bluuebunny/crossref_metadata_2025 huggingface dataset:
Local areas of earlier repolarization cause epicardial repolarization heterogeneity in patients with apparently idiopathic ventricular fibrillation
Authors: Van Rees B , Stoks J , Nguyen Y C , Ter Bekke R M A , Mihl C , Cluitmans M , Volders P G A
Published: October 2021

Background

Sudden cardiac arrest is often due to ventricular fibrillation (VF). In 5–10% of cases, no cause can be identified despite extensive cardiac examination, hence the designation idiopathic VF. Early repolarization with down sloping ST segments has been previously identified in patients with idiopathic VF. Early repolarization may increase repolarization heterogeneity with steep local repolarization time gradients, and thus form a substrate for idiopathic VF.

Purpose

To study the presence of local earlier repolarization and increased repolarization dispersion in idiopathic VF patients with noninvasive electrocardiographic imaging (ECGI).

Methods

A validated, non-commercial, potential-based formulation of ECGI was performed in 17 patients with idiopathic VF and 10 controls with no structural or electrical abnormalities. The ECGI measurement consisted of a body surface potential map with 184–256 electrodes in combination with a CT scan to obtain the torso and heart geometries. ECGI provided local epicardial repolarization times (RT) and RT isochrones. We determined the 1st (RT1%) and 99th percentile (RT99%) of RTs, the total epicardial RT dispersion (ERD: RT99%-RT1%), and the mean RT. Heart-rate corrected QT (QTc), TpTe intervals, and presence of the ER pattern were determined from the 12-lead ECG. All metrics were normalized to the body-surface Q.

Results

QTc and TpTe did not differ between the two groups (P=0.40 and P=0.83, respectively, Figure 1, panel A). One (10%) control subject and three (17.6%) idiopathic VF patients showed an ER pattern on the 12-lead ECG, with a down sloping ST segment only in 2/4 of the latter. With ECGI, the mean RT was similar between the groups (P=0.31), but the ERD was significantly increased in patients with idiopathic VF (P=0.01, figure 1, panel B). Moreover, RT1% was significantly lower in idiopathic VF patients in comparison to the controls (P=0.002), whereas the RT99% did not differ significantly (P=0.40). Subgroup analysis between ER positive and negative patients did not yield significantly different RT results.

Conclusion

Noninvasive ECGI, in contrast to the 12-lead ECG, revealed a wider range of epicardial RTs in patients with idiopathic VF, implying increased repolarization heterogeneity. This heterogeneity is caused by areas of earlier repolarization. Our data indicate the value of noninvasively diagnosing these repolarization abnormalities, and suggest promising potential value of the 1st percentile of RT to identify idiopathic VF patients with true early repolarization.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation Figure 1
Differences in ventricular tachycardia inducibility in patients with Tetralogy of Fallot depending on the clinical indication for the electrophysiologic study
Authors: Herrador Galindo L , Francisco Pascual J , Santos Ortega A , Perez Rodon J , Benito B , Cantalapiedra Romero J , Jordan Marchite P , Dos Subira L , Pijuan Domenech A , Miranda Barrios B , Gonzalez Fernandez V , Gordon Ramirez B , Carbonell Prat B , Ferreira Gonzalez I , Rivas Gandara N
Published: October 2021

Introduction

The arrhythmic risk stratification of patients with repaired Tetralogy of Fallot (TOF) is still controversial. The performance of an electrophysiologic (EP) study before pulmonary valve replacement (PVR), regardless of patient's risk factors, is an extended practice in some centers that is not recommended in current guidelines. The aim of our study was to explore the differences in ventricular tachycardia (VT) inducibility in patients with TOF during programmed ventricular stimulation (PVS) depending on the clinical indication.

Methods

All patients with repaired TOF who underwent an EP study with PVS between January 2001 and October 2020 were included. EP studies performed in the context of ventricular or supraventricular tachycardia ablations that had been previously diagnosed were excluded. We defined two clinical scenarios for performing the EP study: pre-PVR (performed previous to pulmonary valve replacement) or diagnostic EP study (performed due to high risk symptoms which included palpitations, syncope or presyncope). Baseline clinical information, electrocardiogram, echocardiogram and cardiac MRI parameters were retrospective recorded.

Results

A total of 139 EP studies with PVS were included; 87 in the pre-PVR group and 52 in the diagnostic EP study group. There was a greater incidence of palpitations, syncope and presyncope in the “Diagnostic EP study” group. Moreover, there were statistical significant differences in right ventricle dimensions and function between groups. The repair surgical approach was similar in both groups. It was detected a statistical significant difference in VT induction between the pre-PVR group and the diagnostic indicated group (16,1% vs 34,6%, p=0,012).

Conclusions

Differences in VT induction are observed during PVS performing in TOF patients depending on the clinical indication. Symptomatology is an important parameter that must be taken into account in order to decide whether to perform an EP study in this population.

Funding Acknowledgement

Type of funding sources: None.
Risk of dementia according to smoking cessation after newly diagnosed atrial fibrillation: a nationwide cohort study
Authors: Lee H J , Lee S R , Choi E K , Jung J H , Han K D , Oh S I , Lip G Y H
Published: October 2021

Background

Incident atrial fibrillation (AF) is associated with an increased risk of dementia. There are limited data about the impact of smoking cessation after AF diagnosis on the risk of incident dementia.

Purpose

To evaluate the association between changes in smoking status after newly diagnosed AF and the risk of dementia.

Methods

Among patients with new-onset AF between 2010 and 2016, those who received a national health checkup exam within 2 years before and after the AF diagnosis were included. Patients who had prevalent dementia were excluded. Subjects were categorized into 4 groups according to the status of smoking before and after AF diagnosis: (1) never smoker; (2) ex-smoker; (3) quit-smoker after AF diagnosis; and (4) current smoker. The primary outcome was incident dementia during follow-up.

Results

A total of 126,252 patients were included (mean age 63, SD 12.0; men 62%; mean CHA2DS2-VASc 2.7). During a median 3 years of follow-up, dementia occurred in 5,925 patients (1.11 per 1000 person-years [1000PY]) (Alzheimer's dementia 1.5 per 1000 PY and vascular dementia 0.24 per 1000 PY, respectively). Never smokers, ex-smokers, quit-smokers, and current smokers were 52%, 27%, 7%, and 14% of the total study population, respectively. After multivariable adjustment, quit-smokers showed a higher risk of dementia than never smokers (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.03–1.32), but the risk was significantly decreased when compared to current smokers (HR 0.83, 95% CI 0.72–0.95). Alzheimer's dementia and vascular dementia showed consistent results as main (Figure).

Conclusion

All types of smoking were associated with a significantly higher risk of dementia in patients with new-onset AF. Smoking cessation after AF diagnosis showed a lower risk of dementia compared to patients smoking persistently. These findings may support the promotion of smoking cessation to lower the risk of dementia in patients with new-onset AF.

Funding Acknowledgement

Type of funding sources: None.
Lower risk of stroke after alcohol abstinence in patients with incident atrial fibrillation: a nationwide population-based cohort study
Authors: Lee S R , Choi E K , Jung J H , Han K D , Oh S , Lip G Y H
Published: October 2021

Background

In a recent study, alcohol abstinence reduced the atrial fibrillation (AF) recurrence in patients with AF. However, the relationship between alcohol consumption and incident stroke in patients with AF per se remains unclear.

Purpose

To evaluate the association between alcohol consumption status (and its changes) after newly diagnosed AF and the risk of ischaemic stroke.

Methods

Using the Korean nationwide claims and health examination database, we included subjects who were newly diagnosed with AF between 2010 and 2016. Patients were categorized into three groups according to the status of alcohol consumption before and after AF diagnosis: non-drinkers; abstainers from alcohol after AF diagnosis; and current drinkers. The primary outcome was incident ischaemic stroke during follow-up.

Results

Among a total of 97,869 newly diagnosed AF patients, 51% were non-drinkers, 13% were abstainers, and 36% were current drinkers. After inverse probability of treatment weighting, baseline characteristics of three groups were well-balanced. Compared to current drinkers, abstainers and non-drinkers were associated with a lower risk of ischaemic stroke (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.77–0.96 for abstainers and HR 0.75, 95% CI 0.70–0.81 for non-drinkers, respectively). Amongst current drinkers, there was a dose-response relationship between the amount of alcohol consumption and the risk of ischaemic stroke.

Conclusion

Current alcohol consumption was associated with an increased risk of ischaemic stroke in patients with newly diagnosed AF, and alcohol abstinence after AF diagnosis could reduce the risk of ischaemic stroke. Lifestyle intervention, including attention to alcohol consumption, should be encouraged as a part of a comprehensive approach to AF management to improve clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.
Increasing use of amiodarone in Norway
Authors: Anfinsen O.-G , Lima K , Nouri Sharikabad M
Published: October 2021

Background

Amiodarone may be used against ventricular arrhythmias to reduce ICD-shocks, and for rhythm control in patients with atrial fibrillation. The 2020 ESC atrial fibrillation guidelines upgraded the recommendation for amiodarone in rhythm control to class I, level of evidence A, although still with a caution to consider other antiarrhythmic drugs first. Amiodarone is the most potent antiarrhythmic drug in clinical use, but it has frequent and potentially severe side effects affecting several organ systems. We have seen an increasing number of patients with amiodarone-induced thyrotoxicosis.

Purpose

We wanted to study the prescription rate of amiodarone in Norway, which indications were most prevalent, and whether there had been any changes over time.

Methods

From the Norwegian Prescription Registry, we have collected data on how many patients had received amiodarone, and the number of defined daily doses delivered (DDDs), related to various reimbursement categories.

Results

From 2010 to 2019, the number of individuals receiving amiodarone from a pharmacy in Norway increased from 5359 to 7789 (45% increase), and the number of DDDs delivered from 994905 to 1412796 (42% increase) (Figure). With an atrial fibrillation-related reimbursement code, we found during the same period an increase of individuals from 3616 to 5776 (60% increase) and number of DDDs from 661531 to 1061601 (60% increase). The dispenses for ventricular arrhythmia-related reimbursement codes were close to unchanged during the same period of years (Figure). The fraction of amiodarone use related to atrial fibrillation increased from 66% in 2009 to 75% in 2019.

Conclusion

We observed a 42–45% increase in the total use of amiodarone over 10 years, and almost the whole increase was related to atrial fibrillation. In 2019, atrial fibrillation-related diagnoses accounted for 75% of the total amount of amiodarone dispensed in Norway. Due to the several side effects of amiodarone, we are concerned if the threshold for use of amiodarone diminishes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Norwegian Institute of Public HealthOslo University Hospital, Rikshospitalet Number of patientsNumber of DDDs
Recurrences of atrial fibrillation in patients with heart failure without reduced ejection fraction: a role for CA125
Authors: Perez Rivera J A , Merino-Merino A , Saez-Maleta R , Gundin-Menendez S
Published: October 2021

Background

Atrial fibrillation (AF) and heart failure (HF) without reduced ejection fraction often occur together, and their combination is associated with increased morbidity and mortality compared with each disorder alone. Sinus rhythm maintenance seems to be beneficial but challenging in these patients.

Purpose

We studied the possible value of CA125 to predict recurrences in patients with persistent AF and HF without reduced ejection fraction who underwent electrical cardioversion (ECV).

Methods

We designed a prospective cohort study by consecutively including all the patients who underwent ECV in our hospital with symptomatic persistent non-valvular AF and a concomitant diagnosis of HF without reduced ejection fraction. We excluded patients with clinical instability or ejection fraction <40%. We defined HF as the presence of diastolic dysfunction in echo (left atrium indexed volume >34 ml/m2 or e/e' >8) or ejection fraction between 40 and 50%. We followed-up them during 6 months for detecting AF recurrences with an ECG-Holter 3 months after ECV and an ECG at 6th month. We considered a recurrence as any AF documentation in ECG or ECG-Holter after the ECV. A peripheral blood sample was extracted just before ECV and CA125 was determined. Kaplan-Meyer analysis was used to study the possible relationship between CA125 plasmatic levels, dichotomized according to the median value, and AF recurrence.

Results

We included 95 patients with a medium age of 64±9 years old. Of them, 31 (32.6%) were women, 14 (14.7%) had diabetes and 56 (58.9%) hypertension. The medium ejection fraction was 58.14±10.27% and the median CA125 was 10.98±8.97 U/ml. We detected 54 (57.4%) recurrences in 6 months. In patients with AF recurrences, CA125 values were higher than in patients who maintained sinus rhythm (19.28±29.11 U/ml vs. 14.98±17.02 U/ml). CA125 was significantly related with AF recurrences (log-rank 5.37; p=0.021).

Conclusions

In our sample of patients with persistent AF and HF without reduced ejection fraction, CA125 plasmatic levels are related with AF recurrences after ECV. CA125 has been associated with the clinical severity of HF and the symptoms and signs of fluid congestion. This probably means more ventricular and atrial myocardial damage that might predispose to AF. Sinus rhythm maintenance is specially challenging in patients with HF so those with higher levels of CA125 probably need a closer surveillance and a more aggressive rhythm control.

Funding Acknowledgement

Type of funding sources: None.
Accuracy and acute efficacy of a novel occlusion tool to guide cryoballoon-based pulmonary vein isolation
Authors: Rottner L , Moser F , Schleberger R , Weimann J , Moser J , Lemoine M , Muenkler P , Dinshaw L , Risius T , Kirchhof P , Ouyang F , Reissmann B , Metzner A , Rillig A
Published: October 2021

Background

Cryoballoon (CB)-based pulmonary vein isolation (PVI) currently requires to verify occlusion of each pulmonary vein (PV) using fluoroscopy and dye injection.

Objective

The current study evaluated whether the novel CB-occlusion tool integrated into the wide-band dielectric imaging system KODEX-EPD reliably verifies occlusion of PV according to a novel dye-injection based algorithm.

Methods

Consecutive patients suffering from symptomatic atrial fibrillation (AF) underwent CB-based PVI using the KODEX-EPD and the novel occlusion-tool (group I). To confirm accurate display of the PVs, selective PV-angiography was performed in the first half of the patients of group I (group Ia) in addition to a three-dimensional left atrial (LA) map using a spiral mapping catheter (Achieve, SMC1, Medtronic, MN, USA). PV-angiographies were waived for the following patients (group Ib). Procedural duration and radiation exposure were compared to a control group of patients undergoing conventional CB-based PVI.

Results

CB-based PVI was successful in 50/50 patients of group I (mean age 63±11 years, 18 paroxysmal (36%)) and 25/25 patients of group II (66±10 years, 9 paroxysmal (60%)). Concordance of PV-occlusion as assessed by either PV-occlusion-angiography or KODEX-EPD, was documented in 237/272 (87%) occlusion-analyses among 198 PVs (95% for left superior PV, 93% for left inferior PV, 86% for right inferior PV and 77% for right superior PV).

In the final evaluation phase (group Ib) LA fluoroscopy times and dose area products were comparable to the conventional CB-ablation group (10.5±5 vs 8.8±4 minutes (p=0.23) and 403±425 vs 321±202 cGycm2 (p=0.44), whereas the amount of dye could be significantly reduced (group Ib: 31±10 ml vs group II: 70±20 ml, p<0.0001).

Conclusion

The novel KODEX-EPD PV-occlusion tool allows for accurate PV-occlusion assessment in the majority of PVs and a high acute success rate. The system has the potential to reduce dye and radiation exposure. This should be evaluated in controlled clinical trials.

Funding Acknowledgement

Type of funding sources: None.
Antiarrhythmic drug therapy after catheter ablation for atrial fibrillation has no impact on recurrences, cardiovascular events and mortality – insights from the German Ablation Registry
Authors: Schleberger R , Metzner A , Kuck K H , Andresen D , Willems S , Hoffmann E , Deneke T , Eckardt L , Brachmann J , Hochadel M , Senges J , Rillig A
Published: October 2021

Background

Data on the optimal treatment strategy for antiarrhythmic drug therapy (AAD) after atrial fibrillation (AF) catheter ablation are inconsistent. While AAD potentially stabilizes sinus rhythm, it also increases the patients' treatment burden.

Methods

Patients from the prospective German Ablation Registry (n=3275) discharged with or without AAD after AF catheter ablation were compared regarding long-term success, cardiovascular events and patient reported outcome.

Results

In patients with paroxysmal AF (n=2138) recurrence and rehospitalization rates did not differ when discharged with (n=1051) or without (n=1087) AAD (recurrence: adjusted odds ratio (OR) 1.13, 95% confidence interval (CI) [0.95–1.35]; rehospitalization: OR 1.08, 95% CI [0.90–1.30]). The reablation rate was higher and reduced treatment satisfaction was reported more often in those discharged with AAD (reablation: OR 1.30, 95% CI [1.05–1.61]; reduced treatment satisfaction: OR 1.76, 95% CI [1.20–2.58]).

Similar rates of recurrences, rehospitalisations, reablations and treatment satisfaction were found in patients with persistent AF (n=1137) discharged with (n=641) or without (n=496) AAD (recurrence: OR 1.22, 95% CI [0.95–1.56]; rehospitalization: OR 1.16, 95% CI [0.90–1.50]; reablation: OR 1.21, 95% CI [0.91–1.61]; treatment satisfaction: OR 1.24, 95% CI [0.74–2.08]).

The incidence of cardiovascular events and mortality did not differ at follow-up in paroxysmal and persistent AF patients discharged with or without AAD.

Conclusion

The rates of recurrences, cardiovascular events and mortality did not differ between patients discharged with or without AAD after AF catheter ablation. However, AAD should be considered carefully in patients with paroxysmal AF, in whom it was associated with a higher reablation rate and reduced treatment satisfaction.

Funding Acknowledgement

Type of funding sources: None.
Dyssynchronous cardiomyopathy in patients with WPW syndrome and its reversibility after RFA of accessory pathway
Authors: Svintsova L , Plotnikova I , Dzhaffarova O , Kartofeleva E
Published: October 2021

Introduction

In some cases accessory pathway-mediated ventricular preexcitation can be associated with electro-mechanical dyssynchrony and, consequently, with dyssynchrony-related dilated cardiomyopathy, even in the absence of supraventricular tachycardia (SVT). Sometimes rapid progression of ventricular dysfunction developed in such patients after birth.

Methods and materials

8 patients with asymptomatic WPW and dyssynchronous cardiomyopathy were examined in our Institute from 2017 till 2019. Four patients of the group were observed in other clinics with dilated cardiomyopathy (DCM) and prescribed appropriate therapy without significant clinical effect. The absence of complaints of heartbeat and episodes of tachycardia at the scheduled Holter monitoring allowed eliminating incessant tachycardia as a possible cause of cardiomyopathy. After radiofrequency ablation (RFA) all patients were performed ECG to assess QRS duration, Holter monitoring, echocardiography (Echo) for assessment of heart chamber volume and left ventricle (LV) contractile function and Speckle tracking – Echo with LV longitudinal strain assessment. The average age of the patients was 9.5 years (from 2 to 14 years). 6 children had heart failure (NYHA Class II).

Results

According to Echo all patients had widened QRS complex. Dilatation and enlargement of LV volume were marked in 6 pts. According to Echo7 patients had decrease of LV contractile function. According to Speckle tracking – Echo all patients had intraventricular dyssynchrony, decrease of longitudinal strain indices. At intracardiac electrophysiology study right-sided accessory pathways was diagnosed in all patients, successful RFA was performed. Preexitation relapsed, and the repeated RFA was performed in 2 pts. Complications caused by RFA were not marked.

After RFA all patients showed a regular normalization of QRS duration. At the 5th day after RFA Echo was performed to all patients. The patients with initially decreased LV ejection fraction had it increased. The patients with initial dilatation and LV volume enlargement had normalization of the given indices. According to Speckle tracking – Echo normalization of global and regional myocardial function, LV longitudinal strain, disappearance of intraventricular and interventricular dyssynchrony were marked in all patients. The index of longitudinal strain was 17,0±0,64% before RFA, after RFA - 23,75±0,92% (p=0,ehab724.035946).

Conclusion

As a result of RFA of accessory pathways electromechanical resynchronization causes LV demodeling and restoration of its contractile ability. The presented clinical examples are an additional indication for RFA of accessory pathways even in the absence of SVT in patients regardless of age.

Funding Acknowledgement

Type of funding sources: None.
Linear increase in the number of non-pulmonary vein triggers from paroxysmal to persistent and long-standing persistent AF in patients undergoing repeat procedure after successful isolation of pulmona
Authors: Mohanty S , Trivedi C , Della Rocca D G , Gianni C , MacDonald B , Mayedo A , Burkhardt J D , Bassiouny M , Gallinghouse G J , Horton R , Al-Ahmad A , Di Biase L , Natale A
Published: October 2021

Introduction

This study evaluated the prevalent triggers responsible for recurrence following successful PVI in different types of atrial fibrillation (AF).

Methods

Consecutive AF patients undergoing repeat catheter ablation with permanently isolated PV were included in the analysis. High-dose isoproterenol challenge (20- 30μg/min for 15–20min) was used to confirm PV reconnection and identify non-PV triggers.

Circular mapping catheter (CMC) was used to map the site of origin of significant ectopic activity by comparing the activation sequence of the sinus beat with that of the ectopic beat. For the coronary sinus (CS), ablation catheter was positioned at the level of the mitral valve annulus, parallel to the one positioned in the CS. Left atrial appendage (LAA) firing was detected by placing the CMC in the left superior PV and thus recording far-field potentials from the LAA.

Results

This prospective study included 1850 AF patients undergoing repeat AF ablation (Table 1), of which 573 (31%) had received one and the remaining 1277 patients had received 2 earlier ablations. Permanent PVI was confirmed with isoproterenol challenge.

Table 1 shows the distribution of non-PV triggers. A linear increase in the number of non-PV triggers was observed from PAF to PerAF to LSPAF. Significantly higher number of LSPAF patients had detectable non-PV triggers compared to PerAF and PAF cases.

Conclusion

We observed a linear increase in the number of non-PV triggers in PAF to PerAF and LSPAF patients experiencing recurrence with successful isolation of PVs. As non-PV triggers are often not targeted by operators, this could be the underlying mechanism for more frequent recurrences in non-paroxysmal AF.

Funding Acknowledgement

Type of funding sources: None. Table 1
Novel cryoballoon to isolate pulmonary veins in patients with paroxysmal atrial fibrillation: one-year outcomes in a multicenter study
Authors: Martin A , Breskovic T , Ouss A , Dekker L , Yap S C , Bhagwandien R , Cielen N , Albrecht E M , Richards E , Tran B , Lever N , Anic A
Published: October 2021

Background

Recently, a novel cryoballoon (CB; POLARx) has been developed with increased steerability which maintains size and pressure throughout the ablation. Initial clinical data has demonstrated acute procedural safety and efficacy in de novo pulmonary vein isolation (PVI) procedures in patients with paroxysmal atrial fibrillation (AF). However, there are limited studies demonstrating the long-term efficacy of the CB.

Purpose

To evaluate the long-term safety and efficacy of the novel CB in treating paroxysmal AF.

Methods

This was a non-randomized, prospective, multi-center study. Fifty-eight consecutive patients with paroxysmal AF were enrolled at 4 centers for de novo PVI procedures. Cryoablation was delivered for 180s if time to isolation was ≤60s. Otherwise a 240s cryoablation was performed. PVI was confirmed with entrance and exit block testing. Patients were followed for 1 year with 24-hour Holter monitoring at 3, 6, and 12 months. After a 3-month blanking period, recurrence was defined as having any documented, symptomatic episode(s) of AF or atrial tachycardia.

Results

Acute isolation with the CB was achieved in 230 of 231 pulmonary veins (99.6%) with 5.2±1.5 cryoapplications per patient (1.3±0.6 cryoapplications per vein). There were 4 patients (6.9%) with phrenic nerve injury (3 resolved during the index procedure; 1 resolved at 6 months follow-up). One serious adverse device event was reported: femoral arterial embolism event occurring 2 weeks post index procedure (1.7%). Of the 56 patients that had complete 12-month follow-up, 43 (76.8%) were free from recurrent atrial arrhythmias.

Conclusion

Initial multicenter clinical experience with the novel CB has demonstrated long-term safety and efficacy of PVI in patients with paroxysmal AF. Further studies are underway to confirm these findings.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boston Scientific
Predictors of survival in patients submitted to typical atrial flutter ablation
Authors: Couto Pereira S , Rodrigues T , Cunha N , Silverio Antonio P , Brito J , Alves Da Silva P , Lima Da Silva G , Carpinteiro L , Cortez-Dias N , Pinto F J , De Sousa J
Published: October 2021

Introduction

Cavo-tricuspid isthmus ablation (CTA) is the first line procedure in patients with typical atrial flutter (AFL) for adequate rhythm and symptoms control with low complication rates and excellent results. Given its apparent simplicity, rarely do we take clinical factors in account before referral.

Aim

To identify predictors of survival after typical AFL ablation.

Methods

Single-center retrospective study of pts with typical AFL submitted to ablation between 2015 and 2019. Pts clinical characteristics were collected. Statistical analysis was performed using Cox regression (for multivariate analysis), Chi-square and Mann-Whitney (for univariate analysis) to identify predictors of survival.

Results

A total of 476 pts (66±12 years, 80% males) underwent CTA. Regarding global clinical characteristics, median body mass index (BMI) 27.3 (IQ 24.5–30.4), median CHA2DS2-VASc score 2 (IQ 1–3), 27.3% with diabetes, 53.9% with dyslipidemia, 69.5% with hypertension, 12% with current tobacco abuse, thyroid disfunction in 10.9%, ischaemic cardiomyopathy in 13.7%, heart failure in 27.8% (3.6% of pts with reduced ejection fraction), chronic kidney disease (CKD) stage 3 or more in 17.7%, obstructive sleep apnea (OSA) in 11.9% and chronic obstructive pulmonary disease (COPD) in 9.5% of pts. Before CTA ablation, 444 pts were under anticoagulation, which was stopped in 293 pts after the procedure. The follow up period was 2.8 years.

In this population, COPD (p=0.005), CKD (p<0.001), heart failure (p=0.0027) and BMI less than 25 (p=0.02) were associated with reduced survival on univariate analysis; patients with BMI between 25 and 30 had better prognosis. On multivariate analysis, CKD was the only independent predictor of reduced survival (HR 0.366; CI95%: 0.132–0.737, p=0.005). There was no difference between genders (p=NS).

A CHA2DS2-VASc score of ≥4 predicted higher mortality (HR: 3.0) in all three groups, although the anti-coagulation suspension had no impact on survival (p=NS).

Conclusion

In this subset of patients, the presence of COPD, heart failure, BMI less than 25 and CHA2DS2-VASc score ≥4 predicted reduced survival, being CKD stage 3 or more an independent predictor. The suspension of anti-coagulation didn't impact on survival. These results can help us to better select pts to the procedure and decide on whether to stop anti-coagulation, although larger studies are still needed.

Funding Acknowledgement

Type of funding sources: None. BMI impact on survivalCKD impact on survival
Carbon footprint as a marker of environmental impact in patients included in a remote monitoring pacemaker programme
Authors: Perez Diaz P , Jimenez Diaz J , Higuera Sobrino F , Bastante Diaz M C , Campos Perez De Madrid E , Fernandez Trujillo A , Cano Rosado L , Bermejo Calvillo N , Casas De Miguel A M ,   University General Hospital of Ciudad Real, Ciudad Real, Spain.
Published: October 2021

Background

When patients fitted with pacemakers have to attend arrhythmia appointments, this often involves their caregivers having to take time off work, along with an increase in spending on transport and the amount of CO2 emissions into the atmosphere (carbon footprint). The remote monitoring of pacemakers implemented at our Arrhythmia Unit reduces the social, occupational, financial and environmental impact.

Purpose

We describe the impact of remote monitoring of pacemaker implemented by our Arrhythmia Unit in our patient's live and the reduction in social, occupational and financial impact on these patients, and we quantify the decrease in CO2 emissions.

Methods

Prospective observational study including 160 patients on the remote monitoring programme between 2016 and 2017. We handed a satisfaction survey to these patients after the face-to-face monitoring appointment, which analysed variables such as waiting time, attention and treatment received, need for accompaniment of a relative, method of travel and kilometres travelled, etc. Finally, we quantified the carbon footprint of each patient's journey and compared the level to the results if all the monitoring appointments had been in person.

Results

Patients spent a median of 60±30 minutes in remote monitoring, with a distance travelled of 1.4±4.9 km. In face-to-face appointments, most patients were accompanied (85.6%) and arrived by private car (66.3%), with 54% of family members needing to take time off work. The median time spent was 150±120 minutes, and the distance travelled was 63±105 km. The carbon footprint emitted by individuals included in the remote monitoring programme was 138±114, with an estimated saving of 15±33 kg of CO2 (9.6%) per remote monitoring cycle (Figure 1).

Conclusions

The remote monitoring pacemaker programme in the health district of our city has a very positive healthcare, social-occupational and environmental impact, which is manifested both from an objective point of view (greater independence, less time spent per appointment, less distance travelled, fewer healthcare transport needs, less workplace absenteeism by family members and approximately a 10% reduction in CO2 emissions per monitoring cycle) and a subjective point of view (lower impact of appointments on patients' lives and greater perception of satisfaction from the patients and their companions).

Funding Acknowledgement

Type of funding sources: None.
Assessment of cardiac autonomic function in patients with permanent and paroxysmal atrial fibrillation
Authors: Khan A.A , Junejo R.T , Thomas G.N , Fisher J.P , Lip G.Y.H
Published: October 2021

Background

Atrial fibrillation (AF) is the commonest abnormal heart rhythm with significant related morbidity and mortality. There is increasing evidence that abnormalities of the cardiac autonomic nervous system (ANS) are involved in the pathogenesis of AF. Exploring the ANS is possible through heart rate variability (HRV) evaluation.

Purpose

To investigate whether HRV is more abnormal in patients with permanent AF compared to paroxysmal AF.

Design

In a cross-sectional comparison, we studied two patient groups: permanent AF (n=30) and paroxysmal AF (n=31). Time-domain, frequency-domain and non-linear measures of HRV were determined using eMotion Faros ECG sensor. Participant's breathing was controlled with a metronome set at 12 breaths per minute. Data was analysed using SPSS software.

Results

Time-domain and non-linear indices of HRV were significant higher in permanent AF group compared to paroxysmal AF (table 1). Permanent AF was the only independent predictor of HRV on multivariable analysis in this cohort of patients (p=0.006)

Conclusions

First study investigating autonomic function in patients with permanent AF and paroxysmal AF. HRV indices were significantly higher in permanent AF compared to paroxysmal AF which may suggest pronounced cardiac autonomic influence in the pathophysiology of permanent AF.

Funding Acknowledgement

Type of funding sources: None.
Circulatory microRNAs as potential biomarkers for major adverse cardiac events in patients with atrial fibrillation
Authors: Nopp S , Van Der Bent M.L , Koenigsbruegge O , Wojta J , Pabinger I , Ay C , Nossent A.Y
Published: October 2021

Background

Stratification for subsequent cardiovascular events among patients with atrial fibrillation is of great interest and could aid in guiding preventative strategies. However, current clinical and routine laboratory markers lack in accuracy to predict major adverse cardiac events (MACE). Thus, new prognostic approaches are needed. Small non-coding RNAs are present and stable in the circulation and reflect their tissue, or even their vascular bed, of origin, and may therefore be optimal candidate biomarkers to reflect disease status.

Purpose

We aimed to investigate small non-coding RNAs (e.g. microRNAs [miRNAs], transfer RNAs [tRNAs] -derived fragments) and their prognostic potential as biomarkers for cardiovascular events in patients with atrial fibrillation.

Methods

We conducted a nested case-control study within the framework of the BRAHMS (BioRepository of Atrial Fibrillation and HeMostasiS) registry, in which patients with atrial fibrillation were included and followed-up at a 6- to 12-month interval. Patients who experienced MACE (i.e. stroke, myocardial infarction, cardiovascular death) within a year after inclusion were defined as cases (n=13) and were matched by age, sex, and CHA2DS2-VASc score to controls who remained event-free (n=13). In all 26 patients, total small RNA-sequencing was performed on plasma samples collected and stored at study inclusion. The Benjamini-Hochberg procedure was used to control the false discovery rate (FDR).

Results

We detected 184 well-expressed miRNAs, 47 tRNAs, and 280 other non-coding RNAs, and did not find differences in expression between cases and controls, respecting a threshold of an FDR-adjusted p-value <0.05. However, in the subgroup analysis of patients with subsequent cardiovascular death (5 cases vs. matched controls), three miRNAs (miR-150-5p, miR-127-3p, miR-1908-5p) were significantly associated with cardiovascular mortality (FDR-adjusted p<0.05) (Figure 1).

Conclusion

This study proposes three well-expressed circulating miRNAs derived from peripheral blood as potential biomarkers for early cardiovascular death in patients with atrial fibrillation. Our findings are currently being verified in a larger study and in a different patient population.

Funding Acknowledgement

Type of funding sources: None.
Prevalence and impact of frailty in patients with atrial fibrillation: a systematic review and meta-analysis
Authors: Proietti M , Romiti G.F , Raparelli V , Diemberger I , Boriani G , Marzetti E , Lip G.Y.H , Cesari M
Published: October 2021

Background

Frailty is a clinical syndrome characterized by a reduced physiologic function, increased vulnerability to stressors, and an increased risk of adverse outcomes. Patients with Atrial Fibrillation (AF) are often burdened with a high number of comorbidities and prone to frailty. The prevalence of frailty, its management and association with major outcomes in patients with AF are still unclear.

Purpose

To estimate the pooled prevalence of frailty in patients with AF, as well as its association with AF-related risk factors and comorbidities, oral anticoagulants (OAC) prescription, and major outcomes.

Methods

We systematically searched PubMed and EMBASE, from inception to 31st January 2021, for studies reporting the prevalence of frailty (irrespective of the tool used for assessment). Pooled prevalence, odds ratio (OR), and 95% Confidence Intervals (CI) were computed using random-effect models; heterogeneity was assessed through the inconsistency index (I2). This study was registered in PROSPERO: CRD42021235854.

Results

A total of 1,116 studies were retrieved from the literature search, and 31 were finally included in the systematic review (n=842,521 patients). The frailty pooled prevalence was 39.6% (95% CI=29.2%-51.0%, I2=100%; Figure 1). Significant subgroup differences were observed according to geographical location (higher prevalence found in European-based cohorts; p=0.003) and type of tool used for the assessment (higher prevalence in studies using the Clinical Frailty Scale and Tilburg Frailty Index tools; p<0.001). Meta-regressions showed that study-level mean age and prevalence of hypertension, diabetes, and history of stroke were directly associated with frailty prevalence. Frailty was significantly associated with a 29% reduced probability of OAC prescription in observational studies (OR=0.71, 95% CI=0.62–0.81). Frail patients with AF were at higher risk of all-cause death (OR=4.12, 95% CI=3.15–5.41), ischemic stroke (OR=1.55, 95% CI=1.01–2.38), and bleeding (OR=1.55, 95% CI=1.12–2.14), compared to non-frail patients with AF.

Conclusions

In this systematic review and meta-analysis analysis, the prevalence of frailty was high in patients with AF, and associated with study-level mean age and prevalence of several stroke risk factors. Frailty may influence the management of patients, and worsening the prognosis for all major AF-related outcomes.

Funding Acknowledgement

Type of funding sources: None. Prevalence of Frailty among AF patients
Quarterly versus annual ECG screening for atrial fibrillation in older Chinese (AF-CATCH): a prospective, randomised, controlled trial
Authors: Zhang W , Chen Y , Wang J.G ,   AF-CATCH
Published: October 2021

Background

Screening for atrial fibrillation before symptoms manifested and subsequent initiation of oral anticoagulants (OACs), could prevent stroke and death. The most cost-effective strategy to screen atrial fibrillation in high-risk population aged 65 and over remains unknown.

Methods

We performed a randomised controlled trial that compares different screening frequencies of 30-second single-lead electrocardiography (ECG) in the detection of atrial fibrillation in Chinese residents (≥65 years old) in 5 community health centres in Shanghai. Participants without atrial fibrillation were randomised in a 1:1 ratio into annual (G1) and quarterly screening (G2) groups: the quarterly screening group was further randomised in a 3:1 ratio into subgroups of quarterly screening (G2–1) and quarterly screening PLUS (G2–2, ECG weekly for 1-month then quarterly). The primary outcome was the detection rate of atrial fibrillation. The intention-to-treat analysis was performed for all randomised patients who had at least one ECG recording during follow-up.

Results

Between April 17, 2017, and June 26, 2018, a total of 8240 participants were randomised into G1 (n=4120), G2–1 (n=3090) and G2–2 (n=1030), with a mean of 1.6, 3.5 and 5.2 ECG records respectively during a median of 2.1 years follow-up (13,284 person-years). 73 incident cases of atrial fibrillation occurred: 26 in G1 (4.1/1000 person-years) and 47 in G2 (6.7/1000 person-years; hazard ratio with G1, 1.71; 95% confidence interval [CI] 1.06–2.76; P=0.03). 40 incident cases were detected in G2–1 (7.2/1000 person-years; hazard ratio with G1, 1.83; 95% CI 1.12–3.00; P=0.02) and 7 in G2–2 (4.8/1000 person-years; hazard ratio with G1, 1.24; 95% CI 0.54–2.86; P=0.61). No significant difference was noted between G2–1 and G2–2 (hazard ratio with G2–1, 0.68; 95% CI 0.30–1.52; P=0.35).

Conclusion

Quarterly 30-second single-lead ECG screening significantly increased the detection rate of incident atrial fibrillation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bayer Healthcare Company
Diagnostic accuracy of D-dimer to detect left atrial thrombus in patients with atrial fibrillation: a systematic review and meta-analysis
Authors: Diaz-Arocutipa C , Gonzales-Luna A.C , Branez-Condorena A , Hernandez A.V
Published: October 2021

Background

There is limited evidence on the use of biomarkers to diagnose left atrial thrombus in atrial fibrillation.

Purpose

We evaluated the diagnostic accuracy of D-dimer to detect left atrial thrombus in patients with atrial fibrillation.

Methods

We searched four electronic databases from inception to December 16, 2020 for observational studies evaluating diagnostic accuracy of D-dimer. Reference standard was left atrial thrombus detected by transesophageal echocardiography. Study quality was assessed with the QUADAS-2 tool. We performed a bivariate random-effects meta-analysis to calculate the pooled sensitivity and specificity with their 95% confidence intervals (95% CI). In addition, a summary receiver operating characteristic curve and optimal cut-off were estimated.

Results

Eleven cross-sectional studies involving 4380 patients were included. The mean age ranged from 49.8 to 74.1 years and 70% of patients were men. Left atrial thrombus was present in 7% of cases. In seven studies, the pooled sensitivity of D-dimer at 500 ng/mL was 53% (95% CI, 26–79%) and the pooled specificity was 92% (95% CI, 80–97%). The pooled sensitivity of age-adjusted D-dimer was 35% (95% CI, 18–57%) and the pooled specificity was 100% (95% CI, 100–100%) in two studies. The optimal cut-off was 390 ng/mL in 10 studies with a pooled sensitivity of 68% (95% CI, 44–85%) and a pooled specificity of 73% (95% CI, 54–86%). The risk of bias was low or unclear for all domains. Concerns regarding applicability were generally low for almost all studies

Conclusion

Our meta-analysis suggests that D-dimer has the potential to be useful to the detection of left atrial thrombus in patients with atrial fibrillation.

Funding Acknowledgement

Type of funding sources: None.
Left ventricular diastolic dysfunction in non-severe chronic obstructive pulmonary disease as a step forward in cardiovascular comorbidome
Authors: Cherneva Z.H , Cherneva R
Published: October 2021

Background

Chronic obstructive pulmonary disease (COPD) augments the likelihood of having left ventricular diastolic dysfunction (LVDD) – precursor of heart failure with preserved ejection fraction (HFpEF). LVDD shares overlapping symptomatology (cough and dyspnea) with COPD.

Purpose

Our aim was to evaluate the predictive value of inflammatory, oxidative stress, cardio-pulmonary and echocardiographic parameters at rest for the diagnosis of stress LVDD in non-severe COPD patients, who complain of exertional dyspnea and are free of overt cardiovascular diseases.

Methods

A total of 104 COPD patients underwent echocardiography before cardio-pulmonary exercise testing (CPET) and 1–2 minutes after peak exercise. Patients were divided into two groups based on peak E/e': patients with stress induced left ventricular diastolic dysfunction (LVDD) - E/e' >15 (HFpEF) and patients LVDD (without HFpEF). CPET and echocardiographic parameters at rest were measured and their predictive value for stress E/e' was analysed. Markers for inflammation (resistin, prostaglandine E2) and oxidative stress (8-isoprostanes) were also determined.

Results

Stress induced LVDD occurred in 67/104 patients (64%). Those patients had lower work load, lower VO2 consumption, lower minute ventilation and higher VE/VCO2 slope in comparison to patients without. Except for prostglandine E2, none of the inflammatory, oxidative stress markers correlated to stress E/e'. The best independent predictors for HFpEF were RAVI, right ventricular parasternal diameter and RV E/A >0.75. Their combination predicted HFpEF with the accuracy of 91.2%.

Conclusion

There is a high prevalence of HFpEF in non-severe COPD with exertional dyspnea, free of overt cardiovascular disease. RAVI, right ventricular parasternal diameter and RV E/A >0.75 were the only independent clinical predictors of HFpEF.

Funding Acknowledgement

Type of funding sources: None.
Automated external defibrillators delivered by drones to patients with suspected out-of-hospital cardiac arrest
Authors: Schierbeck S , Hollenberg J , Nord A , Svensson L , Nordberg P , Ringh M , Forsberg S , Lundgren P , Axelsson C , Claesson A
Published: October 2021

Background

Early defibrillation is critical for the chance of survival in in out-of-hospital cardiac arrest (OHCA). Drones, used to deliver automated external defibrillators (AEDs), may shorten time to defibrillation, but this has never been evaluated in real-life emergencies.

Purpose

The aim of this study was to investigate the feasibility of AED-delivery by drones in real-life cases of OHCA.

Methods

In this prospective clinical trial, three AED-equipped drones were placed within controlled airspace in Sweden, covering approximately 80,000 inhabitants (125km2). Drones were integrated in the emergency medical services for automated deployment in beyond-visual-line-of-sight flights in; a) consecutive real-life suspected OHCAs b) test-flights from 06–01–20 to 09–30–20. Primary outcome was the proportion of successful AED-deliveries when drones were dispatched in cases of suspected OHCA. Among secondary outcomes were the proportion of cases where AED-drones arrived prior to ambulance and time benefit vs. ambulance.

Results

Totally 14 cases were eligible for dispatch during the study period in which AED-drones took off in 12 alerts to suspected OHCA; with a median distance to location 3,1 km (IQR:2,8–3,4). AED-delivery was feasible within 9 meters (IQR:7,5–10,5) from the location and successful in 11 alerts, 92%. AED-drones arrived prior to ambulances in 64%, with a median time benefit of 01:52 minutes (IQR:01:35–04:54). In an additional 61 test-flights the AED-delivery success rate was 90% (55/61).

Conclusion

In this pilot study, we have shown that AED-delivery by drones in real-life cases of OHCA is feasible with a substantial time benefit and a successful delivery rate of 92%. Further technological improvements are needed to increase dispatch rate and time gains.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swedish heart-lung foundation