bluuebunny/crossref_metadata_2025 huggingface dataset:
P-wave beat-to-beat analysis to predict atrial fibrillation recurrence after catheter ablation
Authors: Tachmatzidis D , Mouselimis D , Tsarouchas A , Filos D , Antoniadis A P , Lysitsas D N , Mezilis N , Sakellaropoulou A , Giannopoulos G , Bakogiannis C , Triantafyllou K , Fragakis N , Efremidis M , Chouvarda I , Vassilikos V P
Published: October 2022

Introduction

Identification of patients prone to atrial fibrillation (AF) relapse after catheter ablation is essential for better patient selection and risk stratification.

Purpose

The current prospective cohort study aims to validate a novel P-wave index based on beat-to-beat (B2B) P-wave morphological and wavelet analysis designed to detect patients with low burden AF, as a predictor of AF recurrence within a year after successful catheter ablation.

Methods

12-lead ECG and 10-minute vectorcardiogram (VCG) recordings were obtained from 138 consecutive patients scheduled for AF ablation. Pre-ablation B2B P-wave index, along with standard P-wave indices, clinical scores and patients history and physical examination parameters were evaluated as AF recurrence predictors.

Results

Univariate analysis revealed that patients with higher B2B P-wave index had a two-fold risk for AF recurrence (HR: 2.35, 95% CI: 1.24–4.44, p: 0.010). Prolonged P-wave, interatrial block, early AF recurrence, female gender, heart failure history, previous stroke, and CHA2DS2-VASc score ≥2 were also found to be related to higher recurrence rate. Multivariate analysis of predictors that can be assessed before ablation revealed that B2B P-wave index, along with heart failure history and history of previous stroke or transient ischemic attack are independent predicting factors of AF relapse.

Conclusion

B2B P-wave morphology and wavelet analysis, is a promising, non-invasive technique, able to identify patients prone to AF recurrence after pulmonary veins ablation. Further studies are needed to assess the predictive value of B2B index with greater accuracy and evaluate a possible relationship with atrial substrate analysis.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Hellenic Society of Cardiology
Safety and effectiveness of near-zero fluoroscopy paroxysmal AF radiofrequency ablation with a temperature-controlled, contact force-sensing catheter: a Q-FFICIENCY study sub-analysis
Authors: Hussein A , Delaughter M C , Monir G , Natale A , Dukkipati S , Oza S , Daoud E , Di Biase L , Mansour M , Fishel R , Valderrabano M , Ellenbogen K , Osorio J
Published: October 2022

Background/Introduction

Q-FFICIENCY evaluated 12-month (M) safety and efficacy of temperature-controlled paroxysmal atrial fibrillation ablation with a novel contact force-sensing, radiofrequency catheter with 3 microelectrodes and 6 thermocouples. Patients underwent pulmonary vein isolation with very high-power short-duration (vHPSD; 90 W/ up to 4 s) mode in combination with conventional-power temperature-controlled (CPTC; 25–50 W) mode.

Purpose

To assess procedural efficiency, safety, and 12M outcomes of participants ablated under near-zero fluoroscopy guidance compared to procedures performed with standard fluoroscopy.

Methods

In this US multi-centre (22 sites), non-randomised investigational study, patients underwent pulmonary vein isolation with vHPSD as primary ablation mode; CPTC was used for PV touch-up or non-PV ablation. Primary safety endpoint was incidence of primary adverse events ≤7 days post-procedure. Primary effectiveness was freedom from documented atrial tachyarrhythmia recurrence and additional pre-defined failure modes (acute failure, repeat ablation, new/higher dose anti-arrhythmic drug). Participants were followed-up through 12M post-ablation (3M blanking & 9M evaluation) to assess safety, effectiveness, and healthcare utilisation.

Results

Of 191 participants enrolled (63.5±10.7 years, CHA2DS2-VASc 2.4±1.5, 60.7% men), 166 were ablated with the investigational catheter, and 165 had fluoroscopy data available for inclusion in this analysis. Forty-four participants received ≤1 minute of fluoroscopy. Compared to the >1-minute of fluoroscopy cohort, the ≤1-minute group showed improved efficiencies in all procedural parameters (Table). Primary adverse event rates were similar among groups (≤1-minute, 4.5%; >1-minute, 3.3%). Kaplan-Meier estimated 12M clinical success rates (i.e., freedom from documented symptomatic recurrence) were similar regardless of fluoroscopy exposure (≤1-minute, 85.4%; >1-minute, 86.0%). Freedom from cardiovascular hospitalisation 12M post-ablation was comparable among groups (90.8% vs 88.0%).

Conclusion

Near-zero fluoroscopy paroxysmal atrial fibrillation ablation with the novel temperature-controlled catheter in vHPSD mode, alone or combined with CPTC, led to enhanced procedural efficiencies with good effectiveness and clinical success without comprising safety.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Biosense Webster, Inc.
Catheter ablation of persistent atrial fibrillation with heart failure improves hemodynamic status without deteriorating renal function in the elderly
Authors: Okahara A , Kawai S , Tokutome M , Matsuura H , Noma A , Hara A , Nakashima H , Watanabe T , Sakemi T , Okabe K , Matsukawa R , Masuda S , Mukai Y
Published: October 2022

Background/Introduction

Atrial fibrillation (AF) and heart failure (HF) frequently coexist in the elderly people, leading to worse clinical outcomes. HF with preserved ejection fraction (HFpEF) is the most common form of HF in the elderly, particularly in women, associated with AF. Ablation of AF in younger patients with HF with reduced EF (HFrEF) has become an established treatment option. However, clinical impact of ablation for persistent AF accompanying with HF in the elderly remains unclear.

Purpose

This study aimed to evaluate the effect of catheter ablation of persistent AF with heart failure in the elderly.

Methods

Consecutive 70 patients who underwent catheter ablation of persistent AF accompanying with HF (NYHA class> II, mean LVEF 51.7%) in our institution were retrospectively analyzed with regards to their 1-year clinical outcomes, HF markers such as BNP, renal function and transthoracic echocardiographic findings. Patients were dichotomized by age of 75-year-old (31 elderly vs 39 younger subjects) and separately analyzed.

Results

Mean age of the studied population was 70.5 year-old; 79.6±3.8 in the elderly group and 63.2±8.5 in the younger group. The elderly patients were more frequently females (45% vs 21%). Longstanding persistent AF was observed in 32% in the elderly and 28% in the younger group. Circumferential pulmonary vein isolation (PVI) was performed in all patients, with additional ablations of liner lesions and/or non-PV foci as needed. PVI alone was observed in 54.8% in the elderly and 41% in the younger group. There were no serious complications associated with the procedure. During 1 year after ablation, recurrence of AF was observed in 15 patients [6/31 (19%) in the elderly, 9/39 (23%) in the younger]. Readmission due to HF was observed in only 1 patient in the elderly and 2 patients in the younger group (3% vs. 5%, respectively). Cardiovascular events were observed in 3 patients [2/31 (6%) in the elderly, 1/39 (3%) in the younger], but there was no death. The BNP level as well as the NYHA class significantly decreased at 1-year follow-up compared to baseline in the both groups (Figure A and B). There was no change in serum creatinine level in the both groups (Figure C). The left atrial dimension and the LA volume index decreased at 1-year follow-up in the both groups (Figure D and E). The LVEF improved only in the younger group (Figure F).

Conclusions

Ablation of persistent AF in the elderly with HF (mostly with preserved EF) was associated with hemodynamic and functional improvements without deteriorating renal function in a mid-term, which was mostly comparable to the results in the younger.

Funding Acknowledgement

Type of funding sources: None.
Paroxysmal atrial fibrillation ablation with a novel flexible tip radiofrequency catheter incorporating contact force sensing: acute results of the TactiFlex AF IDE trial
Authors: Nair D , Martinek M R , Colley J , Sundaram S , Hariharan R , Morales G , Sommer P , Healy S , Siddiqui U , Williams C , Sarver A , Lo M
Published: October 2022

Background

Catheter ablation is an established therapy for paroxysmal atrial fibrillation (PAF). The TactiFlex™ Ablation Catheter, Sensor-Enabled™ (TactiFlex SE) is a next-generation radiofrequency ablation catheter incorporating highly accurate fiber optics-based contact force sensing technology with a flexible, laser-cut tip.

Purpose

To demonstrate that ablation with TactiFlex SE is safe and effective for the treatment of drug refractory, symptomatic PAF.

Methods

The TactiFlex AF IDE is a prospective, non-randomized, multi-center clinical study which enrolled 355 subjects worldwide. Enrollment in the main study began on June 26, 2020 and completed on June 18, 2021. Subjects underwent de novo Pulmonary Vein Isolation (PVI) and, if indicated, a Cavotricuspid Isthmus ablation (CTI line) for CTI-dependent atrial flutter.

Results

Subjects were divided into two as treated subgroups: High Standard Power (HSP, n=189), defined as subjects with 100% of left atrial lesions ablated at ≥40 W, and Low Standard Power (LSP, n=119), defined as subjects with at least one left atrial lesion ablated at <40W. First pass success, defined as isolation of all pulmonary veins (PVs) confirmed after a minimum 20 min waiting period was achieved in 93.5% (175/186) and 84.5% (98/116) of HSP and LSP subjects, respectively (p=0.0104). Significant decreases in the HSP versus LSP procedures were also seen in total procedure time (112.0 min [89.0, 139.5] and 149.0 [115.0, 182.0], respectively [p<0.001]), total RF time for PV ablation (14.0 min [11.0, 19.0] and 29.0 [19.0, 41.0], respectively [p<0.0001]), total fluoroscopy time (4.0 min [0.0, 11.0] and 8.0 [3.0, 17.0], respectively [p<0.0001]) and irrigation fluid volume (378.0 mL [310.0, 466.0] and 636.0 [476.0, 829.0], respectively [p<0.0001]) (values given as Median [Q1, Q3]), see Figure 1. Both HSP and LSP subjects had a low rate of repeat procedures (1.6% [3/182] and 4.3% [5/115], respectively [p=0.2684]) and primary safety endpoint events (4.8% [9/189] and 4.2% [5/119], respectively [p=0.8182]) through 90 days post-index procedure.

Conclusion

The acute data on the TactiFlex SE catheter demonstrates safe and effective treatment of PAF using either a HSP or LSP ablation strategy. Ablation procedures performed using a HSP strategy were shorter and required less irrigation fluid and fluoroscopy. It is anticipated these results will be reflected in the 12-month safety and effectiveness primary endpoints.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott
Low voltage area as a predictor of recurrence after a single pulmonary vein isolation procedure: results of the WAVE-MAP AF study
Authors: Starek Z , Di Cori A , Betts T , Clerici G , Gras D , Lyan E , Della Bella P , Li J , Hack B , Zitella Verbick L , Sommer P
Published: October 2022

Background/Introduction

Pulmonary vein isolation (PVI) is a recommended approach for atrial fibrillation (AF) ablation procedures. Substrate modification beyond PVI has mixed results but identifying and ablating low voltage zones and ablating those targets in addition to PVI may be beneficial. Electroanatomic mapping is critical to identify subjects that may require further substrate modification. Low voltage area may be predictive of optimal treatment approach.

Purpose

This was a prospective, multicenter, interventional study of a high-density grid-style mapping catheter (HD Grid) to characterize left atrial low voltage substrate during sinus rhythm (SR) and AF and identify associations with 12 month recurrence rates after a single de novo radiofrequency (RF) ablation using a PVI only approach.

Methods

This study (NCT03882021) enrolled 300 subjects at 18 centers in Europe and Israel. Subjects underwent de novo RF ablation for paroxysmal AF (PAF) (N=113), early persistent AF (PsAF; AF sustained 7 days to 3 months) (N=86) or non-early PsAF (AF sustained >3 months to 12 months) (N=101). High density voltage maps were collected with HD Grid. Two pre-ablation maps, in SR and AF, were created for each subject (N=196) followed by PVI only ablation. Low voltage area (using cutoffs of 0.1 mV to 1.5 mV) was investigated in SR and AF. Follow up visits were at 3, 6 and 12 months post-ablation, with a 24-hour Holter monitor at 12 months. A Cox proportional hazards model was used to identify associations between mapping data and 12 month AF/atrial flutter (AFL)/atrial tachycardia (AT) recurrence after a single PVI procedure.

Results

At 12 months, 75.5% of subjects were free from AF/AFL/AT recurrence. On average, PsAF subjects had more low voltage area than PAF subjects in SR and AF. However, while univariate analysis found no correlation between recurrence and PAF or PsAF diagnosis (p=0.1261), those with recurrence had a significantly larger percent left atrial low voltage area under 0.5 mV with simultaneous orthogonal bipole wave configuration (HDW) in both AF (p=0.0011) and SR (p=0.0210) than those without recurrence. Using HDW, low voltage area (identified as <0.5 mV) greater than 28% of the left atrium in SR (HR: 4.82, 95% CI: 2.08–11.18, p=0.0003) and greater than 72% in AF (HR: 5.66, 95% CI: 2.34–13.69, p=0.0001) were associated with a higher risk of AF/AFL/AT recurrence at one year.

Conclusion(s)

Using a standard cutoff of 0.5 mV, a larger percent low voltage area was associated with increased risk of recurrence in both SR and AF. Future analyses will explore optimal low voltage cutoffs and thresholds predictive of recurrence that may necessitate additional substrate modification beyond PVI.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott
Safety of same day discharge after atrial fibrillation ablation
Authors: Ijaz H , Al-Sadawi M , Aslam F , Aleem S , Jacob R , Cao K , Santore L , Almasry I , Singh A , Fan R , Rashba E
Published: October 2022

Background

Atrial fibrillation (AF) ablation is an outpatient procedure with traditionally an overnight hospital observation (OHO). Recently, there has been a trend towards same day discharge (SDD).

Purpose

Compare AF ablation procedure safety outcomes with SDD vs. OHO.

Methods

We reviewed consecutive AF procedures performed from January 2013 to June 2021 at a single academic center. Patients underwent OHO until June 2020, after which patients had SDD whenever feasible. Adverse events were assessed at three months, which included pericardial effusion, pericarditis, post-procedure hypotension, embolic events, and vascular complications. We also assessed emergency department (ED) visits and procedure-related hospital admissions.

Results

There were 1254 patients who underwent 1575 AF ablations. 1440 patients underwent OHO and 135 had SDD. Mean age was 62.2 years, BMI 33 kg/m2, 65% were male, and 27.6% had persistent AF, without significant differences in baseline characteristics between OHO and SDD. We found that SDD was not associated with increased complications (OHO 0.20% v. SDD 0.49%; p>0.05), ED visits, or hospital admissions (2% v. 5%; p>0.05) (Figure 1, 2). There were no gender or age-related disparities in all outcomes (p>0.05).

Conclusion

SDD protocol after AF ablation is feasible and not associated with higher incidence of complications, ED visits, and procedure-related hospitalizations.

Funding Acknowledgement

Type of funding sources: None.
Effects of early recurrence and extra-PV triggers on long-term recurrence after catheter ablation for atrial fibrillation
Authors: Park Y , Yu H T , Kim T H , Uhm J S , Joung B , Lee M H , Pak H N
Published: October 2022

Background

Although early recurrence (ER) within 3 months after atrial fibrillation (AF) catheter ablation (AFCA) was recently reported to be a reliable predictor of late recurrence (LR), the mechanism is not clear.

Purpose

We explored the characteristics of patients with ER and compared the long-term late recurrence (LR) pattern depending on the existence of extra-pulmonary vein trigger (ExPV-trigger).

Methods

Among 3643 patients who underwent de novo AFCA, we included 1249 patients (59.2±11.0 years old, 31.3% persistent AF) who underwent isoproterenol provocation and regular follow-up over three years after AFCA. We evaluated the risk factors for ER and compared the patients with ER alone (10.1%), LR alone (16.6%), and ER+LR (15.9%), and the outcome of repeat procedure.

Results

Overall ER (ER alone and ER+LR) was independently associated with persistent AF (OR 1.58 [1.16–2.14], p=0.003), extra-PV triggers (OR 2.80 [1.90–4.13], p<0.001), and empirical extra-PV ablation (OR 1.54 [1.15–2.07], p=0.004). Overall LR (LR alone and ER+LR) risk was significantly higher in the ER with ExPV-trigger group than in ER without ExPV-trigger or no ER groups (Log-rank p<0.001). The rhythm outcome of the second procedure did not differ between ER+LR and LR alone groups (Log-rank p=0.160), but was worse in the ER+LR ExPV-trigger than in ER+LR without ExPV-trigger or LR alone groups (Log-rank p=0.005).

Conclusion

ER was independently associated with LR after de novo AFCA. ExPV-trigger played crucial roles in ER and LR after de novo AFCA and worse rhythm outcome after redo AFCA.

Funding Acknowledgement

Type of funding sources: None.
Effect of the epicardial fat volume on the outcomes after a left atrial posterior wall isolation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation
Authors: Kim D , Yu H T , Kwon O S , Kim T H , Uhm J S , Joung B , Lee M H , Pak H N
Published: October 2022

Background

While the effect of a circumferential pulmonary vein isolation (CPVI) alone is unsatisfactory, that of an additional electrical posterior wall box isolation (POBI) is controversial in persistent atrial fibrillation (PeAF) patients. Increased epicardial adipose tissue (EAT) is associated with higher recurrence rates after AF catheter ablation (AFCA).

Purpose

We investigated the possible effects of a POBI on rhythm outcomes with varying EAT volumes.

Methods

We included 1,187 patients with PeAF undergoing a de novo AFCA (79.6% male, median age 60 years) into two groups including those receiving a CPVI alone (n=687) and those an additional POBI (n=500). The rhythm outcomes at two years post-AFCA were compared in subgroups stratified by the total EAT volume using propensity overlap weighting.

Results

A reduced total EAT volume was linearly associated with more favorable rhythm outcomes for an additional POBI treatment than for a CPVI alone (P for interaction=0.002). Among the patients with smaller EAT volumes (≤116.23 ml, the median value, n=594), an additional POBI was associated with a reduced AF recurrence risk as compared to a CPVI only (weighted hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.56–0.99; weighted log-rank P=0.039). In contrast, among the remaining 593 patients with greater EAT volumes (>116.2 3mL), there was no difference in the AF recurrence risk between an additional POBI and CPVI alone (weighted HR 1.13, 95% CI 0.84–1.52; weighted log-rank P=0.410). Among 185 patients with a repeat ablation, the POBI reconnection rate tended to be higher in the large EAT group (75.0%) than small EAT group (55.4%, P=0.060).

Conclusion

While PeAF patients with a smaller EAT volume averted AF recurrence by an additional POBI after the CPVI, no benefit of the POBI was observed in those with a greater EAT volume. The EAT volume might identify AF patients likely to benefit from linear ablation in addition to the CPVI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Korean Ministry of Science, ICT & Future Planning (MSIP)Korean Ministry of Health and Welfare
Patient age, gender, and early outcome after PVI atrial ablation: analysis of a large regional database
Authors: Cooper J , Joseph C , Xiong T , Brar D , Kostov V , Kulstad E , Daniels J
Published: October 2022

Background

Demographics such as patient age and gender have been inconsistently found to be associated with outcome after ablation to achieve pulmonary vein isolation (PVI). A database created by the Dallas-Fort Worth Hospital Council (DFWHC) includes a collaboration of 90 member hospitals in North Texas reporting data on procedures, diagnoses, and discharges. All patients in this system can be followed longitudinally via unique identification number. The availability of this large, regional database offers opportunities to better characterize trends.

Objective

Characterize the association between age, gender, and 60-day outcome in patients receiving PVI over a 7-year time span.

Methods

Using the DFWHC database, all PVI procedures performed from January 2013 to December 2019 were identified. Follow up visits for this cohort of patients were then obtained, and outcomes recorded. Early mortalities (occurring less than 60 days from PVI), mean age and patient gender were determined for each of the groups and compared.

Results

A total of 11,880 unique PVI procedures were performed over this 7 year timeframe. Mean patient age was 64±10 years, with 66% male and 34% female. A total of 130 mortalities at any time after PVI occurred (1.1%), with 19 (0.16%) occurring within 60 days of the procedure. In multivariate analysis, the risk of 60-day mortality increased with year of procedure (OR 1.07, 95% CI 0.85 to 1.4) and female gender (OR 1.43, 95% CI 0.57 to 3.6), and decreased with age (OR 0.99, 95% CI 0.95 to 1.03); however no variable demonstrated statistically significant association with outcome.

Conclusions

Although trends towards increasing mortality over time and in female patients were seen, the total number of events remained low, and no statistically significant associations between age, gender, and early mortality were identified in this large regional database.

Funding Acknowledgement

Type of funding sources: None.
Variations in atrial fibrillation screening after ischemic stroke or transient ischemic attack in Sweden
Authors: Straat K , Wester P , Svennberg E , Anggardh Rooth E , Laska A C , Asberg S , Engdahl J
Published: October 2022

Background/Introduction

The risk of recurrent stroke and mortality is high among patients with ischemic stroke or transient ischemic attack (TIA) and untreated atrial fibrillation (AF). Hence, AF screening after an event has high priority in national and international guidelines. Despite the abundance of evidence on AF detection using different AF screening modalities, there is still no evidence on a prognostic benefit of ECG monitoring post ischemic stroke. There is a risk for variations in clinical practice for AF screening after ischemic cerebrovascular events due to this gap of evidence.

Purpose

The aim of this study was to investigate the clinical practice of AF screening after TIA or ischemic stroke at Swedish stroke units.

Methods

In collaboration with the stakeholders of the Swedish stroke register (Riksstroke) important fields to study were identified, e.g. AF screening method, first choice of method (multiple answers possible), monitoring duration, clinical follow-up etc. A draft for a digital survey was constructed and then tested and revised by 5 stroke consultants. The survey consisted of 18 multiple choice questions with free text comments and was sent by e-mail to the medical supervisors at all stroke units in Sweden in November 2021.

Results

All 72 stroke units in Sweden responded to the survey. Almost all (69/72) stroke units reported that ≥75% of ischemic stroke patients are screened for AF. Of the stroke units 81% had inpatient telemetry as their first choice of AF screening method (Figure 1), but 7% had no access to inpatient telemetry. In case of inpatient telemetry, 30% reported 0–24 hours and 54% reported 24–48 hours as their standard monitoring time. Most had the attending physician at the stroke unit as the primary ECG reader, some with access to support from cardiologist. Different standard monitoring durations for Holter were used (Figure 2) and 17% reported Holter as their first choice of AF screening method. Approximately 85% reported repeated ECG monitoring if high suspicion of cardiac embolization, preferably with repeated Holter (73%) or handheld ECG (49%). Implantable loop recorder (6%), event loop recorder (14%) and 2 weeks registration with ECG-patch (3%) was more infrequently used for this purpose.

Conclusions

Clinical practice for AF screening after ischemic stroke or TIA at Swedish stroke units showed considerable variations with a range of different AF screening methods and monitoring durations. Further, the standards and quality of inpatient ECG monitoring is unknown. There is an urgent need for evidence and evidence-based recommendations in this field, the present situation also implies inequality in care.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Stiftelsen Hjartat
Should we initiate oral anticoagulants for patients with atrial fibrillation staying well without oral anticoagulants for years?
Authors: Chao T , Lip G Y H , Chen S A
Published: October 2022

Background

Although non-vitamin K antagonist oral anticoagulants (NOACs) were more and more commonly prescribed for stroke prevention for patients with atrial fibrillation (AF), underuse of OACs is still not uncommon. Data about the initiations of OACs in AF patients who did not experience ischemic stroke without any OACs for years since incident AF was diagnosed were limited. We aimed to investigate the associations between the initiations of warfarin or NOACs and clinical outcomes among this population.

Methods

From January 1st, 2007 to December 31st, 2010, a total of 167,176 newly-diagnosed AF patients aged ≥20 years were identified from the Taiwan National Health Insurance Research Database as the study population. Among the study population, 32,917 patients with a CHA2DS2-VASc score >1 for males or >2 for females who did not receive warfarin or NOACs and survived for at least 90 days after June 1st, 2015 were defined as the “original non-OAC cohort”. These patients were then categorized into 3 groups according to the stroke prevention strategies they received after June 1st, 2015; that is, without OACs (n=31,195), warfarin (n=230) and NOACs (n=1,492).

Results

Compared to patients staying on non-OACs, the risk of ischemic stroke was lower for patients who initiated NOACs (aHR 0.867; p=0.043). The risk of all-cause mortality was lower for patients who started to receive warfarin (aHR 0.876; p=0.036) or NOACs (aHR 0.798; p=0.047). The composite risk of ischemic stroke or major bleeding was also lower for patients who initiated warfarin (0.849; p<0.001) or NOACs (0.789; p<0.001) (Figure 1). Compared to warfarin, NOACs use was associated with a lower risk of ischemic stroke (aHR 0.819; p<0.001), ischemic stroke or intracranial hemorrhage (aHR 0.927; p=0.042) or ischemic stroke or major bleeding (aHR 0.912; p<0.001).

Conclusions

Initiations of OACs, especially NOACs, should still be considered for AF patients who stayed well without OACs for years since incident AF was diagnosed.

Funding Acknowledgement

Type of funding sources: None.
Clinical phenotypes of older adults with non-valvular atrial fibrillation not treated with oral anticoagulants by hierarchical cluster analysis in the ANAFIE registry
Authors: Suzuki S , Yamashita T
Published: October 2022

Background and purpose

The All Nippon AF In the Elderly (ANAFIE) registry evaluated the current status of anticoagulant therapy in older adult patients (aged ≥75 years) with non-valvular atrial fibrillation (NVAF) in Japan. Although older adult NVAF patients requires anticoagulation therapy, some of them do not receive it and the reasons would be diverse. Therefore, we aimed to identify the phenotypes of older adult NVAF patients not treated with oral anticoagulants using data from the ANAFIE registry.

Methods

In this sub-analysis of the ANAFIE registry, the phenotypes of patients who were not receiving anticoagulants at baseline were evaluated by cluster analysis using Ward's linkage hierarchical algorithm. We used 20 categorical variables and 6 continuous variables for the cluster analysis which were used as the risk factors in the main analysis of the ANAFIE registry [1].

Results

Of 33,275 enrolled patients, 2445 (7.3%) were not receiving anticoagulants. Two clusters were identified: (1) elderly paroxysmal AF (PAF) patients with a low prevalence of comorbidities (58%) and (2) very elderly patients with a high previous major bleeding prevalence (42%). For each cluster, mean ages were 79.9 and 85.7 years, mean CHADS2 scores were 2.3 and 3.1, PAF prevalences were 83% and 54%, heart failure prevalences were 18% and 48%, the proportions of patients with a history of major bleeding were 0% and 25%, the proportions of patients with a history of catheter ablation were 21% and 8%, respectively. Annual incidence rates of each cluster were 2.62% and 9.08% for all-cause death, 1.72% and 5.83% for major adverse cardiovascular or neurological events, 1.22% and 3.14% for stroke or systemic embolism, and 0.53% and 1.43% for major bleeding.

Conclusions

In this cohort of elderly NVAF patients not receiving anticoagulants, more than half (∼60%) were PAF patients and had a low incidence of adverse outcomes. The remaining ∼40% were characterized as very elderly patients with a high prevalence of previous major bleeding and a high incidence of adverse outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Co., Ltd.
Oral anticoagulation therapy in atrial fibrillation patients with advanced chronic kidney disease: CODE-AF Registry
Authors: Park H , Yu H T , Kim T H , Park J , Park J K , Kang K W , Shim J , Kim J B , Choi E K , Park H W , Lee Y S , Joung B
Published: October 2022

Background and objectives

Advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD) on dialysis, increases thromboembolic risk among patients with atrial fibrillation (AF). This study examined the comparative safety and efficacy of direct-acting oral anticoagulant (DOAC) compared to warfarin or no OAC among AF patients with advanced CKD or ESRD on dialysis.

Methods

Using data from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, 260 non-valvular AF patients with advanced CKD (defined as estimated glomerular filtration rate [eGFR] <3 0ml/min per 1.73 m2) or ESRD on dialysis were enrolled from June 2016 to July 2020. The study population was categorized into DOAC, warfarin, and no OAC group, and differences in major or clinically relevant non-major (CRNM) bleeding, stroke/systemic embolism (SE), myocardial infarction/critical limb ischemia (CLI), and death were assessed.

Results

During a median 24 months of follow-up, major or CRNM bleeding risk was significantly reduced in the DOAC group compared to the warfarin group (hazard ratio [HR] 0.21, 95% confidence interval [CI] 0.05 to 0.95, p=0.042). In addition, the risk of composite adverse clinical outcome (major or CRNM bleeding, stroke/SE, myocardial infarction/CLI, and death) was significantly reduced in the DOAC group compared to the no OAC group (HR 0.32, 95% CI 0.11 to 0.96, p=0.043).

Conclusion

Among AF patients with advanced CKD or ESRD on dialysis, DOAC was associated with a lower risk of major or CRNM bleeding compared to warfarin and a lower risk of composite adverse clinical outcome compared to no OAC.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Korean Healthcare Technology R&D project funded by the Ministry of Health & Welfare (HI15C1200, HC19C0130)
Acute and long-term success of left atrial anterior line and mitral isthmus line ablation in patients after mitral valve surgery
Authors: Lemes C , Rottner L , Heeger C H , Maurer T , Reissmann B , Ouyang F , Mathew S , Metzner A , Schlueter M , Kuck K H
Published: October 2022

Background

Perimitral flutter and atrial fibrillation may occur in patients with prior surgical mitral valve (MV) repair or replacement and can be challenging for percutaneous catheter ablation.

Objective

This study sought to determine the feasibility, acute success and durability of catheter ablation of atrial fibrillation or atrial tachycardia by way of a mitral isthmus line (MIL) or an anterior line (AL).

Methods

A total of 81 patients (49 males, mean age 62±11 years) with prior MV replacement (n=30) or repair (n=51) underwent creation of a MIL (n=34) and/or an AL (n=72). Control group patients without prior surgery were matched 1:1 with the valve group (MIL, n=34; AL, n=72).

Results

Acute bidirectional block of the MIL was successfully achieved in 24/34 cases and of the AL in 64/72 patients with prior MV surgery. In the control group, acute bidirectional block was achieved in 31/34 MIL patients and 65/72 AL patients. In terms of durability, the MIL valve subgroup showed the poorest results (probability of long-term failure 2.224, as opposed to 0.605 in the MIL control subgroup; hazard ratio [HR]=0.27, 95% confidence interval [CI], 0.11–0.65; p=0.004). In the AL subgroups, long-term outcomes were similar (probability of failure in AL valve subgroup 0.844 vs. AL control subgroup 1.03; HR=1.22, 95% CI, 0.66–2.26; p=0.523).

Conclusions

Percutaneous creation of MIL and AL is feasible and safe in patients with prior MV replacement/repair. Because of poor long-term outcomes, MIL creation appears not advisable in patient with prior MV surgery.

Funding Acknowledgement

Type of funding sources: None.
Type 2 diabetes is associated with higher risk of 3rd degree atrioventricular block: a Danish nationwide registry study
Authors: Haxha S , Halili A , Malmborg M , Pedersen-Bjergaard U , Philbert B T , Lindhardt T B , Hoejberg S , Schjerning A M , Ruwald M H , Gislason G H , Torp-Pedersen C , Bang C N
Published: October 2022

Background

Type 2 diabetes (T2DM) is suggested to affect the function of the cardiomyocytes and electrical pathways which could cause conduction abnormalities and cardiac arrhythmias, such as 3rd degree atrioventricular block. The association of T2DM and 3rd degree atrioventricular block has never been confirmed in large nationwide studies.

Purpose

To determine the association between T2DM and 3rd degree atrioventricular block.

Method

This nationwide nested case-control study design included patients older than 18 years, diagnosed with 3rd degree atrioventricular block between 1st of July 1995 and 31st of December 2018. Five controls from the risk set of each case of 3rd degree atrioventricular block were matched on age and sex to fit a Cox regression model with time-dependent exposure (T2DM) and time-dependent covariates and baseline hazard function stratified for age and sex. Subgroup analysis was conducted with Cox models for each subgroup.

Results

We identified 31.177 cases with 3rd degree atrioventricular block that were matched with 155.885 controls. The mean age was 78 years and 60% were males. Cases had higher prevalence of T2DM (20% vs 7.8%), hypertension (70% vs 43%) myocardial infarction (16% vs 6.6%), and heart failure (21% vs 5.9%) compared to the control group. In a Cox analysis T2DM was significantly associated with a higher rate of 3rd degree atrioventricular block [HR 2.61 (95% CI: 2.54–2.71)]. The association remained in several subgroup analyses of diseases suspected to be associated with 3rd degree atrioventricular block. There was a significant interaction with sex and age groups and comorbidities of interest including hypertension, atrial fibrillation, heart failure and myocardial infarction (Figure 1).

Conclusion

T2DM is associated with a higher rate of 3rd degree atrioventricular block. The findings were consistent across subgroups.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was funded by the independent research foundation Skibsreder Per Henrik, R. og Hustrus Fond
Etiologies and predictors for cardiac implantable electronic device implantation in young patients hospitalized for complete atrioventricular block
Authors: Margolis G , Elbaz Greener G , Kazatzker M , Meisel S , Kleiner Shochat M , Heist E K , Ruskin J , Amir O , Roguin A , Rozen G
Published: October 2022

Introduction

Information regarding the etiologies of complete atrioventricular block (CAVB) in young patients is scarce. We aimed to investigate the potential causes for non-iatrogenic CAVB in young patients, as well as to identify possible predictors for need of implantable cardioverter-defibrillator (ICD) or permanent pacemaker (PPM) implantation in young patients presenting with CAVB.

Methods

Using the National Inpatient Sample (NIS) database, we identified patients aged 18–60 hospitalized with CAVB in the US between 2015 (last quarter)-2019. Patients who had concurrent cardiac surgery or electrophysiological procedures were excluded. Baseline demographics, clinical characteristics, potential etiologies for CAVB as well as outcomes including the need for temporary cardiac pacing (TCP), ICD and PPM implantation were analyzed. Multivariable logistic regression models were used to identify predictors of ICD or PPM implantation in patients with unknown etiology.

Results and discussion

An estimated total of 56,385 patients aged 18–60 with CAVB and no concurrent surgical or EP interventions were identified. The mean (±SD) age was 49 (±10) years and 59% were males. Approximately 55% of patients had no identified cause for CAVB (Table 1). While 16% of patients received TCP, 32% and 6% of patients were eventually implanted with a PPM and ICD, respectively (Figure 1), In patients with CAVB of unknown etiology, advanced age and need for TCP emerged in multivariable analyses as independent predictors of the need for both PPM and ICD implantation. Female gender was identified as a predictor for PPM implantation but was associated with a lower chance of ICD implantation.

Conclusion

The majority of non-iatrogenic young CAVB patients had no identified etiology in a nationwide database and less than 40% of the patients received an implantable cardiac device. Better risk stratification and diagnostic algorithms are needed for this population of patients.

Funding Acknowledgement

Type of funding sources: None.
Cardioneuroablation focused on the atrioventricular node: a comparison of right and left atrial approach
Authors: Wichterle D , Jansova H , Stiavnicky P , Peichl P , Stojadinovic P , Haskova J , Cihak R , Kautzner J
Published: October 2022

Background

Radiofrequency catheter ablation of posteromedial left ganglionated plexus is a critical step to eliminate the vagal input to the atrioventricular node (AVN) for the treatment of symptomatic episodes of functional AV block. This ganglionated plexus can be effectively targeted from the coronary sinus (CS) or from the endocardial aspect of the right (RA) and left (LA) atria.

Purpose

We investigated the effect of ablation at individual sites on the suppression of parasympathetic modulation of AVN.

Methods

The study included 20 patients (age: 42±13 years, 45% males) who underwent cardioneuroablation in general anesthesia. Posteromedial left ganglionated plexus was ablated from [1] the CS (proximal 2-cm segment), [2] the RA aspect (between the fossa ovalis and inferior vena cava), and [3] the LA aspect (middle bottom part adjacent to inferior rim of fossa ovalis). Patients were randomly (1:1) assigned to CS-to-RA or RA-to-CS ablation order. LA ablation was always the last step. The response to extracardiac vagus nerve stimulation (ECVS; 50 Hz, 0.05 ms, 1 V/kg [<70V], 5 s) while atrial pacing (100 bpm) was recorded at baseline and after each ablation step. The number of non-AV-conducted beats during the ECVS was considered a measure of AV nodal denervation. Both right and left vagus nerves were sequentially stimulated and the stronger response of the AV node was taken into account.

Results

Temporal development of outcome measure with the progression of ablation is shown in Figure 1. CS ablation resulted in much stronger AV nodal denervation compared to RA ablation (P=0.02). However, RA ablation still provided some effect on top of CS ablation. The combination of CS + RA ablation resulted in complete AVN denervation in 8 (40%) patients. Subsequent LA ablation increased the number of denervated patients to 14 (70%). Two more patients were subsequently denervated by ablation elsewhere. In four patients, AVN denervation was not achieved but their responsiveness to ECVS was significantly suppressed compared to the baseline.

Conclusions

All ablation clusters targeting posteromedial ganglionated plexus convey complementary effects. Biatrial cardioneuroablation seems essential for efficacious suppression of parasympathetic modulation of AVN.

Funding Acknowledgement

Type of funding sources: None.
Diagnostic value of electroanatomical mapping in patients with suspected arrhythmogenic cardiomyopathy
Authors: Berg J , Villatore A , Sivilotti F , Pili G , Sala S , Della Bella P , Peretto G
Published: October 2022

Background

Case series suggested that low voltage areas (LVA) on invasive electroanatomical mapping (EAM) could identify arrhythmogenic cardiomyopathy (ACM) at an earlier stage as compared to late gadolinium enhancement (LGE) and fatty infiltration on cardiac magnetic resonance (CMR). Data comparing LVA with structural abnormalities on CMR are lacking.

Purpose

To report the prevalence of substrate abnormalities identified by EAM vs. CMR in a cohort of patients with suspected ACM.

Methods

We retrospectively identified 66 consecutive patients with suspected ACM, who underwent EAM following clinical onset with ventricular arrhythmias. The cutoff value for EAM-defined LVA was <0.5 mV bipolar, <8 mV unipolar. Data from a prior CMR, performed no more than 12 months before, were used for comparison.

Results

The study cohort (mean age 47 years, range 21–76; 83% males; mean left ventricular ejection fraction 53%, range 28–70%) was composed of patients with suspected ACM involving either the right (n=62) or the left ventricle (n=4) following presentation with sustained monomorphic ventricular tachycardia. EAM was obtained by isolated endocardial, epicardial, or combined approach, respectively, in 11 (17%), 15 (23%) and 40 (61%) patients. Overall, 61 patients (92%) had documented LVA, of whom 89% showed an epicardial localization. In the same population, CMR identified a lower prevalence of substrate abnormalities (LGE 65%; fatty infiltration 50%). In particular, there were 27 patients (41%) with EAM-defined LVA and absent substrate abnormalities on CMR. Based on the 2010 Task Force Criteria and the 2021 Padua Criteria, a definite diagnosis of ACM was missing for a total of 19 patients (29%): due to the uniform identification of LVA in the absence of CMR abnormalities, EAM helped to establish the most likely diagnosis of ACM in all of them (19/19).

Conclusions

Our data suggest that EAM is capable of identifying substrate abnormalities in a consistent proportion of patients with suspected ACM and absent abnormalities on CMR. In this setting, the implementation of LVA to the current diagnostic criteria could improve the diagnostic yield for ACM.

Funding Acknowledgement

Type of funding sources: None.
Prognosis of hypertrophic cardiomyopathy in Japanese patients with an implantable cardioverter defibrillator -focus on apical hypertrophic cardiomyopathy
Authors: Nakano M , Kondo Y , Nakano M , Kajiyama T , Ito R , Kitagawa M , Sugawara M , Chiba T , Ryuzaki S , Yoshino Y , Kobayashi Y
Published: October 2022

Background

Patients with hypertrophic cardiomyopathy (HCM) are at high risk of lethal arrhythmias, and implantable cardioverter defibrillators (ICD) are widely used for prevention of sudden cardiac death (SCD). Apical HCM is a phenotype variant of HCM, with hypertrophy predominantly affecting apex, that was initially described 30 years ago. Apical HCM patients may have different clinical prognosis compared with other subsets of HCM. In previous studies, apical HCM patients seem to have a more benign prognosis than other types of HCM. However, little is known about the long-term outcomes of apical HCM patients and there are many unclear points. Moreover, there are few reports about the clinical prognosis in apical HCM patients with an ICD.

Objective

The aim of this study is to identify the difference between the prognosis of apical and the other types of HCM patients with an ICD.

Methods

We retrospectively analyzed the database of our ICD clinic. All subjects underwent ICD implantation between October 2006 and September 2018. We classified HCM patients into LV outflow tract obstruction (LVOTO) and midventricular obstruction (MVO), apical HCM and other non-obstructive types. We divided all the patients into apical and other types of HCM, and examined their background, incidence of appropriate ICD therapies, hospitalization for heart failure, electrical storm and death.

Results

A total of consecutive 64 Japanese HCM patients with an ICD (follow-up period, 86±24 months; age, 65±14 years; male sex, 83%; left ventricular ejection fraction, 56±14%; LV max wall-thickness, 19±7mm; LV apical aneurysm, 9.4%; 5-year risk of SCD, 4.4±2.1) were enrolled in this study. We classified them into 14 apical HCM and 50 other types of HCM patients. The clinical characteristics and major clinical events of these patients are shown in the Table 1. During the follow-up periods, there were no significant differences in the incidence of electrical storm, hospitalization for heart failure and death between the 2 groups (p=0.11; p=0.60; p=0.39). Appropriate ICD therapies occurred in 6 of 14 (43%) patients with apical HCM and 5 of 50 (10%) patients with other types of HCM (p=0.010). The risk factors of patients with apical HCM patients are shown in Table 2.

Conclusions

Appropriate ICD therapy was more prevalent in patients with apical HCM, compared to patients with other types of HCM. Aggressive intervention such as catheter ablation for ventricular tachycardia and ventricular fibrillation may be considered in patients with apical HCM and higher score of 5-year risk of SCD. Further studies are needed to clarify the manifestations and long-term outcome of apical HCM patients.

Funding Acknowledgement

Type of funding sources: None.