bluuebunny/crossref_metadata_2025 huggingface dataset:
All-cause mortality and cardiac resynchronization therapy with or without defibrillation in primary prevention
Authors: Bisson A
Published: November 2020

Aims

Cardiac resynchronization therapy with (CRTD) or without (CRTP) defibrillator is recommended in selected patient with systolic chronic heart failure and wide QRS. There is no guideline firmly indicating choice between CRTP and CRTD in primary prevention, particularly in older patients.

Methods

Based on the French administrative hospital-discharge database, information was collected from 2010 to 2017 for all patients implanted with CRTP or CRTD in primary prevention. Outcomes analyses were undertaken in the total study population and in propensity-matched samples.

Results

A total of 45,697 patients were analyzed (19,266 with CRTP and 26,431 with CRTD). The nationwide numbers of implantations increased between 2010 and 2017 (+29.6% for CRTD, +28.8% for CRTP). Proportion of CRTP implantation over CRTD remained similar over these years. During follow up (913 days, SD 841, median 701, IQR 151–1493), incidence rate (%patient/year) of all-cause mortality was higher in CRTP (11.6%) than in CRTD patients (6.8%) (Hazard Ratio [HR] 1.70, 95% CI 1.63–1.76, p<0.001). After propensity-matched analyses, mortality of patients over 75 years-old with non-ischemic cardiomyopathy (NICM) was not different with CRTP and CRTD (HR 0.93, 95% CI 0.80–1.09, p=0.39). CRTP patients under 75 yo with NICM had a higher mortality than CRTD patients (HR 1.22, 95% CI 1.08–1.37, p=0.01). Mortality rate was also higher with CRTP than with CRTD irrespectively of age in patients with ischemic cardiomyopathy (ICM) (<75 yo: HR 1.13, 95% CI 1.04–1.33, p<0.01; ≥75 yo: HR 1.22, 95% CI 1.08–1.37, p=0.01).

Conclusion

This real-life study gives up-to-date information about unselected patients implanted with CRTP and CRTD in primary prevention, and provides additional data which may help physicians choosing between CRTP and CRTD at the time of implantation. Benefit of CRTD seemed clear for all-cause mortality in patients with ICM and in patients with NICM under 75 yo. Patients over 75 yo with NICM seemed less likely to benefit from primary prevention CRTD implantation.

Event free curves for mortality outcomes

Funding Acknowledgement

Type of funding source: None
Utility of novel Omnipolar activation mapping for the detection of ventricular premature contraction origin
Authors: Maeda S , Kawabata M , Yonai R , Tsuda Y , Kawashima T , Atarashi H , Hirao K
Published: November 2020

Background

Bipolar electrograms are significantly influenced by direction of the propagating wavefront in relation to the recording bipole. Omnipolar voltage mapping may be superior to standard bipolar mapping since it obtains maximum voltage of all possible bipolar electrode orientations without the need for catheter rotation. Therefore, omnipolar maps can provide voltage maps with larger voltages as well as better defined boundaries.

Purpose

Whether omnipolar activation maps also describe better activation maps versus traditional bipolar maps during ventricular premature contraction (VPC) catheter ablation is unclear.

Methods

A high-density mapping catheter was advanced to the ventricular outflow tract and a high-resolution activation map was created. Each electrode along and across the splines of the catheter are 4mm apart. Bipoles were calculated along (MAP 2), across (MAP 3) and bidirectional (MAP 4) the splines while omnipoles (MAP 1) were derived from a right triangle clique. Within a square area, four omnipolar and two bipolar values along, across and bidirectional values were defined.

Results

Though the earliest activation site was vague by along and across maps (arrow), white color became evident by bidirectional map, and the VPC origin became distinct with omnipolar mapping. RF lesions were given via an open-irrigated ablation catheter targeting a lesion size index 5.0. The VPC was eliminated by radiofrequency ablation.

Conclusion

Omnipolar activation mapping may be more accurate than traditional bipolar mapping during ventricular premature contraction (VPC) catheter ablation.

Figure 1

Funding Acknowledgement

Type of funding source: None
Novel occlusion tool software for pulmonary vein occlusion verification in atrial fibrillation cryoballoon ablation
Authors: Solimene F , Cauti F.M , Stabile G , Rossi P , Schillaci V , Polselli M , Arestia A , Iaia L , Shopova G , Bianchi S
Published: November 2020

Background

Optimal pulmonary vein (PV) occlusion, checked with selective contrast injection, is mandatory to obtain an effective PV isolation with a cryoballoon.

Purpose

The purpose of this study was to verify the feasibility of a new dielectric sensing system in assessing PV occlusion during cryoballoon ablation in patients with atrial fibrillation (AF).

Methods

We enrolled 25 consecutive patients with paroxysmal or persistent AF. After transseptal access a detailed image reconstruction of left atrium and PVs was achieved with a decapolar circular mapping catheter and a novel dielectric imaging system. The degree of PV occlusion with the inflated cryoballoon catheter was verified by a new occlusion tool software of the dielectric imaging system and compared to the angiography with dye injection in each PV.

Results

A total of 114 PV cryoballoon occlusion were tested. The new occlusion tool software showed a 91.7% sensitivity and 81.5% specificity in assessing a complete PV occlusion verified with dye injection. The positive predictive value was 84.6% and the negative predictive value was 89.8%. Acute isolation was achieved in all PVs. No 30 days complications were observed.

Conclusion

This is the first study that demonstrates the feasibility of a new occlusion tool software, using the novel dielectric imaging system, in verifying the degree of PV occlusion during cryoballoon ablation.

Funding Acknowledgement

Type of funding source: None
Quality of life measured in first-line therapy during the Cryo-FIRST study: a comparison between cryoballoon catheter ablation versus antiarrhythmic drug therapy
Authors: Chierchia G.B , Pavlovic N , Velagic V , Hermida J.S , Healy S , Arena G , Badenco N , Meyer C , Chen J , Iacopino S , Anselme F , Kuniss M
Published: November 2020

Background

By consensus statements, catheter ablation is a recommended treatment for patients with symptomatic drug-refractory paroxysmal atrial fibrillation (AF), as patients try to alleviate the burdensome AF symptoms that reduce the Quality of Life (QoL). Yet, first-line treatment of symptomatic patients via catheter ablation prior to initiation of antiarrhythmic drugs (AADs) is only a reasonable alternative (Class IIa). Clearly, more clinical data is necessary that compares catheter ablation to AAD therapy in treatment naïve patients.

Purpose

The Cryo-FIRST trial was designed to compare AAD treatment against pulmonary vein isolation (PVI) while using a cryoballoon catheter (Arctic Front Advance; Medtronic, Inc.). This current data analysis examines the QoL endpoints when comparing AADs to cryoballoon ablation in patients with symptomatic treatment naïve paroxysmal AF.

Methods

This randomized multicenter trial enrolled 220 patients from 18 sites in 9 countries (Europe, Australia, and Latin America) in a prospective open-blinded endpoint study design. Patients had not been administered a class I or III AAD for longer than 48 hours for inclusion into the study. Subjects were randomized (1:1) into a cohort that was administered AAD therapy or a cohort that received PVI via cryoablation. The prespecified QoL endpoint at 12 months was measured using the Atrial Fibrillation Effect on Quality of Life (AFEQT) scores, and QoL recordings were taken at baseline, 1, 3, 6, 9, and 12 months following the index treatment.

Results

Of the 218 patients randomized (age 52±13 years, 68% male) 86% completed the 12-month follow-up. Crossovers occurred in 9% of subjects (N=20), including: 1 subject in the cryoablation arm and 19 subjects in the AAD arm. At 12 months, 86.5% of the patients in the cryoablation arm and 70.4% of the patients in the AAD arm where without symptoms (EHRA score 1). The mean AFEQT summary score was more favorable in the catheter ablation group compared to the drug therapy group at 12 months (88.9 vs. 78.1 points, respectively). The adjusted difference was 9.9 points (95% CI: 5.5–14.2; P<0.0001).

Conclusions

Cryoballoon ablation resulted in a significant improvement in QoL at 12 months compared to AAD therapy in treatment naïve patients with first-line symptomatic paroxysmal AF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic International Trading Sàrl
Prognostic role of left ventricular late gadolinium enhancement (LV-LGE) in patients who received implantable cardioverter defibrillator (ICD) for secondary prevention
Authors: Mattesi G , Baldi E , Guerra F , Toniolo M , Cipriani A , Cauti F , Marcantoni L , Manfrin M , Lanzillo C , Savastano S , Zorzi A
Published: November 2020

Introduction

LV myocardial fibrosis detected as LGE on cardiac magnetic resonance (CMR) is a predictor of arrhythmic risk in primary prevention both in ischaemic and non-ischaemic cardiomyopathy. However, we still do not know the prognostic role of LV-LGE in patients who suffered cardiac arrest (CA).

Purpose

To evaluate the prognostic role of CMR, and in particular of LV-LGE suggesting myocardial scar, in predicting appropriate ICD interventions in secondary prevention patients.

Methods

Ninety-seven consecutive patients 1) aged ≥14 years 2) hospitalized for CA because of ventricular arrhythmias from 2009/01/01 3) who underwent/undergoing a CMR within one month from the event 4) who received/receiving an ICD for secondary prevention and 5) with at least 1 year-follow-up, were enrolled for this multicentric study.

Results

97 patients (68 males, 70%), mean age 46±16 years, were enrolled. Seventy-six percent of patients received bystander cardiopulmonary resuscitation (CPR) and ventricular fibrillation (VF) was the first rhythm in 86% of cases. ST elevation was present in 18% of cases at the admission; however, angiography was found negative in 80% of patients. Myocardial oedema and LGE were identified in 26% and 64% of patients respectively. A diagnosis was made in 83.5% of cases, while in the remaining 16.5% CA was considered idiopathic. During a four-year-follow-up, 25% of patients had appropriate ICD therapy (10% of which ATP only). A significant correlation between LGE and appropriate ICD intervention was not found (p=0.89).

Conclusions

One fourth of patients who received ICD for secondary prevention had appropriate ICD therapy during a four-year-follow-up. In this setting, LV-LGE does not provide a prognostic value.

Funding Acknowledgement

Type of funding source: None
Are body mass index and age independent risk factors for new-onset atrial fibrillation after cardiac surgery regardless of left atrial size and left ventricular ejection fraction value?
Authors: Stefano P , Bugetti M , Michelucci A , Del Monaco G , Popescu G , Pieragnoli P , Ricciardi G , Perrotta L , Checchi L , Rondine R , Bevilacqua S , Marchionni N
Published: November 2020

Background

Obesity, advanced age and left atrium dimensions have been linked to atrial fibrillation (AF).

Purpose

This study aimed at evidencing if the above mentioned risk factors have a role among the others in conditioning the onset of post operative AF (PoAF) in patients undergoing cardiac surgery without previous AF.

Methods

This study evaluated 249 consecutive patients undergoing coronary artery by-pass surgery either isolated or in combination with aortic or mitral valve repair/replacement, or isolated valve repair/replacement. Prior to surgery, in all patients the following data were collected: age (yrs), body mass index (BMI, kg/m2), left atrium (LA) diameter (cm), LA area (cm2), left ventricular ejection fraction (LVEF, %), the presence/absence of arterial hypertension (AH) and diabetes, creatinine (mg/dL). To detect the presence of PoAF, cardiac rhythm was continouosly recorded during the first seven postoperative days.

Results

PoAF occurred in 127 patients (51%). We compared patients with and without PoAF. Mean values (±1 SD) of continuous variables and the frequency of dicothomic ones are reported in the table. No difference was observed for sex, LA diameter, LA area, LVEF and diabetes. Instead, patients with PoAF had higher values of age, BMI, creatinine and a greater prevalence of AH. According to multivariable binary logistic analysis the independent predictors of PoAF were: age (OR = 1.05, CI 95%: 1.026–1.074, p=0.018) and BMI (OR = 1.09, CI 95%: 1.015–1.171, p=0.0001).

Conclusions

Results suggest that advanced age and a higher value of BMI could be strong risk factors for PoAF in patients who undergo cardiac surgery without previous AF. This considering that in the present population the values of LA diameter, LA area and LVEF showed no statistically significant difference between patients with and without PoAF.

Funding Acknowledgement

Type of funding source: None
Chinese spirits consumption is an independent risk factor of left atrial appendage thrombosis in non-valvular atrial fibrillation patients
Authors: Yang L , Tian Y
Published: November 2020

Background

Alcohol consumption is often associated with an increased risk of atrial fibrillation; however, its association with left atrial appendage (LAA) thrombosis in patients with non-valvular atrial fibrillation (NVAF) remains undefined.

Purpose

To investigate the relationship between Chinese spirits consumption and LAA thrombosis in NVAF patients.

Methods

504 consecutive adult patients with NVAF undergoing first radiofrequency catheter ablation who were enrolled retrospectively from January 2016 to April 2019. LAA thrombosis was identified by transesophageal echocardiography before catheter ablation. Risk factors for LAA thrombosis were determined by uni-/multivariate analysis of data derived from a questionnaire on alcohol consumption and other risk factors for AF, and biochemical and imaging information.

Results

Of the 504 patients studied, 86 (17.1%) had a drinking habit, and 59 patients (11.7%) had LAA thrombosis. The proportion of alcohol drinking patients was 47.5% (28/59) in the thrombosis group and 12.7% (58/455) in the non-thrombosis group (P<0.001). In multivariate analysis, Chinese spirits consumption (≥12g daily; OR 15.025, 95% CI 6.123–36.815, P<0.001), non-paroxysmal AF (OR 8.301, 95% CI 3.946–17.460, P<0.001), AF duration (OR 1.019, 95% CI 1.010–1.027, P<0.001), CHA2DS2-VASc score (OR 2.078, 95% CI 1.625–2.658, P<0.001), and effective anticoagulation (OR 0.348, 95% CI 0.132–0.921, P=0.033) were independently associated with LAA thrombosis.

Conclusions

Chinese spirits consumption was independently associated with LAA thrombosis in NVAF patients. Whether avoiding alcohol consumption might reduce the occurrence of LAA thrombosis and thromboembolism in NVAF patients requires further study.

Funding Acknowledgement

Type of funding source: None
Association between natriuretic peptides and left atrial structural and functional properties in atrial fibrillation following catheter ablation
Authors: Olsen F.J , Darkner S , Gotze J.P , Chen X , Henningsen K , Pehrson S , Gislason G , Svendsen J.H , Biering-Sorensen T
Published: November 2020

Background

Atrial natriuretic peptides (ANP) and brain natriuretic peptides (BNP) are acutely released from the atrial myocytes upon increased mechanical distension of the atria. The relationship between imaging measures of left atrial (LA) structure and function and natriuretic peptides following catheter ablation (CA) have not been clearly delineated.

Purpose

To characterize the relationship between LA structure and function and natriuretic peptides.

Methods

We performed an echocardiographic substudy of a randomized trial of AF patients scheduled for CA. Echocardiographic measurements included: LA volume at end-systole (LAVi), at end-diastole (LAEDVi), emptying fraction (LAEF), LA reservoir strain (LAs), and global longitudinal strain (GLS). Patients were stratified by tertiles of mid-regional proANP (MR-proANP) concentrations in circulation (<92 pmol/l, 92–146 pmol/l, >146 pmol/l), and NT-proBNP (<10pmol/l, 10–38 pmol/l, >38 pmol/l). Linear regressions were performed to compare baseline echocardiographic measures to natriuretic peptide concentrations at baseline, 1 month, 3 months and 6 months of follow-up. MR-proANP and NT-proBNP were logarithm transformed in these analyses. Multivariable adjustments were made for: age, gender, AF subtype, AF burden, rhythm during echocardiogram, rhythm at study visit for blood sampling, time known with AF, beta-blocker use, and CHA-2DS2-VASc score.

Results

We included 101 patients with AF. The mean age was 58 years, 82% were men, 46% had persistent AF. Increasing tertiles of MR-proANP at baseline were associated with abnormal LA size and function (3rd vs 1st tertile: LAVi: 42mL/m2 vs 32mL/m2; LAEDVi: 31mL/m2 vs 20mL/m2; LAEF: 38% vs 26%; LAs: 27% vs 19%; GLS: −18% vs −14%) whereas both LA and left ventricular measures were associated with increasing NT-proBNP concentrations at baseline. After multivariable adjustments, only LA volumes and LAEF remained significantly associated with MR-proANP, whereas only LA volumes and GLS remained significantly associated with NT-proBNP. At follow-up, impaired LA function associated with persistently elevated concentrations, which was not the case for LAVi (figure).

Conclusion

MR-proANP reflects LA dysfunction better than NT-proBNP. Measures of LA function rather than LAVi associates with persistently elevated natriuretic peptide concentrationsw, which may indicate that functional measures are more closely associated with evidence of LA myocardial stretch than LAVi.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Danish Heart Foundation
Association of biomarkers of inflammation with hospitalization for heart failure and death in patients with atrial fibrillation
Authors: Benz A.P , Aeschbacher S , Krisai P , Blum S , Meyre P , Blum M.R , Rodondi N , Di Valentino M , Kobza R , De Perna M.L , Bonati L.H , Beer J.H , Kuehne M , Osswald S , Conen D
Published: November 2020

Background

Hospitalization for heart failure and death are among the most common adverse clinical outcomes in patients with atrial fibrillation (AF). The underlying mechanisms are poorly understood.

Purpose

We hypothesised that inflammation, quantified by plasma levels of C-reactive protein (CRP) and interleukin 6 (IL-6), is independently associated with hospitalization for heart failure and death in a large, contemporary cohort of AF patients.

Methods

Patients with established AF and 65 years of age or older were enrolled in two large, prospective, multicentre cohort studies in Switzerland. Plasma levels of high-sensitivity (hs) CRP and IL-6 were measured from frozen EDTA plasma samples obtained at baseline. Using these two biomarkers, we calculated an inflammation score ranging from 0 to 4 (1 point for each biomarker between the 50th and 75th percentile, 2 points for each biomarker above the 75th percentile). We constructed multivariable Cox proportional hazards models to quantify the associations of hs-CRP, IL-6 and the inflammation score with time to first hospitalization for heart failure and time to all-cause mortality, respectively.

Results

A total of 3,784 patients with AF (median age 72 years, 28% women, 24% with a prior history of heart failure and 84% anticoagulation use at baseline) were followed for a median (interquartile range [IQR]) of 4.0 (2.9–5.1) years. The median (IQR) plasma levels of hs-CRP and IL-6 at baseline were 1.64 (0.81–3.69) mg/L and 3.42 (2.14–5.60) pg/mL, respectively. The incidence rates of hospitalization for heart failure and death were 3.04 and 2.80 per 100 person-years, respectively. After multivariable adjustment, both biomarkers were significantly associated with the risk of hospitalization for heart failure (per increase in 1 standard deviation [SD], adjusted hazard ratio [aHR] 1.22, 95% confidence interval [CI] 1.11–1.34 for log-transformed hs-CRP, and aHR 1.48, 95% CI 1.35–1.62 for log-transformed IL-6) and death (per increase in 1 SD, aHR 1.40, 95% CI 1.27–1.54 for log-transformed hs-CRP, and aHR 1.67, 95% CI 1.53–1.81 for log-transformed IL-6). Incidence rates of hospitalization for heart failure increased from 1.34 to 7.31 per 100 person-years across categories of the inflammation score (Figure 1). A strong relationship persisted after multivariable adjustment. Similar findings were observed for all-cause mortality.

Conclusions

Inflammation is a strong predictor of hospitalization for heart failure and death in patients with AF. Targeting inflammation may be a promising treatment strategy to improve outcomes in these patients at high risk for adverse outcomes.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation
Gender differences in patterns of relationship between body mass index and AF incidence
Authors: Senoo K , Nakata M , Teramukai S , Yamamoto T , Nishimura H , Matoba S
Published: November 2020

Background

Obesity is reportedly associated with the new incidence of atrial fibrillation (AF). However, gender differences in patterns of relationship between body mass index (BMI) and the risk of AF are unknown.

Methods

We analyzed 21,382 middle-aged Japanese subjects (10923 men, 10459 women) without AF from a cohort of employees undergoing annual health examinations, with a follow-up period of 4.8±3.7 years. We examined the relationship between BMI at baseline to AF incidence in unadjusted and adjusted analyses. This relationship was also studied using linear and quadratic models.

Results

AF had developed in 137 subjects (119 men; mean age, 54.4±8.2 years; incidence, 2.19 and 0.38 per 1000 person-years in men and women, respectively). In multivariable Cox proportional-hazard models, increasing age (hazard ratio [HR], 2.72 per year; 95% CI, 2.22 to 3.33; P<0.001), male gender (HR, 3.28; 95% CI, 1.86 to 5.76; P<0.001) and BMI (HR, 1.08; 95% CI, 1.02 to 1.15; P=0.007) were associated with the new incidence of AF in all cohorts. The shape of the BMI-incident AF relationship showed a linear association in women and a J-shaped association in men. (Figure) In particular, a U-shaped relationship was observed in young men aged 40–49, with increased risk among those with higher BMI and with very low BMI. In analyses adjusted for comorbidities and risk factors for CV disease, the U-shaped AF incidence versus BMI curves were not attenuated, suggesting that other genetic or congenital factors may mediate this relationship.

Conclusion

Our results indicate that the shape of the BMI-incident AF relation differs by sex and in particular a U-shaped relationship was observed in young men.

Patterns of relation among BMI and AF

Funding Acknowledgement

Type of funding source: None
Incidence of atrial fibrillation in an opportunistic screening campaign in a general practitioner setting: a prospective population study
Authors: Denas G , Battaggia A , Fusello M , Novelletto B.F , Cancian M , Pengo V
Published: November 2020

Introduction

The detection of atrial fibrillation (AF) largely depends on the method used, thus the reported true rate of incident AF is controversial. The detection of symptomatic AF is straight forward in most cases, while it is unclear which strategies provide the best results for the detection of silent AF. Traditional methods like pulse palpation have a low accuracy and pulse guided ECG confirmation is not deemed cost-effective.

Purpose

The aim of the study was to detect the incidence symptomatic AF, using ECG, and opportunistic screening of silent AF, using an AF-detection capable automatic sphygmomanometer, in patients ≥65 years old in the general practitioner (GP) setting.

Methods

This was a population-based prospective cohort study of unselected general population referred for routine visits in 93 randomly selected GPs. Patients of both sexes of ≥65 years without previous diagnosis of AF were considered for the study. Each patient if symptomatic was directly referred to perform an ECG, otherwise if asymptomatic, underwent blood pressure monitoring with an AF-detection capable automatic sphygmomanometer followed by an ECG in case the device signaled AF.

Results

The final population comprised of 14987 individuals of ≥65 years old. The follow up extended to 16838 patient-years. The overall incidence of AF was 2.25% patient-years (95% CI 2.03–2.48). AF incidence was significantly higher in male (male/female ratio 1.29), overweight (BMI: 28.2 kg/m2 vs 27.0 kg/m2), older (79.1 vs 75.4 years old) individuals, with 44.9% belonging to the ≥80-year-old group. Other risk factors for incident AF were higher systolic BP measurements, history of stroke/TIA, congestive heart failure and chronic kidney disease. On multivariate analysis, age (annual increment), mitral valve disease, previous stroke and the number of annual visits (>10), were independent predictors of incidental AF.

About 25% of cases were silent AF (0.56% patient-years, 95% CI 0.46–0.69) and were identified using the AF-detection capable automatic sphygmomanometer. Independent predictors of silent AF were age (per year increment), overweight (BMI >28 kg/m2) and the number of visits (>10) in the GPs' office.

Conclusions

We found a higher than previously reported incidence of AF possibly due to capturing silent AF. This simple protocol, using an AF-capable automatic sphygmomanometer, might be feasible and easily implemented on the routine GP care where high rates of coverage can be achieved.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Veneto Region Italy
Temporal relationship between atrial fibrillation and ischaemic stroke in a large cohort with continuous rhythm monitoring
Authors: Singer D , Ziegler P.D , Koehler J , Sarkar S , Passman R
Published: November 2020

Background/Introduction

Atrial fibrillation (AF) increases the risk of ischaemic stroke, but the temporal relationship is uncertain.

Purpose

To assess the temporal relationship between AF episodes and ischaemic stroke in patients with cardiovascular implantable electronic devices (CIED) utilizing a case-crossover analysis.

Methods

We linked a very large U.S. aggregated de-identified electronic health record database (2007–2017), containing claims for ischaemic stroke hospitalizations, to a manufacturer's CIED database with continuous AF monitoring. All stroke patients with ≥120 days of pre-stroke rhythm data were included. For each stroke patient, we compared the presence of a day with ≥5.5 hours of AF (the TRENDS study threshold) in the case period (days 1–30 pre-stroke) to that in the control period (days 91–120 pre-stroke). Matched analyses for dichotomous outcomes generated odds ratios with confidence intervals and p values.

Results

We identified 891 ischaemic stroke patients (71.3±10.5 years, 65% male, 27% pacemakers, 60% defibrillators, 13% insertable cardiac monitors) with continuous monitoring data in the 120 days pre-stroke. The vast majority had either no AF in both the case and control periods (n=682, 77%) or AF in both periods (n=143, 16%), i.e., non-informative records. However, among the 66 patients with informative, discordant arrhythmic states, 52 had AF in the case period versus 14 in the control period, for an odds ratio of 3.71 (95% C.I. 2.06–6.70, p<0.001). Analysed by 5-day periods, stroke risk was markedly increased within 30 days of the AF episode (figure). For days 1–5 following an AF episode, the odds ratio was 9.7 (95% C.I. 5.9–16.1). Risk diminished towards non-AF risk after 30 days.

Conclusion

Our analysis of this largest cohort with continuous rhythm monitoring prior to ischaemic stroke demonstrates that stroke risk is highest within a few days of an episode of AF and diminishes rapidly thereafter. Our findings support a strategy of time-limited anticoagulation for patients with infrequent episodes of AF and available continuous rhythm monitoring.

Funding Acknowledgement

Type of funding source: None
National trends of use of oral anticoagulants and severities of stroke among patients with atrial fibrillation
Authors: Chao T.F , Liao J.N , Lip G.Y.H , Chen S.A
Published: November 2020

Background

Underuse of oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation (AF) is a common issue in the daily practice. The introduction of non-vitamin K antagonist OACs (NOACs) has changed the landscape of stroke prevention in AF. The goal of the present study was to investigate the trends of use of OACs and severities of stroke among AF patients using a nationwide AF database.

Methods

The present study used the Taiwan Nationwide Health Insurance Research Database (NHIRD). From year 2002 to 2015, a total of 66,331 AF patients aged >20 years who experienced ischemic stroke were identified from 447,259 AF patients. The temporal trends of use of OACs (either warfarin or NOACs) and the severities of stroke were analyzed. The estimated National Institutes of Health Stroke Scale (eNIHSS) calculated by 7-item NHIRD based stroke severity index, which has been validated before, was used to represent the stroke severities.

Results

The percentages of AF patients who were already anticoagulated when stroke occurred significantly increased from 20.3% in year 2002 to 40.5% in year 2015 (Figure A). The increment was more obvious in the era of NOACs (after year 2012 in Taiwan). In year 2015, NOACs accounts for around 69.6% of prescriptions of OACs. The mean eNIHSS gradually decreased from 17.3 (year 2002) to 14.3 (year 2015) (Figure B).

Conclusions

In the era of NOACs, the prescription rates of OACs significantly increased among AF patients who experienced ischemic stroke, temporally associated with a decrease in the stroke severity.

Funding Acknowledgement

Type of funding source: None
Time saving, simple and reproducible method to quantify left ventricular function in patients with atrial fibrillation
Authors: Bunting K.V , Gill S , Sitch A , Mehta S , O'Connor K , Hodson J , Lip G.Y.H , Stanbury M , Kirchhof P , Griffith M , Townend J.N , Steeds R.P , Kotecha D
Published: November 2020

Introduction

Echocardiography is essential for the management of patients with atrial fibrillation (AF), but current methods are time consuming and lack any evidence of reproducibility.

Purpose

To compare conventional averaging of consecutive beats with an index beat approach, where systolic and diastolic measurements are taken once after two prior beats with a similar RR interval (not more than 60 ms difference).

Methods

Transthoracic echocardiography was performed using a standardized and blinded protocol in patients enrolled into the RAte control Therapy Evaluation in permanent AF randomised controlled trial (RATE-AF; NCT02391337). AF was confirmed in all patients with a preceding 12-lead ECG. A minimum of 30-beat loops were recorded. Left ventricular function was determined using the recommended averaging of 5 and 10 beats and using the index beat method, with observers blinded to clinical details. Complete loops were used to calculate the within-beat coefficient of variation (CV) and intraclass correlation coefficient (ICC) for Simpson's biplane left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and filling pressure (E/e').

Results

160 patients (median age 75 years (IQR 69–82); 46% female) were included, with median heart rate 100 beats/min (IQR 86–112). For LVEF, the index beat had the lowest CV of 32% compared to 51% for 5 consecutive beats and 53% for 10 consecutive beats (p<0.001). The index beat also had the lowest CV for GLS (26% versus 43% and 42%; p<0.001) and E/e' (25% versus 41% and 41%; p<0.001; see Figure for ICC comparison). Intra-operator reproducibility, assessed by the same operator from two different recordings in 50 patients, was superior for the index beat with GLS bias −0.5 and narrow limits of agreement (−3.6 to 2.6), compared to −1.0 for 10 consecutive beats (−4.0 to 2.0). For inter-operator variability, assessed in 18 random patients, the index beat also showed the smallest bias with narrow confidence intervals (CI). Using a single index beat did not impact on the validity of LVEF, GLS or E/e' measurement when correlated with natriuretic peptides. Index beat analysis substantially shortened analysis time; 35 seconds (95% CI 35 to 39 seconds) for measuring E/e' with the index beat versus 98 seconds (95% CI 92 to 104 seconds) for 10 consecutive beats (see Figure).

Conclusion

Index beat determination of left ventricular function improves reproducibility, saves time and does not compromise validity compared to conventional quantification in patients with heart failure and AF. After independent validation, the index beat method should be adopted into routine clinical practice.

Comparison for measurement of E/e'

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Research UK
Can atrioventricular node ablation be safely performed in patients with permanent His bundle pacing? Data from a multicentric registry
Authors: Chaumont C , Auquier N , Mirolo A , Popescu E , Milhem A , Al Arnaout A , Savoure A , Godin B , Eltchaninoff H , Anselme F
Published: November 2020

Introduction

Ventricular rate control is essential in the management of atrial fibrillation. Atrioventricular node ablation (AVNA) and ventricular pacing can be an effective option when pharmacological rate control is insufficient. However, right ventricular pacing (RVP) induces ventricular desynchronization in patients with normal QRS and increases the risk of heart failure on long term. His bundle pacing (HBP) is a physiological alternative to RVP. Observational studies have demonstrated the feasibility of HBP but there is still very limited data about the feasibility of AVNA after HBP.

Purpose

To evaluate feasibility and safety of HBP followed by AVNA in patients with non-controlled atrial arrhythmia.

Methods

We included in three hospitals between september 2017 and december 2019 all patients who underwent AVNA for non-controlled atrial arrhythmia after permanent His bundle pacing. No back-up right ventricular lead was implanted. AVNA procedures were performed with 8 mm-tip ablation catheter. Acute HBP threshold increase during AVNA was defined as a threshold elevation >1V. His bundle capture (HBC) thresholds were recorded at 3 months follow-up.

Results

AVNA after HBP lead implantation was performed in 45 patients. HBP and AVNA were performed simultaneously during the same procedure in 10. AVNA was successful in 32 of 45 patients (71%). Modulation of the AV node conduction was obtained in 7 patients (16%). The mean procedure duration was 42±24min, and mean fluoroscopy duration was 6.4±8min. A mean number of 7.7±9.9 RF applications (347±483 sec) were delivered to obtain complete / incomplete AV block. Acute HBC threshold increase occurred in 8 patients (18%) with return to baseline value at day 1 in 5 patients. There was no lead dislodgment during the AVNA procedures. Mean HBC threshold at implant was 1.26±0.69V@0.5ms and slightly increased at 3 months follow-up (1.34±0.86V@0.5ms). AV node re-conduction was observed in 5 patients (16% of the successful procedures) with a second successful ablation procedure in 4 patients. No ventricular lead revision was required during the follow-up period. The baseline native QRS duration was 102±21 ms and the paced QRS duration was 107±18 ms.

Conclusion

AVNA combined with HBP for non-controlled atrial arrhythmia is feasible and does not compromise HBC but seems technically difficult with significant AV nodal re-conduction rate. The presence of a back-up right ventricular lead could have changed our results and therefore would require further evaluation.

Unipolar HBP after AV node ablation

Funding Acknowledgement

Type of funding source: None
Real-time local impedance monitoring to assess tissue lesion during pulmonary vein isolation: a new tool for AF ablation
Authors: Di Cori A , Segreti L , Zucchelli G , Viani S , Tarasco F , Barletta V , Giannotti Santoro M , Parollo M , De Lucia R , Paperini L , Cellamaro T , Branchitta G , Carluccio M , Soldati E , Bongiorni M.G
Published: November 2020

Background

Contact force catheter ablation is the gold standard for treatment of atrial fibrillation (AF). Local tissue impedance (LI) evaluation has been recently studied to evaluate lesion formation during radiofrequency ablation.

Purpose

Aim of the study was to assess the outcomes of an irrigated catether with LI alghorithm compared to contact force (CF)-sensing catheters in the treatment of symptomatic AF.

Methods

A prospective, single-center, nonrandomized study was conducted, to compare outcomes between CF-AF ablation (Group 1) and LI-AF ablation (Group 2). For Group 1 ablation was performed using the Carto 3© System with the SmartTouch SF catheter and, as ablation target, an ablation index value of 500 anterior and 400 posterior. For Group 2, ablation was performed using the Rhythmia™ System with novel ablation catheter with a dedicated algorithm (DirectSense) used to measure LI at the distal electrode of this catheter. An absolute impedance drop greater than 20Ω was used at each targeted. According to the Close Protocol, ablation included a point by point pulmonary vein isolation (PVI) with an Inter-lesion space ≤5 mm in both Groups. Procedural endpoint was PVI, with confirmed bidirectional block.

Results

A total of 116 patients were enrolled, 59 patients in Group 1 (CF) and 57 in Group 2 (LI), 65 (63%) with a paroxismal AF and 36 (37%) with a persistent AF. Baseline patients features were not different between groups (P=ns). LI-Group showed a comparable procedural time (180±89 vs 180±56, P=0.59) but with a longer fluoroscopy time (20±12 vs 13±9 min, P=0.002). Wide antral isolation was more often observed in CF-Group (95% vs 80%, P=0.022), while LI-Group 2 required frequently additional right or left carina ablation (28% vs 14%, P=0.013). The mean LI was 106±14Ω prior to ablation and 92.5±11Ω after ablation (mean LI drop of 13.5±8Ω) during a median RF time of 26 [19–34] sec for each ablation spot. No steam pops or complications during the procedures were reported. The acute procedural success was 100%, with all PVs successfully isolated in all study patients. Regarding safety, only minor vascular complications were observed (5%), without differences between groups (p=0.97). During follow up, 9-month freedom from atrial fibrillation/atrial flutter/atrial tachycardia recurrence was 86% in Group 1 and 75% in Group 2 (P=0.2).

Conclusions

An LI-guided PV ablation strategy seems to be safe and effective, with acute and mid-term outcomes comparable to the current contact force strategy. LI monitoring could be a promising complementary parameter to evaluate not only wall contact but also lesion formation during power delivery.

Procedural Outcomes

Funding Acknowledgement

Type of funding source: None
Catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction: a systematic review and meta-analysis
Authors: Aldaas O.M , Lupercio F , Malladi C.L , Mylavarapu P.S , Darden D , Han F , Hoffmayer K.S , Krummen D , Ho G , Raissi F , Feld G.K , Hsu J.C
Published: November 2020

Background

Catheter ablation improves clinical outcomes in symptomatic atrial fibrillation (AF) patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, the role of catheter ablation in HF patients with a preserved ejection fraction (HFpEF) is less clear.

Purpose

To determine the efficacy of catheter ablation of AF in patients with HFpEF relative to those with HFrEF.

Methods

We performed an extensive literature search and systematic review of studies that compared AF recurrence at one year after catheter ablation of AF in patients with HFpEF versus those with HFrEF. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method for dichotomous variables, where a RR<1.0 favors the HFpEF group.

Results

Four studies with a total of 563 patients were included, of which 312 had HFpEF and 251 had HFrEF. All patients included were undergoing first time catheter ablation of AF. Patients with HFpEF experienced similar recurrence of AF one year after ablation on or off antiarrhythmic drugs compared to those with HFrEF (RR 0.87; 95% CI 0.69–1.10, p=0.24), as shown in Figure 1. Recurrence of AF was assessed with electrocardiography, Holter monitoring, and/or event monitoring at scheduled follow-up visits and final follow-up.

Conclusion

Based on the results of this meta-analysis, catheter ablation of AF in patients with HFpEF appears as efficacious in maintaining sinus rhythm as in those with HFrEF.

Funding Acknowledgement

Type of funding source: None
Sex differences and arrhythmia recurrence after catheter ablation for atrial fibrillation
Authors: Tanaka M , Shizuta S , Komasa A , Yoshizawa T , Kohjitani H , Kimura T
Published: November 2020

Background

Several previous studies reported female sex is associated with high recurrence rate of atrial tachyarrhythmia (ATA) after catheter ablation (CA) for atrial fibrillation (AF).

Purpose

We investigated the relationship between sex differences and recurrence rate of ATA after CA for AF in a large single-center database.

Methods

We enrolled consecutive 2033 patients undergoing first time CA for AF in our institution between Feb.2004 and Dec. 2017.

We compared the long-term outcomes between female (N=603) and male (N=1430).

Results

Female patients were older (70.8 vs. 66.3, p<0.0001), and had lower prevalence of persistent AF (23.1% vs. 33.5%, p<0.0001). Also, left atrial dimension was smaller (40.0 vs. 41.1, p=0.0005). and prior antiarrhythmic drug use was more prevalent (38.2% vs. 28.7%, p<0.0001) in female patients.

Ablation method for pulmonary vein isolation (PVI) was radiofrequency catheter ablation in 1634 patients (80.4%) and cryoballoon ablation in 399 (20.6%).

Median follow-up duration was 1342±115 days. The 3-year ATA recurrence rate after first CA was 35.8% overall: 39.9% in female and 34.2% in male (Log-rank P=0.01).

A multivariate analysis revealed that the factors associated with higher ATA recurrence rate were female (p=0.01), persistent AF (p=0.006), and larger left atrial dimension (p=0.007).

Conclusions

Female gender is an independent predictor of arrhythmia recurrence after CA for AF.

Funding Acknowledgement

Type of funding source: None
B-Type natriuretic peptide predicts major adverse cardiac and cerebrovascular events after catheter ablation of atrial fibrillation: insights from AF frontier ablation registry
Authors: Kato T , Usuda K , Tada H , Tsuda T , Takeuchi K , Niwa S , Hayashi K , Furusho H , Takamura M , Nagashima K , Okumura Y
Published: November 2020

Background

High plasma B-Type natriuretic peptide (BNP) level is associated with cardiac events or stroke in patients with atrial fibrillation (AF). However, it is still unknown whether BNP predicts worse clinical outcomes after catheter ablation ofAF.

Purpose

We aimed to see if plasma BNP level is associated with major adverse cardiac and cerebrovascular events (MACCE) after catheter ablation of AF.

Methods

We retrospectively analyzed 1,853 participants (73.1% men, mean age 63.3±10.3 years, 60.7% paroxysmal AF) who received first catheter ablation of AF with pre-ablation plasma BNP level measurement and completed follow-up more than 3 months after the procedure from AF Frontier Ablation Registry, a multicenter cohort study in Japan. We evaluated an association between plasma BNP level before catheter ablation and first MACCE in cox-regression hazard models adjusted for known risk factors. MACCE were defined as stroke/transient ischemic attack (TIA), cardiovascular events or all-cause death.

Results

The mean plasma BNP level was 120.2±3.7 pg/mL. During a mean follow-up period of 21.9 months, 57 patients (3.1%) suffered MACCE (ischemic stroke 8 [14.0%], hemorrhagic stroke 5 [8.8%], TIA 5 [8.8%], hospitalization for heart failure 11 [19.2%], acute coronary syndrome 9 [15.8%], hospitalization for other cardiovascular events 8 [14.0%] and all-cause death 11 [19.2%]). Plasma BNP level of patients with MACCE were significantly higher than those without MACCE (291.7±47.0 vs 114.7±3.42 pg/mL, P<0.001). Multivariate analysis revealed that plasma BNP level (hazard ratio [HR] per 10 pg/mL increase 1.014; 95% confidence interval [CI] 1.005–1.023; P=0.001), baseline age (HR 1.052; 95% CI 1.022–1.084; P=0.001), heart failure (HR 2.698; 95% CI 1.512–4.815; P=0.001), old myocardial infarction (HR 3.593; 95% CI 1.675–7.708; P=0.001) and non-ischemic cardiomyopathy (HR 2.676; 95% CI 1.337 - 5.355; P=0.005) were independently associated with MACCE. At receiver-operating characteristic curve analysis, plasma BNP level before catheter ablation ≥162.7 pg/mL was the best threshold to predict MACCE (area under the curve: 0.71). Kaplan-Meier curve analysis (Figure) showed that the cumulative incidence of MACCE was significantly higher in patients with a BNP ≥162.7 pg/mL than in those with a BNP below 162.7 pg/mL (HR 4.85; 95% CI 2.86–8.21; P<0.001).

Conclusions

Elevation of plasma BNP level was independently related to the increased risk of MACCE after catheter ablation ofAF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bristol-Meiers Squibb
A simple method to detect phrenic nerve impairment during cryoballoon ablation of atrial fibrillation using aVF in the standard surface ECG
Authors: Schaerli N , Knecht S , Spies F , Madaffari A , Osswald S , Sticherling C , Kuehne M
Published: November 2020

Background

Phrenic nerve palsy (PNP) is the most common complication in cryoballoon ablation of atrial fibrillation. Monitoring techniques such as compound motor action potential (CMAP) measurements using additional leads, or catheters positioned in the subdiaphragmatic hepatic vein or the esophagus have demonstrated to be effective to prevent PNP.

Purpose

This study investigates the safety and feasibility of a simple monitoring strategy using the lead aVF of the standard surface 12 lead ECG for CMAP monitoring to prevent PNP.

Methods

In 263 continuous patients undergoing cryoballoon ablation, a decapolar catheter was placed in the right subclavian vein to stimulate the phrenic nerve during ablation of the right sided pulmonary veins (12V@2.9 ms at 60 bpm). Capture was continuously monitored using the CMAP potential in the inferior aVF lead of the surface ECG and manually by palpation of the abdominal movement. The freeze was terminated early if the amplitude of the aVF signal decrease by >25% in three consecutive beats or if the diaphragmatic contraction decreased.

Results

Phrenic nerve injury documented by a reduction of the signal in aVF was observed in 13 of the 263 patients (5%) during freezes of the right superior pulmonary vein. Reduced diaphragmatic contraction detected by palpation of the abdomen was never observed without previous reduced amplitude in the surface aVF signal and was therefore never the trigger to stop a freeze. In patients with phrenic nerve injury, the mean initial amplitude was 1mV (SD ±0.3mV) and the mean minimal amplitude was 0.3mV (SD ±0.2mV). Mean time to recovery of the aVF amplitude was 160 seconds. Twelve patients (4.6%) showed complete recovery whereas one patient (0.4%) showed only partial recovery, as demonstrated in a sniff test at the end of the procedure. This patient showed no clinical signs of phrenic nerve palsy the following day, and full recovery was demonstrated in a sniff test 3 months later.

Conclusion

Monitoring of CMAP using the aVF signal from a standard 12-lead ECG during phrenic nerve stimulation to reduce the incidence of phrenic nerve palsy is safe and feasible. This technique is readily available during every standard ablation without placing additional electrodes and more sensitive than manual palpation.

aVF signal before and during ablation

Funding Acknowledgement

Type of funding source: None