model works like a black box. For comparison purposes, we used a “random forest” (RF) model of ML to obtain forecast results using HRV parameters with and without PB. This model allows the evaluation of the relevance of HRV parameters and of PB used for the forecast. We calculated the area under the curve of the receiving operating characteristic curve for the different time windows counted in RR intervals before the AF onset.

Results

As shown in the table, the forecasting value of the deep neural network model (ML) was not superior to the random forest algorithm. Prediction value of both decreased when analyzing the RR intervals further away from the onset of AF

Conclusions

These results suggest that HRV plays a predominant role in triggering AF episodes and that premature beats could add minor information. Moreover, the closer the window from AF onset, the better the accuracy, regardless of the method used. Such detection algorithms once implemented in pacemakers, might prove useful to prevent AF onset by changing pacing sequence while patients would still be in sinus rhythm, however this remains to be demonstrated

Funding Acknowledgement

Type of funding source: None
Blood pressure lowering treatment for prevention of cardiovascular events in patients with atrial fibrillation: an individual-participant data meta-analysis
Authors: Pinho-Gomes A.C , Azevedo L , Copland E , Canoy D , Nazarzadeh M , Remakrishnan R , Berge E , Sundstrom J , Kotecha D , Woodward M , Rahimi K
Published: November 2020

Background

Randomised evidence showing that pharmacological blood pressure (BP) lowering can reduce cardiovascular risk of patients with atrial fibrillation (AF) is limited.

Purpose

This study aimed to compare the effect of BP-lowering treatment on fatal and non-fatal cardiovascular outcomes in patients with and without AF overall and by major drug classes.

Methods

We extracted individual participant data from all trials with over 1,000 person-years of follow-up that had randomly assigned patients to different classes of BP-lowering drugs, BP-lowering drugs vs placebo, or to more vs less intensive BP-lowering regimens. We investigated the effects of BP-lowering treatment on a composite endpoint of major cardiovascular events (stroke, ischaemic heart disease or heart failure) according to AF status at baseline using fixed-effect one-stage individual participant data meta-analyses based on Cox proportional hazards models stratified by trial.

Findings

Twenty-two trials were included with 188,570 patients, of whom 13,266 (7%) had AF at baseline. Patients with AF had lower BP at baseline than patients without AF (143/84 mmHg, SD 21/12mmHg) versus 155/88 mmHg, SD 21/13 mmHg, respectively). Meta-regression showed that relative risk reductions were proportional to trial-level intensity of BP lowering, both in patients with and without AF. The hazard ratio for major cardiovascular events was 0.91 in patients with AF (95% confidence interval [0.83–1.00]) and 0.91 without AF (95% confidence interval [0.88–0.93]) for each 5-mmHg reduction in systolic BP, with no difference between subgroups (p=0.91) (Figure 1). Similar patterns were observed for individual components of the composite primary outcome. In patients with AF, there was no evidence that treatment effects varied according to baseline systolic BP or use of specific drug classes.

Conclusion

This study demonstrated that BP-lowering treatment reduces the risk of major cardiovascular events in patients with AF to a similar extent to that of patients without AF, even when baseline BP is below recommended treatment thresholds. Owing to their higher absolute cardiovascular risk, treatment in patients with AF is likely to result in greater absolute risk reduction than in patients without AF. Guidelines should be updated to clearly recommend pharmacological BP lowering for prevention of cardiovascular events in patients with AF.

Figure 1. Forest plot

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation
Clinical impact of regression from sustained to paroxysmal atrial fibrillation: the Fushimi AF registry
Authors: Fujino A , Ogawa H , Ikeda S , Doi K , Hamatani Y , An Y , Ishii M , Iguchi M , Masunaga N , Esato M , Tsuji H , Wada H , Hasegawa K , Abe M , Akao M
Published: November 2020

Background

Atrial fibrillation (AF) commonly progresses from paroxysmal type to sustained type in the natural course of the disease, and we previously demonstrated that the progression of AF was associated with increased risk of clinical adverse events. There are some patients, though less frequently, who regress from sustained to paroxysmal AF, but the clinical impact of the regression of AF remains unknown.

Purpose

We sought to investigate whether regression from sustained to paroxysmal AF is associated with better clinical outcomes.

Methods

Using the dataset of the Fushimi AF Registry, patients who were diagnosed as sustained (persistent or permanent) AF at baseline were studied. Conversion of sustained AF to paroxysmal AF during follow-up was defined as regression of AF. Major adverse cardiac events (MACE) were defined as the composite of cardiac death, stroke, and hospitalization for heart failure (HF). Event rates were compared between the patients with and without regression of AF. In patients with sustained AF at baseline, predictors of MACE were identified using Cox proportional hazards model.

Results

Among 2,253 patients who were diagnosed as sustained AF at baseline, regression of AF was observed in 9.0% (202/2,253, 2.0 per 100 patient-years) during a median follow-up of 4.0 years. Of these, 24.3% (49/202, 4.6 per 100 patient-years) of the patients finally recurred to sustained AF during follow-up. The proportion of asymptomatic patients was lower in patients with regression of AF than those without (with vs without regression; 49.0% vs 69.5%, p<0.01). The percentage of beta-blocker use at baseline was similar between the two groups (37.2% vs 33.8%, p=0.34). The prevalence of patients who underwent catheter ablation or electrical cardioversion during follow-up was higher in patients with regression of AF (catheter ablation: 15.8% vs 5.5%; p<0.01, cardioversion: 4.0% vs 1.4%; p<0.01, respectively). The rate of MACE was significantly lower in patients with regression of AF as compared with patients who maintained sustained AF (3.7 vs 6.2 per 100 patient-years, log-rank p<0.01). Figure shows the Kaplan-Meier curves for MACE, cardiac death, hospitalization for heart failure, and stroke. In patients with sustained AF at baseline, multivariable Cox proportional hazards model demonstrated that regression of AF was an independent predictor of lower MACE (adjusted hazard ratio [HR]: 0.50, 95% confidence interval [CI]: 0.28 to 0.88, p=0.02), stroke (HR: 0.51, 95% CI: 0.30 to 0.88, p=0.02), and hospitalization for HF (HR: 0.50, 95% CI: 0.29 to 0.85, p=0.01).

Conclusion

Regression from sustained to paroxysmal AF was associated with a lower incidence of adverse cardiac events.

Funding Acknowledgement

Type of funding source: None
Temporal changes in quality of life amongst European atrial fibrillation patients: relationship to all-cause mortality. A report from the ESC-EHRA EORP-AF General Long-Term Registry
Authors: Vitolo M , Proietti M , Harrison S , Fauchier L , Marin F , Potpara T , Lane D.A , Boriani G , Lip G.Y.H
Published: November 2020

Background

Atrial fibrillation (AF) significantly impacts on patients' quality of life (QoL). An impaired QoL has been associated with worse outcomes even in AF patients, but contemporary data in a large-scale pan-European population are limited.

Purpose

We aimed to assess temporal changes in AF patients' QoL across 2 years follow-up observation, and the relationship of QoL changes with all-cause death.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. The EQ-5D-5L questionnaire was used to assess QoL. A Health Utility Score (HUS), indicating the overall health state (1 equals perfect health), was derived. Differences throughout the follow-up (Baseline, 1-Y FU, 2-Y FU) observation were assessed. The study outcome was all-cause mortality.

Results

Out of a total of 11906 patients, 8097 (73.0%) were available for this analysis. Mean (SD) age was 69.1 (11.5) years; 60.8% males; median CHA2DS2-VASc and HASBLED scores were 3 (IQR 2–4) and 1 (1–2), respectively. The mean (SD) HUS at baseline was 0.815 (0.200) and 0.834 (0.196), 0.829 (0.195) at 1-year follow-up and 2-year follow-up, respectively (p<0.0001 for changes over time). Patients with a higher CHA2DS2-VASc score (CHA2DS2-VASc 6–9) reported a significant reduction in the quality of life, compared to the other CHA2DS2-VASc strata, with a mean (SD) HUS decreasing from 0.754 (0.214) at baseline to 0.727 (0.238) at 2-year follow-up (F=6.538, p<0.0001) (Figure). Multivariate analysis demonstrated that age [−0.001 (95% CI [−0.002, −0.121]) and coronary artery disease (CAD) [−0.016 (95% CI [−0.029, −0.004] were independently inversely associated with increasing QoL. Positive changes in HUS over time were inversely associated with an increase in the risk of all-cause death, even after adjusting for chronic kidney disease, liver disease, chronic obstructive pulmonary disease, oral anticoagulants and type of AF (OR:0.24, 95% CI: 0.13–0.45 for increasing HUS difference, as a continuous variable).

Conclusions

In a contemporary European-wide cohort of AF patients, significant temporal changes in QoL were found. Patients at higher stroke risk according to CHA2DS2-VASc score showed a significant reduction in the QoL. Age and CAD were independently associated with changes in QoL. A greater reduction in HUS (i.e. worsening QoL) over time was associated with a higher risk of all-cause death.

Temporal changes in HUS

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Since the start of EORP, several companies have supported the programme with unrestricted grants
Scar and arrhythmic isthmus characterization in patients with D-TGA treated with atrial switch surgery using a new high density mapping grid catheter
Authors: Francisco Pascual J , Llerena Butron S , Pascual Gonzalez G , Perez Rodon J , Santos Ortega A , Benito B , Rodriguez Garcia J , Roses Noguer F , Dos Subira L , Pijuan Domenech A , Subirana Domenech M.T , Miranda Barrio B , Garrido L , Ferreira Gonzalez I , Rivas Gandara N
Published: November 2020

Introduction

Patients with D- transposition of the great arteries (TGA) treated with Senning or Mustard surgeries have several atrial scars that predispose them to develop atrial tachycardias (AT). Identification of scar zones and possible arrhythmic isthmus in voltage mapping will help to guide the ablation.

Aim

To describe the feasibility of using a specific mapping catheter to identify possible arrhythmic isthmus in this set of patients.

Methods

Prospective observational study in patients with history of SVT and atrial switch surgery, that underwent electrophysiologic study (EP) and electroanatomic (EA) mapping with a new 8Fr deflectable, multipoint wavefront-activation-orientation independent Grid catheter, in a third level hospital since April 2018 until January 2020, with medium-term follow-up.

Results

A total of 9 EPs were performed in 8 patients (3 (37,5%) Female, median age 35.2 y.o. (IQI 29,2–37,6)). Figure 1A shows an example of an activation and substrate mapping. Figure 1B shows the localization and percentage of scar identified in both atria. A total of 7 tachycardias were induced. In this, an arrhythmogenic isthmus was identified and in all patients at least one non-arrhytmogenic isthmus was documented. Figure 1C shows anatomical and electrophysiological characteristics of the isthmus. Arrhythmogenic isthmus had slower conduction velocity than non-arrhytmogenic (mean 0,31m/s (IQI 0,14–0,63) vs 0,94 m/s (IQI 0,81–1,24) p=0.02) and fractionated potentials were detected more frequently (100% vs 55% p=0.05)

Conclusion

EA mapping with a new a multipoint, high-definition, Grid Cather allows the identification and electrophysiological characterization of arrhythmogenic and non-arrhytmogenic isthmus in patients with TGA treated with atrial switch surgery.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Hospital Universitari Vall d'Hebron. VHIR
Takotsubo cardiomyopathy related complete heart block: a nationwide cohort analysis
Authors: Patil S.P , Gonuguntla K , Rojulpote C , Kumar M , Chen K.G
Published: November 2020

Background

Complete heart block (CHB) is considered to be a relatively rare complication of Takotsubo cardiomyopathy (TC), a condition characterized by transient left ventricular systolic dysfunction.

Purpose

We aim to investigate the incidence, in-hospital mortality and trends of permanent pacemaker (PPM) placement in patients with TC-related CHB.

Methods

We utilized the United States National Inpatient Sample (NIS) data from 2010–2014 to identify adult patients (≥18 years) with TC (ICD 9 code: 429.83). CHB cases were identified using ICD-9 code 426.0. Annual incidence of CHB, in-hospital mortality and trends of PPM placement were analyzed. Cochran-Armitage test was employed and p values were calculated for trend.

Results

A total of 56,431 patients with TC were identified, of which 495 (0.7%) had CHB (median age 71 years, 85% women). Incidence of TC-related CHB was 0.5% in 2010 and 0.8% in 2014.

However, trend analysis did not show an increase in the incidence (ptrend=0.12). In-hospital mortality was higher in patients with CHB (7.5% vs. 2.9%, aOR = 1.9, 95% CI= 1.29–2.8, p=0.001). Temporary transvenous pacemaker (TTVP) was used in 158 (40.1%) and PPM in 217 (54.9%) patients. Trend analysis showed a significant increase in the PPM placement from 41.9% in 2010 to 76.2% in 2014 and a simultaneous decrease in use of TTVP (ptrend<0.001).

Median length of stay (4 vs. 3 days, p<0.001) was prolonged and hospitalization cost ($92,731 vs. $35,905, p<0.001) was higher in TC patients with CHB.

Conclusion

TC-related CHB is uncommon, but independently associated with increased in-hospital mortality. The majority of these patients required PPM, implicating a non-reversible feature of the conduction system abnormality.

Funding Acknowledgement

Type of funding source: None
The management of Atrioventricular Blocks in Tako-Tsubo Syndrome, a therapeutic dilemma?
Authors: Piroli F , Franchin L , Errigo D , De Filippo O , D'Ascenzo F , De Ferrari G
Published: November 2020

Introduction

Atrioventricular blocks (AVBs) are a rare complication of Tako-Tsubo syndrome (TTS). Acute management of these patients is still a matter of debate since the long-term outcomes are difficult to predict and a complete recovery after PPM implantation may occur.

Methods

A critical review of current literature focusing on PPM implantation time in this patients' cohort was performed after a patient with TTS and AVB received a PPM in our medical center with a subsequent complete recovery in one month.

Results

Twenty-four case-reports of TTS-related AVBs were collected. A total of five patients went through a complete AV conduction recovery within few days, while of nineteen patients receiving a PPM during hospitalization, three showed a complete recovery within one to three months and one after two years. In six cases an electrophysiology (EP) study was performed to assess the functional nature of the AVB, resulting in four supra-Hisian blocks and two infra-Hisian blocks. In the supra-Hisian group there was a conduction recovery in three cases in a period from few days to one month while only one patient didn't improve at three-months. On the other hand, in the infra-Hisian group only one patient recovered AV conduction after two years.

Conclusion

Infra-Hisian and supra-Hisian blocks appear to have different outcomes with the latter more likely to develop a faster recovery. EP study could be a useful tool for clinicians during decision-making process and a wait-and-see strategy may be considered to avoid unnecessary PPM implantations.

Funding Acknowledgement

Type of funding source: None
Incidence, characteristics, determinants and prognostic impact of recurrent syncope
Authors: Zimmermann T , Du Fay De Lavallaz J , Nestelberger T , Gualandro D , Badertscher P , Lopez-Ayala P , Widmer V , Freese M , Twerenbold R , Wussler D , Koechlin L , Walter J , Kuehne M , Reichlin T , Mueller C
Published: November 2020

Background

The incidence, characteristics, determinants, and prognostic impact of recurrent syncope are largely unknown, causing uncertainty for both patients and physicians.

Methods

We characterized recurrent syncope including sex-specific aspects and its impact on death and major adverse cardiovascular events (MACE) in a large prospective international multicenter study enrolling patients ≥40 years presenting with syncope to the emergency department (ED). Syncope etiology was centrally adjudicated by two independent and blinded cardiologists using all information becoming available during syncope work-up and 12-month follow-up. MACE were defined as a composite of all-cause death, acute myocardial infarction, surgical or percutaneous coronary intervention, life-threatening arrhythmia including cardiac arrest, pacemaker or implantable cardioverter defibrillator implantation, valve intervention, heart-failure, gastrointestinal bleeding or other bleeding requiring transfusion, intracranial hemorrhage, ischemic stroke or transient ischemic attack, sepsis and pulmonary embolism.

Results

Incidence of recurrent syncope among 1790 patients was 20% (95%-confidence interval (CI) 18% to 22%) within 24 months. Patients with an adjudicated final diagnosis of cardiac syncope (hazard ratio (HR) 1.50, 95%-CI 1.11 to 2.01) or syncope of unknown etiology even after central adjudication (HR 2.11, 95%-CI 1.54 to 2.89) had an increased risk for syncope recurrence (Figure). LASSO regression fit on all patient information available early in the ED identified more than three previous episodes of syncope as the only independent predictor for recurrent syncope (HR 2.13, 95%-CI 1.64 to 2.75). Recurrent syncope within the first 12 months after the index event carried an increased risk for all-cause death (HR 1.59, 95%-CI 1.06 to 2.38) and MACE (HR 2.24, 95%-CI 1.67 to 3.01), whereas recurrences after 12 months did not have a significant impact on outcome measures.

Conclusion

Recurrence rates of syncope are substantial and vary depending on syncope etiology. There seem to be no reliable patient characteristics available early on the ED that allow for the prediction of recurrent syncope with only a history of more than three previous syncope being associated with a higher risk for future recurrences. Importantly, recurrent syncope within the first 12 months carries an increased risk for death and MACE.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation
Device therapy guided by implantable loop recorders: predictors of bradyarrhythmic events
Authors: Cardoso A , Faria B , Von Hafe P , Dias G , Pereira T , Ribeiro S , Calvo L , Rodrigues B , Alves A , Fernandes M , Sanfins V , Lourenco A
Published: November 2020

Background

Implantable loop recorders (ILR) improved diagnostic yield in unexplained syncope patients (pts). Data on possible predictive factors for bradycardia requiring device implantation in these pts is limited. We aim to identify clinical predictors for device implantation due to a significant bradyarrhythmia in patients who underwent ILR insertion for the study of syncopal/presyncopal (S/pS) events.

Methods

Single-center retrospective study of patients who implanted an ILR for the study of unexplained S/pS episodes between 2013 and 2018. The primary endpoint was a documented bradyarrhythmia requiring device implantation during the follow-up.

Results

A total of 251 pts were included. Mean age was 68±15 years and 53% were female. The majority of pts (220; 88%) had normal ejection fraction. Fifty-two (21%) pts had atrial fibrillation (AF). Regarding basal electrocardiographic characteristics, 34 (14%) pts had 1st degree auriculo-ventricular block (AVB), 31 (12%) pts had left bundle branch block (L-BBB), 22 (9%) pts had R-BBB and 13 (5%) pts had bifascicular block.

During a median follow-up of 20 (IQR 9–34) months, 74 (29%) pts required device implantation because of a significant bradyarrhythmia (92% pacemaker, 4% CRT, 4% ICD). Median duration from ILR until device implantation was 5 (IQR 1–10) months. The indications were sick-sinus-syndrome in 47 (64%) pts, advanced AV block in 23 (31%) pts and symptomatic slow AF in 4 (5%) pts.

Patients who required device implantation were older (73±12 vs 66±15 years, p <0.001), had more hypertension (73% vs 59% p=0.048), a higher prevalence of AF (34% vs 15% p=0.001) and a lower glomerular filtration rate (GFR<60 ml/min: 32% vs 21%, p=0.047). They also had more 1st AVB (22% vs 11%, p=0.026) and intraventricular conduction disturbances (38% vs 25%, p=0.025). There was a trend for a higher device implantation in pts with concomitant 1st AVB and left anterior fascicular block (7% vs 2%, p=0.063)

In a logistic regression model, age >75 years (HR: 1.7; 95% CI: 1.1–2.8) and the presence of AF (HR: 1.8; 95% CI: 1.1–3.0) were independent predictors for device implantation.

Conclusion

An older age and the presence of AF were independent predictors for device therapy in pts who implanted an ILR for the study of S/pS. These factors may identify a higher risk group and should be considered in the initial workup of these pts.

Funding Acknowledgement

Type of funding source: None
Impact of sensing vector on insertable cardiac monitor detection of P and R wave amplitude
Authors: Pitman B.M , Tarone R , Jones E , Kadhim K , Linz D , Roberts-Thomson K , Young G.D , Mariani J , Wong C.X , Sanders P , Lau D.H
Published: November 2020

Background

P-wave visibility is useful for diagnosis of atrial arrhythmias via insertable cardiac monitors (ICM).

Purpose

To compare the sensing capability of ICM with different vector length: Medtronic REVEAL LINQ (45mm) vs. Biotronik Biomonitor BMIII (75mm).

Methods

We accessed de-identified remote monitoring transmissions from n=40 patients with BMIII from Biotronik for comparison with n=80 gender- and body mass index (BMI)-matched patients with REVEAL LINQ. Digital measurement of calibrated ICM electrograms was performed using DigitizeIt© (V2.3.3, Germany) of 5 consecutive P-QRS complexes by 3 investigators independently. P-wave amplitude was measured from baseline to peak and R-wave amplitude was measured from peak-to-peak. Further, we evaluated the impact of BMI on P-wave visibility.

Results

Patients in both groups are well matched for gender and BMI (53% male, mean BMI 26.7 kg/m2; both p=NS). P-wave and R-wave amplitude were 89% & 20% larger in the BMIII vs. LINQ (0.072±0.039 vs. 0.038±0.022mV, p=0.0001; & 0.83±0.42 vs. 0.69±0.45mV, p=0.095 respectively; Figure). Consequently, the P/R-wave ratio was 44% greater for the BMIII (p=0.002). Multivariate regression analysis showed that increasing BMI, female gender and LINQ were independently associated with lower P-wave amplitude (all P<0.001). Inter-operator reproducibility of P-wave measures was very good (ICC 0.91, P<0.001).

Conclusion

The longer ICM sensing vector of BMIII yielded considerable larger P-wave amplitude than LINQ, that was not impacted by increasing BMI. Better P-wave visibility may improve clinical decision-making after device-detected arrhythmias while further studies are needed to determine its impact on clinical outcomes.

P-wave visibility comparison of ICMs

Funding Acknowledgement

Type of funding source: None
Idiopathic HFrEF. Is there room left for defibrillators?
Authors: Gama F , Carvalho M.S , Rodrigues G , Costa F.M , Matos D , Carmo J , Mendes F , Feliciano S , Santos I , Durazzo A , Carmo P , Cavaco D , Morgado F , Adragao P
Published: November 2020

Background and aim

Prophylactic implantation of an implantable cardioverter-defibrillator (ICD) is class 1 recommendation for heart failure (HF) patients with reduced ejection fraction (HFrEF) even though its proven advantage is weaker among nonischemic aetiology. In fact, in an era where both optimal medical therapy (OMT) and cardiac resynchronization therapy (CRT) significantly reduce sudden cardiac death (SCD), it is questionable whether ICD still have additional value. The aim of this study was to assess the current benefit of ICDs in preventing sudden cardiac death through resuscitated cardiac arrest (RCA), appropriate therapy for sustained ventricular tachycardia (VT) or fibrillation (VF) in a contemporary population of idiopathic HFrEF patients.

Methods

Single-centre retrospective study of consecutive symptomatic (NYHA class II to IV) idiopathic HFrEF patients with an ICD (either alone or in association with CRT), and remote monitoring with the corresponding software (MerlinTM, LatitudeTM, CarelinkTM, MicroPortTM or BiotronikTM) to assure appropriate event supervising. Idiopathic aetiology was assumed after excluding other probable causes. Coronary angiogram was required to exclude ischemic aetiology. Only those with prophylactic ICD implantation were included. RCA was defined as collapse with clinical signs of cardiac arrest and VF or VT appropriately terminated by ICD. In order to be sustained, VT episode had to have last at least 30 seconds.

Results

From 781 remote monitoring controlled patients, a total of 187 consecutive symptomatic idiopathic HFrEF patients with an ICD (125 men, mean age 64±18 years) were enrolled. Patients were on optimal medical therapy (ACEi/ARB: n=168, 90%; BB: n=154, 82%; mineralocorticoid antagonists: n=91, 49%; CRT: n=130, 70%; see Table). After a median follow-up of 99 months (IQR 62.2), RCA occurred in 10.7% (n=20) and 36.9% (n=69) had appropriately terminated VT. Both left ventricular ejection fraction (LVEF) improvement and CRT implantation did not independently reduce the incidence of RCA and VT requiring ICD therapy (OR, 1.02; 95% CI, 0.99–1.05; P=0.146 and OR, 0.85; 95% CI, 0.34–2.13; P=0.728; respectively). All cause mortality was 20 (10.7%). Inappropriate therapy was given as shocks to 41 patients (21.9%) and as antitachycardia pacing (ATP) to 30 (16%), opposing with appropriately given therapy to 43 (23%) and 63 (33.7%) patients, respectively (see Figure), contributing to a net clinical benefit (NCB) of 18.8%, favouring ICD implantation.

Conclusion

In this contemporaneous real-world population of symptomatic idiopathic HFrEF patients, episodes of impending cardiac death were frequent. Prophylactic ICD implantation seems to have added further benefit reducing SCD on top of optimal medical therapy, LVEF improvement and coexisting CRT.

Funding Acknowledgement

Type of funding source: None
Long-term prognosis in patients with non-type 1 Brugada ECG: results from a large Japanese cohort of Brugada syndrome
Authors: Takagi M , Shinohara T , Kamakura T , Sekiguchi Y , Yokoyama Y , Aihara N , Hiraoka M , Aonuma K
Published: November 2020

Background

Most recent consensus conference report recommends Brugada syndrome (BrS) is diagnosed in patients with ST segment elevation with spontaneous, drug-induced or fever-induced type 1 morphology. Prognosis in patients with type 2 or 3 ECG without drug-induced or fever-induced type 1 ECG is still unknown.

Purpose

To evaluate a long-term prognosis in patients with non-type 1 Brugada ECG in a large Japanese cohort of BrS (The Japan Idiopathic Ventricular Fibrillation Study [J-IVFS]).

Methods

From 528 patients in J-IVFS, a total of 28 consecutive non-type 1 patients (54±14 years, all male, previous sustained ventricular tachyarrhythmias (VTs) 1, syncope 11, asymptomatic 16) were enrolled. Cardiac events (CI: sudden cardiac death or VTs) during the follow-up period were evaluated, and risk factors for the cardiac events were assessed.

Results

During a mean follow-up period of 111±91 months (median 134 months), 4 patients experienced cardiac events (1.5%/yr), who all had received implantable cardioverter defibrillator implantation. There was no statistically significant clinical risk factor for cardiac events. However, the incidences of cardiac events tended to be higher in symptomatic patients (CI: 25.0, non-CI: 6.3%, p=0.17), those with wide QRS duration >90 msec in lead V2 (CI: 30.0, non-CI: 6.3%, p=0.11), and those with inducible VTs (CI: 21.1, non-CI: 0%, p=0.20), as determined by the Kaplan-Meier method. The annual incidences of cardiac events in patients with symptom, wide QRS duration >90msec in lead V2, or inducible VTs were 2.8, 3.5, and 2.0%/yr, respectively. The incidences of cardiac events were significantly higher in patients with all these 3 factors (9.9%/yr) than those without (p=0.01).

Conclusions

Our large-scaled multicentre study revealed long-term prognosis in patients with non-type 1 Brugada ECG. The combination of symptom, wide QRS duration in lead V2, and inducible VTs may be useful to evaluate risk for cardiac events. The patients with all these parameters showed high risk for cardiac events and need to be carefully followed.

Funding Acknowledgement

Type of funding source: None