bluuebunny/crossref_metadata_2025 huggingface dataset:
Gender gap in study inclusion: Insights from the STAR-FIB cohort study
Authors: Tanner H , Goulouti E , Lam A , Elchinova E , Nozica N , Servatius H , Noti F , Seiler J , Baldinger SH , Haeberlin A , Franzeck F , Asatryan B , Reichlin T , Roten L
Published: May 2022

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Swiss National Science Foundation Swiss Heart Foundation

Background

The underrepresentation of women in cardiovascular clinical trials is well described but cannot be fully explained by sex-specific differences in the prevalence of cardiovascular diseases. Data on potential sex- and gender-related differences in study exclusion reasons are scarce.

The STAR-FIB cohort study aimed to estimate the age and sex-specific prevalence of screening-detected atrial fibrillation (AF) in 800 hospitalized patients aged 65-84 years using serial seven-day ECGs. Recruitment for study inclusion was stratified by sex (female/male, as stated in the patient’s records) and age (four age bands, ≥65 to <70, ≥70 to <75, ≥75 to <80, and ≥80 to <85 years), and was truncated for each subgroup after the inclusion of 100 participants.

Purpose

To assess sex and gender differences in patient recruitment for inclusion in the STAR-FIB cohort study.

Methods

A screening log containing sex-category, age, and reasons for exclusion was maintained. Exclusion criteria are shown in the figure. For the purpose of the present study, an explorative analysis of all exclusion criteria with respect to sex category was done.

Results

Overall, 11’470 patients were identified for eligibility, 795 patients (49% women; mean age 75 years) were enrolled, and 10’675 patients (52% women vs. 48% men, p =0.13) were not enrolled. The two major exclusion reasons were unwillingness to participate, which was more frequent in women (27.9% of women vs. 18.4% of men, p < 0.01), and the presence of clinical AF, which was more prevalent in men (27.1% of men vs. 20.5 % of women, p < 0.01). A detailed analysis of all exclusion criteria analysed by sex category is provided in the figure.

Conclusions

Clinical AF was more frequent in men, in accordance with the well described sex-driven (biological) higher prevalence of AF in men. In contrast, we found a higher percentage of women unwilling to participate in this study, which may represent a more gender-based (sociocultural) phenomenon. A further exploration of these findings should be performed and may help to identify and potentially overcome modifiable obstacles for study participation.
Atrial fibrillation is associated with an increased risk of ventricular arrhythmias and sudden death in the general population
Authors: Fawzy AM , Bisson A , Bodin A , Herbert J , Lip GYH , Fauchier L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) has been linked to an increase in the risk of ventricular arrhythmias.

Purpose

We aimed to investigate whether AF is associated with an increased risk of ventricular tachycardia (VT), ventricular fibrillation (VF) and sudden death (SD).

Methods

Hospitalised patients from 2013 with and without AF were identified from the French National database and included if they had at least 5 years of follow-up.

Results

Over a median follow-up period of 5.4 years (interquartile range (IQR) 5.0-5.8 years), a total of 3345638 patients were identified. Of these, 312226 had AF and 3033412 did not have AF. After multivariable analysis, the predictors significantly associated with VT, VF and SD included age, sex, hypertension, diabetes mellitus, heart failure, history of pulmonary oedema, valve disease, dilated cardiomyopathy, coronary artery disease, vascular disease, AF, smoking, dyslipidaemia, obesity, alcohol related diagnoses, chronic kidney disease, lung disease, liver disease, inflammatory diseases, anaemia, previous cancer, poor nutrition, cognitive impairment, and frailty.

The incidence of VT, VF and SD was higher in those with AF compared to those without AF (2.23%/year vs. 0.56%/year). AF was associated with a higher risk of incident outcomes compared to no AF, hazard ratio (HR) 3.657 (confidence interval (CI) 3.604-3.711). After adjustments were made for confounders (Figure 1), this increased risk was still significant HR 1.167 (CI 1.111-1.226). A 1:1 propensity score matched analysis was also performed (n=289,332 in each group), demonstrating the significantly increased risk of ventricular arrhythmias and SD in patients with AF compared to those without AF, HR 1.339 (CI 1.313-1.366).

Conclusion

The findings from our study AF indicate that AF is associated with an increased risk of VT, VF and sudden death in the general population.
Is there clinical utility to replacement of an implantable loop recorder in patients who have previously undergone cryoballoon pulmonary vein isolation?
Authors: Musat D , Milstein N , Saberito M , Bhatt A , Habibi M , Preminger M , Sichrovsky T , Shaw R , Mittal S
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Implantable loop recorders (ILRs) are used for long-term ECG monitoring following catheter ablation in patients (pts) with atrial fibrillation (AF) to guide clinical management. However, little is known about what do when the ILR reaches end of service (EOS).

Purpose

To identify pts who underwent replacement of their ILR and determine the diagnostic yield and clinical utility of the replacement device.

Methods

We enrolled 222 consecutive pts with AF who underwent cryoballoon pulmonary vein isolation (CB PVI) and had an ILR. We identified pts who subsequently underwent ILR replacement. The diagnostic and clinical utility of the newly replaced ILR was determined.

Results

The cohort included 56 pts (64 + 9 years; 35 [63%] male; 27 [48%] PAF; CHA2DS2-VASc 2.3 ± 1.5) in whom the initial ILR reached EOS. They were followed for 3.7 ± 2.1 years. Recurrent AF was observed in 41 (73%) of these pts; this triggered an intervention in 17 (41%) pts (Figure). Of the other 15 (27%) pts without any documented AF, anticoagulation was withheld in 13 [87%] pts. Following ILR replacement, 33 (80%) of the 41 pts had more AF (n=11 [33%] required an intervention) and 5 additional pts had AF for the first time.

Conclusions

Our data show that after CB PVI, ILRs help guide decisions regarding rhythm management and oral anticoagulation. When the initial ILR was replaced by a second ILR, AF was detected (often for the first time) in some patients; the findings were used to guide clinical decision making in the entire cohort. Thus, at this time, it remains undefined when ECG monitoring of these pts can be stopped because it is no longer clinical meaningful.
Comparison of various late gadolinium enhancement magnetic resonance imaging methods to high-definition voltage and activation mapping for detection of atrial cardiomyopathy
Authors: Eichenlaub M , Mueller-Edenborn B , Minners J , Hein M , Ruile P , Lehrmann H , Schoechlin S , Allgeier J , Bohnen M , Trenk D , Neumann F-J , Arentz T , Jadidi A
Published: May 2022

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Medtronic

Background/Introduction

Atrial cardiomyopathy (ACM) is associated with the progression from paroxysmal through persistent to permanent atrial fibrillation (AF) and increased arrhythmia recurrence rates after pulmonary vein isolation (PVI).

Purpose

We compare the most common left atrial (LA) late gadolinium enhancement magnetic resonance imaging (LGE-MRI)-methods (Utah-method and image-intensity-ratio (IIR)-methods) and endocardial voltage mapping for ACM-detection and outcome prediction after PVI for AF.

Methods

In this prospective study, 37 ablation-naive patients (66±9 years, 84% male) with persistent AF were included and electrically cardioverted into sinus rhythm. Subsequently, they underwent LA-LGE-MRI and high-definition voltage and activation mapping (2129±484 sites) in sinus rhythm prior to PVI. MRI-post-processing-analyses were performed by two independent expert laboratories (Marrek for the Utah segmentation as describers of this methodology and Adas 3D medical as developers of the Adas software for the IIR-methods) which were blinded to any clinical data. Arrhythmia recurrence was recorded within 12 months following PVI.

Results

The global ACM-extent was highly variable: median LA low-voltage substrate (LA-LVS) was 12.9% at <1.0mV and 2.7% at <0.5mV; median LA-LGE-extent using the Utah-method was 18.3% and 0.03%-93.1% using the IIR-methods. LA activation time was significantly correlated with LA-LVS (r=0.76 at <0.5mV and r=0.82 at <1.0mV, both p<0.0001), but not with LA-LGE-extent.

The highest regional matching between LA-LVS <0.5mV and LA-LGE was found for the anterior wall in 57% of patients using the Utah-method and in 59% using IIR 1.20. The corresponding values for the posterior wall were 19% and 38%, respectively.

Arrhythmia recurrence occurred in 15 (41%) patients. Freedom from arrhythmia was significantly lower in those with relevant LA-LVS (≥2cm2 at 0.5mV) but not in those with relevant LGE (Utah-stages III&IV): 43% versus 81%, p=0.009 and 50% versus 67%, p=0.338, respectively. Furthermore, relevant

LA-LVS was the only predictor for arrhythmia recurrence in multivariate regression analysis.

Conclusion

The different LA-LGE-MRI methods have large dicrepancies regarding extent and distribution of ACM and are different to the extent and regional distribution of LA-LVS as assessed in endocardial high-definition voltage mapping in sinus rhythm. Further improvements of the LA-LGE-MRI-methods are required to enable correct diagnosis of ACM and for future evaluation of MRI-guided ablation protocols.
Healthy lifestyle and atrial fibrillation recurrence after pulmonary vein isolation
Authors: Krisai P , Knecht S , Badertscher P , Voellmin G , Spiess F , Schaer B , Osswald S , Sticherling C , Kuehne M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Data on the relationship of a healthy lifestyle at the time of atrial fibrillation (AF) ablation with AF recurrence is limited.

Purpose

We investigated the association of healthy lifestyle markers with AF recurrence after ablation.

Methods

In 1439 patients undergoing AF ablation at a tertiary university hospital, a lifestyle score was built. The score included categories of BMI, smoking, blood pressure, fish intake, fruits/vegetable intake, alcohol consumption and physical activity. A higher score indicated a healthier lifestyle and patients were grouped into tertiles. Follow-up included 24h-Holter ECGs at 3 and 6 months and 7d-Holter ECGs at 12 months. Survival analyses and Cox-regression models were used to assess associations of individual factors and score-tertiles with AF recurrence.

Results

Mean age was 61.5 years, 25.9% were female and 59.1% had paroxysmal AF. In 941 patients all lifestyle score variables were available: 129, 675 and 137 patients were in the low, intermediate and high lifestyle group, respectively. Over increasing lifestyle groups, patients were more often female (9.3, 23.3, 38.7%; p<0.0001), had less hypertension (70.5, 53.3, 32.9%; p<0.0001), diabetes (15.5, 6.2, 3.7%; p=0.0002), a smaller left atrial diameter (44.1, 41.0, 37.6mm; p<0.0001) and numerically more paroxysmal AF (56.6, 62.4, 69.4%; p=0.32) with no differences in anti-arrhythmic drugs. In survival analyses (Figure), we saw a trend of more recurrences in the healthiest group compared to the unhealthiest group (logrank p=0.06 for low vs high group). Individually, higher fish intake (logrank p=0.04) and lower blood pressure (logrank p=0.02) were associated with AF recurrence. In Cox-regression models the HR (95% CI) for increasing lifestyle groups was 1.21 (0.98; 1.50, p=0.07). In individual models only higher fish intake (1.25 [1.01; 1.55], p=0.045) was associated with AF recurrence.

Conclusion(s): AF recurrence was numerically more frequent in patients with a healthier lifestyle, despite less comorbidities and smaller LA diameters. This paradoxical relationship might be due to lifestyle changes after PVI, differences in PVI efficacy or residual confounding. Further studies are needed to better understand this association.
Pulsed field ablation for paroxysmal atrial fibrillation is safe for the brain
Authors: Reinsch N , Fueting A , Hoewel D , Bell J , Lin Y , Neven K
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

While symptomatic thromboembolic events are rare, silent cerebral emboli (SCL) or events (SCE) are a common observation after LA ablation for AF, using thermal ablation techniques. Pulsed field ablation (PFA) is a novel, non-thermal ablation modality that is able to ablate myocardial tissue with minimal e!ect on surrounding tissue. Preclinical data show absence of cerebral emboli after extensive PFA ablation. However, clinical data on SCL/SCE after PFA are rare.

Objective

We investigated neurological deficits and/or SCL/SCE after PFA in paroxysmal AF using National Institutes of Health Stroke Scale (NIHSS) scores to quantify cerebral impairment and cerebral MRI.

Methods

LA appendage thrombus exclusion was done by CT-angiography. PVI using PFA was performed with interrupted oral anticoagulation at the day of the procedure and heparin administered before single transseptal puncture (target ACT >325 sec.). In all procedures, extensive high-density pre- and post-ablation 3D bipolar voltage maps were performed to document PVI. NIHSS scores were assessed at baseline, days 2 and 30 after PVI. One day after PVI, a cerebral 1.5 Tesla MRI using di!usion-weighted imaging (DWI) and FLAIR sequences to document occurrence of SCL/SCE was performed.

Results

In 30 patients (age 63 years; 47% male; CHA2DS2-VASc-Score 2), uncomplicated PFA was performed, with all PVs acutely isolated. Skin-to-skin procedure time was 120 min and LA dwell time was 109 min. In-hospital and 30-day clinical follow-up was uneventful. No patient showed neurological deficits. All NIHSS scores at all stadiums were the minimum value of 0. Cerebral MRI scans were normal in 29/30 (97%) patients. In 1/30 (3%) patient, a single 7-mm cerebellar lesion was observed. Forty days after the procedure, a follow-upMRI scan showed complete regression of the lesion. This origin of this single lesion could not be established. Air embolization after multiple catheter exchanges, or embolization of tissue debris after transseptal puncture cannot be ruled out.

Conclusion

PVI using PFA in patients with paroxysmal AF causes no neurological deficits and shows absence of SCL/SCE in 97% of patients. In one patient, a single small SCL/SCE of unknown origin occurred with complete regression after 40 days. PFA seems to be a safe ablation modality for the brain.
Novel cryoballoon system for pulmonary vein isolation: multicenter assessment of efficacy and safety - The ANTARCTICA study
Authors: Heeger CH , Pott A , Sohns C , Sommer P , Tondo C , Fassini G , Bohnen J , Dahme T , Rillig A , Wakili R , Metzner A , Tilz RR
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) either by balloon devices or point by point radiofrequency (RF) and 3D mapping based catheter ablation forms the cornerstone of invasive atrial fibrillation (AF) treatment and has demonstrated high procedural success and encouraging long-term outcomes. Although equally effective cryoballoon (CB) based PVI offers shorter procedure duration as well as lower complication rates compared to RF based PVI. Beside the worldwide established Arctic Front Advance (AFA) cryoablation system a novel CB ablation system, POLARx was recently introduced. The POLARx CB incorporates unique features which may translate into improved efficacy and safety of CB based PVI. However, multicenter assessment of periprocedural efficacy and safety is lacking up to date.

Methods

From August 5th to october 12th 2020, a total of 317 patients with paroxysmal or persistent atrial fibrillation (AF) underwent POLARx CB based PVI in 5 centers from Germany and Italy. Acute efficacy and safety were assessed.

Results

In 317 patients (mean age 64±12 years, 209/317 (66%) paroxysmal AF) a total of 1256 pulmonary veins (PV) were identified and 1252 (99,7%) PVs were successfully isolated utilizing the mainly the short tip POLARx CB (82%). The mean minimal cryoballoon temperature was -57.9±7 °C. Real-time PVI was visualized in 72% of PVs. The mean procedure time 92±41 minutes with a mean fluoroscopy time of 15±10 minutes.

Concerning periprocedural complications 1 (0.3%) cardiac tamponade successfully treated by pericardial puncture and 4 (1.3%) pericardial effusion without any intervention were detected. A total of 13 phrenic nerve injuries (4.1%) occurred during treatment of the right superior PV (9/13) and right inferior PV (4/13). Phrenic nerve injury recovered in 3/13 (23%) patients until discharge. Two minor bleeding of the groin (0.6%), 1 (0.3%) severe bleeding with intervention, 5 transient air embolism (1.6%) and 3 (0.9%) stroke / TIA has been observed.

Conclusions

In this large multicenter assessment the novel POLARx CB shows a promising efficacy and safety profile. Further studies are necessary to draw final conclusion.
Comparison of ostial versus very wide antral circumferential pulmonary vein isolation using pulsed field ablation
Authors: Tilz R , Heeger C , Eitel C , Vogler J , Phan L , Feher M , Keelani A , Kuck K , Kirstein B
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) is the gold standard for first-time atrial fibrillation (AF) ablation procedures. Wide antral circumferential ablation (WACA) in comparison to ostial PVI has been attributed to an improved rhythm outcome after AF ablation. Pulsed field ablation (PFA) is a novel energy source with promising safety and efficacy advantages over existing ablation methods due to its unique myocardial tissue specificity. Feasibility of PFA for very WACA has not been investigated so far.

Objective

To evaluate procedural characteristics and lesion formation during wide antral circumferential PVI in comparison to ostial PVI using a PFA system.

Methods

Thirty-seven consecutive AF patients underwent first-time PFA under deep sedation. Patients eighter received ostial (ostial group; N = 15: 66 % paroxysmal AF; age: 69 years; 66 % male) or very wide antral (vWACA group; N = 22: 59 % paroxysmal AF; age: 62 years; 73 % male) PFA. Pre and post ablation LA voltage maps were acquired using a 20-pole spiral catheter together with a 3-dimensional electroanatomic mapping system (voltage cutoff ≤0.5 mV). On post ablation maps, lesion size by encircling the ablated area was measured. In all patients, 8 pulse trains (2kV/2.5 sec, bipolar, biphasic, 4x basket/flower configuration each) were delivered to each pulmonary vein (PV). In the vWACA-group, extra pulse trains in flower configuration were added to each PV in a wide antral position continuous intraluminal esophageal temperatures (TESO) were monitored with an S-shaped esophageal temperature probe.

Results

A median of 8 [IQR 8;8] and 10 [IQR 10;11] pulse trains per PV for ostial and vWACA PVI were applied. vWACA PFA resulted in significant larger lesion formation (47.3 cm2 [IQR 39.1; 52.0]) in comparison to ostial PFA (35.5 cm2 [IQR 30.3; 38.1], p=0.013) with consecutive posterior LA wall isolation in 19/22 (86 %) patients (Figure 1). In the vWACA group, median TESO increased by 0.7 °C (TESOmax 36.5 °C [IQR 36.0;36.9]). However, the vWACA approach was not associated with a significant increase in procedure time, sedation dosage or exposure to radiation.

Conclusion

Very wide antral circumferential PFA of the PVs is feasible and was associated with significant larger lesion formation in comparison to conventional ostial PFA. Concomitant posterior LA wall isolation occurred in the majority of patient and did not result in a clinically significant increase of intraluminal esophageal temperatures, procedure time, sedation and radiation dosage.
A novel local impedance algorithm to guide effective pulmonary vein isolation in AF patients: preliminary experience among different voltages of atrial substrate
Authors: Segreti L , Maggio R , De Sanctis V , Stabile G , Battaglia A , Zingarini G , Mantica M , Agresta A , Mazza A , Pandozi C , Dello Russo A , Ottaviano L , Cavaiani M , Malacrida M , Solimene F
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Recently, a novel technology able to measure local tissue impedance (LI) and contact force (CF) aimed at validating ablation endpoints has become available for clinical use.

Purpose

This analysis explores the relationship between LI parameters, substrate characteristics and AF type during ablation in AF patients.

Methods

A novel ablation catheter with dedicated algorithm was used to measure LI at the distal electrode. Each ablation point was characterized in terms of RF delivery time, baseline LI and LI drop during ablation according to different voltages (above or below 0.5 mV) of the atrial substrate. Ablation endpoint was PVI as assessed by entrance and exit block with local capture. Data are reported as mean±SD.

Results

A total of 2032 RFC deliveries from 34 consecutive patients were analyzed (71% paroxysmal AF, 29% persistent AF). All PVs were successfully isolated with an overall procedure time of 128±33min (fluoroscopy time=15.6±9min, RF delivery time=9.6±4s, CF=11.1±7g). The baseline LI was 155±17Ω prior to ablation and 136±14Ω after ablation (p<0.0001, absolute LI drop of 21.0±8Ω) with a LI drop rate equal to 2.8±2Ω/s. Ablation spots were more frequently deployed in high-voltage areas (>0.5mv, n=1240, 61%). Baseline LI and LI drops were both higher when underlying atrial voltages were >0.5mV than when <0.5mV (156±18Ω vs 153.6±16Ω for starting LI, p=0.0032; 22.2±8Ω vs 19.1±8Ω for LI drop, p<0.0001, respectively). No differences were found in terms of both CF and LI after ablation between >0.5mV and <0.5mV (11.0±7g vs 11.2±7g for CF, p=0.3435; 136.4±13Ω vs 135.3±15Ω for ablated tissue LI, p=0.1521, respectively). Low-voltage areas were more frequently detected at ablated spots in persistent AF cases (n=288, 51.9%) than in paroxysmal AF cases (n=504, 35.1%, p<0.0001), however, no differences were found in terms of both baseline LI and LI drop between persistent and paroxysmal AF cases (156.3±17Ω vs 154.6±17Ω for starting LI, p=0.135; 20.7±8Ω vs 21.1±9Ω for LI drop, p=0.1722, respectively).

Conclusions

LI measurements well distinguished contact with high-voltage areas from low-voltage areas and were able to detect significant differences in LI drop during ablation according to the voltage level.
The role of CHA2DS2-VASc score in predicting atrial fibrillation recurrence in patients undergoing pulmonary vein isolation with cryoballoon ablation
Authors: Rordorf R , Iacopino S , Arena G , Molon L , Rovaris G , Sciarra L , Sacchi R , Verlato R , Tondo C , Manfrin M , Perego GB , Mantica M , Pieragnoli P
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation by cryoablation (PVI-C) is a standard therapy for the treatment of atrial fibrillation (AF) with high safety and efficacy profiles. The CHA2DS2 -VASc score is also a well-established predictor of AF stroke. Importantly, the role of CHA2DS2-VASc score is still unknown regarding the long-term clinical outcomes following PVI-C.

Purpose

The aim of this analysis is to evaluate the role of CHA2DS2-VASc score in predicting AF recurrence during long term follow up after PVI-C.

Methods

Patients with recurrent and symptomatic AF underwent an index PVI-C. Data were collected prospectively in the framework of 1STOP ClinicalService® project. Patients were categorized into two groups Low risk (LR) and high risk (HR) (CHA2DS2-VASc score = 0-1 and CHA2DS2 -VASc score ≥2, respectively).

Results

Out of 3313 patients, 1910 (57.6%) had CHA2DS2-VASc score = 0-1, while 1403 (42.3%) were in the HR score group (CHA2DS2 -VASc score ≥2). As expected, patient baseline characteristics were significantly different between the two cohorts including: age, sex, BMI, percentage of paroxysmal AF, history of stroke, diabetes, ischemic cardiomyopathy. On the contrary, procedural times and the incidence of acute complications were comparable between the two groups. The 36-month freedom from AF after a single procedure was 72.5% (95% CI 69.8% - 75.0%) in the LR group and 65.9% (62.3% - 69.2%) in the HR score group (HR: 1.26, 95% CI 1.08-1.47, p= 0003, Figure 1). At multivariate analysis, higher CHA2DS2 -VASc score was still a significant predictor of the risk of AF recurrence [HR: 1.33 (1.10 - 1.60, p=0.003]

Conclusions

PVI-C is highly effective in the treatment of AF over the long term. A CHA2DS2 -VASc score ≥2 is an independent predictor of AF recurrence during the follow-up and should be taken into account in the clinical management after the index procedure.
Pre-ablation interatrial conduction delay or block predicts atrial fibrillation recurrence after ablation among obese patients
Authors: Tandon H , Stout K , Shin D , Ruskamp R , Payne J , Goyal N , Tsai S , Easley A , Khan F , Windle J , Anderson D , Schleifer JW , Naksuk N
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Obesity is associated with greater risk of atrial fibrillation (AF) recurrence post-ablation and higher incidence of conduction delay compared to non-obese patients. Pre-ablation P-wave duration (PWD) and morphology (PWM) indicating interatrial delay are easily assessed in the clinic and may predict AF recurrence post-ablation in these patients.

Purpose

Evaluate the predictive value of PWD and PWM on AF recurrence post-ablation in obese patients.

Methods

Pre-ablation PWD and PWM (negative P-wave in lead II or III) were analyzed on consecutive patients with BMI ≥30 kg/m2 who underwent initial AF ablation from 2012–19. The primary outcome was recurrent AF after a 3-month post-ablation blanking period. Multivariate analysis adjusted for baseline characteristics was performed.

Results

For 205 patients (61.0±9.5 years old, 39.0% female), mean BMI was 36.9±5.7 kg/m2 and 71.7% had persistent AF pre-ablation. Recurrent AF post-ablation occurred in 115 (56.1%) during a median follow up of 491 (270, 1001) days. PWD >130 ms was significantly associated with higher AF recurrence (AHR of 1.62, 95%CI 1.04-2.57, p=0.03) after adjusting for age, persistent AF and left atrial volume index (LAVI). In a subgroup with LAVI <42 mL/m2 (n=112), PWD >130 ms and negative P-waves in lead II or III were independently associated with increased risk of recurrent AF (AHR 2.06, 95%CI 1.12-3.91; p=0.019 and AHR 1.94, 95% CI 1.00-3.56; p=0.05, respectively) (Figure 1).

Conclusion

AF recurred in >50% of obese patients within 1.5 years of ablation. Pre-ablation PWD >130 ms and negative P-waves in lead II or III independently predicted recurrent AF post-ablation in this cohort of obese patients. These easily assessed findings add predictive value to other risk factors.
Catheter ablation for patients with atrial fibrillation and heart failure: insights from the swedish heart failure registry
Authors: Von Olshausen G , Benson L , Dahlstrom U , Lund L , Savarese G , Braunschweig F
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): DFG (Deutsche Forschungsgemeinschaft) to G.O.

Aims

To investigate the association between catheter ablation and mortality as well as hospitalization for heart failure (HF) in patients with atrial fibrillation (AF) and HF across the ejection fraction (EF) spectrum in a contemporary cohort.

Methods

Between 2005 and 2019, patients with first-time catheter ablation for AF (ablation group) compared to only medical treated AF patients (medical therapy group) were identified from the Swedish Heart Failure Registry. The primary outcome (all-cause mortality/first HF hospitalization) was assessed by cox regression models in a 1:2 propensity score (PS) matched cohort and pre-specified EF subgroups (preserved EF [HFpEF] [EF≥50%], mildly reduced EF [HFmrEF] [EF 40% to 49%], reduced EF [HFrEF] [EF<40%]) of this cohort.

Results

452 patients in the ablation and 43766 patients in the medical therapy group were identified. After PS matching, 437 patients in the ablation group were compared to 874 patients in the medical therapy group. Over the entire follow-up, catheter ablation was associated with a lower risk of the primary outcome (Hazard ratio [HR] 0.71 [95%CI, 0.59-0.85]) and first cardiovascular (CV) hospitalization (HR 0.85 [95%CI, 0.72-0.99]) in PS matched analysis. Results were consistent across all EF subgroups. In HFpEF patients, catheter ablation was associated with a significantly lower risk of recurrent HF hospitalization (Incidence rate ratio (IRR) 0.17 [95%CI, 0.07-0.42]).

Conclusion

In this nationwide study, catheter ablation was associated with a significant lower risk of the primary outcome (all-cause mortality/first HF hospitalization) in HF patients with AF. This study advocates catheter ablation as a potent treatment option for AF in HF patients across all EF subgroups, including HFpEF.
Yearly incidence and pattern of very late recurrence of atrial fibrillation as detected by continuous electrocardiographic monitoring using an implantable loop recorder
Authors: Musat D , Milstein N , Saberito M , Bhatt A , Habibi M , Preminger M , Sichrovsky T , Shaw R , Mittal S
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

A very late recurrence (VLR) of atrial fibrillation (AF) is considered present when patients have their first recurrence of AF > 12 months post-ablation. Little is known about the yearly rates and patterns of VLR AF recurrence.

Objective

To assess the yearly incidence and pattern of VLR in pts with AF who underwent cryoballoon (CB) pulmonary vein isolation (PVI).

Methods

We prospectively enrolled consecutive patients with AF who underwent CB PVI and had an implantable loop recorder (ILR) inserted up to 3 months post-ablation. Patients were followed for recurrent AF (excluding a 3-month post-ablation blanking period).

Results

Our cohort included 222 patients (66 ± 9 years; 143 [64%] male; 120 [54%] paroxysmal AF; CHA2DS2-VASc 2.6 ± 1.6). At 1-year, 111 (50%) patients remained free of AF. Two-year follow-up was available in 95 of these patients; 62 (65%) remained in sinus. Three-year follow-up was available in 42 of these patients; 36 (86%) remained in sinus (Figure). Of the 39 patients who developed AF after initially being free of AF for at least 1-year post ablation, 24 (62%) patients had either a frequent or persistent pattern of AF.

Conclusions

Our data show that the greatest likelihood of failure following a CB PVI occurs in the first year of ablation. The rate of failure becomes lower year by year. These data suggest that long term outcome may be driven more by the initial ablation as opposed to progressive evolution of the patient’s substrate
Durability of CLOSE-guided pulmonary vein isolation in persistent atrial fibrillation - First results from a prospective remapping study
Authors: Baldinger SH , Servatius H , Seiler J , Madaffari A , Kueffer T , Muehl A , Asatryan B , Haeberlin A , Noti F , Tanner H , Reichlin T , Roten L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

The CLOSE protocol for pulmonary vein isolation (CLOSE-PVI) combines ablation index and inter-lesion distance (≤6 mm) targets. CLOSE-PVI has been shown to result in high clinical success rates. Data on durability of PVI after CLOSE-PVI mainly derive from repeat procedures in paroxysmal atrial fibrillation (AF) patients with recurrent AF.

Purpose

We sought to assess the incidence of pulmonary vein (PV) reconnections during a staged redo procedure performed independently of AF recurrence 6 months after CLOSE-PVI in patients with persistent AF.

Methods

In this prospective, single-center study, patients with symptomatic persistent AF (EHRA score >1) undergoing AF ablation were included. Close-PVI was performed during the index procedure. A blanking period of 3 months was applied. Seven-day Holter ECGs were performed at 3 and 6 months post ablation. All patients underwent a staged redo procedure including high-density voltage mapping of the left atrium at 6 months after the index procedure.

Results

Overall, 20 patients were included (median age: 68 years [IQR 63-71]; 20% women; median duration of persistent AF: 8 months [IQR 5-15]; median LAVI 45 ml/m2 [IQR 43-53]). All PVs were successfully isolated with CLOSE-PVI during the index procedure. Four patients (20%) had AF recurrence. The redo procedure was performed after a median of 6.1 months (IQR 5.6-7.3). Of 80 PVs, 71 (89%) were still isolated. No patient had a common ostium. Reconnections were observed in 3 left superior (15%), in one left inferior (5%), in one right superior (5%) and in 4 right inferior (20%) PVs. Fourteen patients (74%) had completely isolated PVs. Two of four patients with AF recurrence (50%) and 12 of 16 patients without AF recurrence (75%) had completely isolated PVs (p=0.33).

Conclusions

CLOSE-PVI achieves durable PVI after 6 months in the majority of patients with persistent AF. In half of persistent AF patients with recurrence after CLOSE-PVI, all PVs are still isolated. These patients may need adjunctive ablation.
Comparison of left atrial lesion size and troponin release of two novel single shot devices for pulmonary vein isolation: pulsed field ablation vs. multi-electrode radiofrequency balloon
Authors: Lemoine M , My I , Mencke C , Butt M , Schleberger R , Muenkler P , Rottner L , Moser F , Moser J , Dinshaw L , Reissmann B , Ouyang F , Kirchhof P , Rillig A , Metzner A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulsed-field ablation (PFA) and the multi-electrode radiofrequency balloon (RFB) are two novel ablation technologies to perform pulmonary vein isolation (PVI). It is currently unknown whether these technologies differ in lesion formation and lesion extent.

Purpose

We compared the acute lesion extent after PVI induced by PFA and RFB by measuring low-voltage area in high-density maps and the release of biomolecules reflecting cardiac injury.

Methods

PVI was performed with a pentaspline catheter (FARAPULSE) applying PFA or with the compliant multi-electrode radiofrequency balloon (HELIOSTAR). Before and after PVI high-density mapping with CARTO3 was performed. In addition, blood samples were taken before transseptal puncture and after post-PVI remapping. Serum concentrations of high-sensitive Troponin I (hsTropI) were quantified by Immunoassay.

Results

50 patients undergoing PVI by PFA (n=26, age 71±10 y, 58% males, 58% persistent AF) or RFB (n=24; age 64±13 y, 54% males, 25% persistent AF) were evaluated. Acute PVI was achieved in all patients in both groups. Mean number of PFA pulses were n=34±5 and mean number RFB applications were n=8±3. Total posterior ablation area was bigger in PFA (19.0±6.2 cm²) than in RFB (9.0±2.2 cm²; p<0.001). The posterior distance between septal and lateral lesions was shorter in PFA (23.7±10.5 mm) than in RFB (30.0±7.3 mm; p=0.021). In a total of 38 patients increase of hsTropI was higher after PFA (625±138 pg/ml, n=28) vs. RFB (148±36 pg/ml; n=10; p=0.049) supporting the evidence of larger lesion extent by PFA.

Conclusion

Pulse-field ablation delivers larger acute lesion areas and higher troponin release upon successful pulmonary vein isolation than multi-electrode array balloon-based pulmonary vein isolation in this single-center series.
Mechanism and outcomes of atrial tachycardia ablation in patients with mitral valve surgery
Authors: Yorgun H , Kilic GS , Sezenoz B , Aytemir K
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial tachycardia (AT) is a common rhythm disorder after mitral valve surgery which may comprise both atria. Most of atrial arrhythmias are refractory to antiarrhythmic drugs and catheter ablation is usually required in cases with mitral valvular prosthesis.

Purpose

We aimed to evaluate the ablation outcomes of AT in patients with previous mitral valve (MV) surgery.

Methods

A total of 60 symptomatic patients with AT were enrolled. Activation mapping was performed during tachycardia in all patients as well as entrainment mapping when needed. Scar analysis was also performed when left atrial tachycardia detected.

Results

In 79 procedures, a total of 101 ATs were documented [35 (34.6%) ATs were right-sided, 65 (64.3%) ATs were left-sided and 1(0.9%) AT was biatrial]. Mean number of ATs per procedure was 1.4 ± 0.6. Macroreentry was the primary mechanism in right and left atrium (97% and 66.1%, respectively). Localization and mechanisms of ATs were demonstrated in Figure-1. Anterior wall [53.2%(17.9%-74.6%)], septum [53.7% (34.7%-80.0%)] and roof [40.1% (21.3%-72.5%)] were the left atrial sites with highest ratio of low voltage areas . The mean follow-up duration was 33.4 ± 17.7 months. Freedom from ATa after index procedure was 78.3% at 12 months and 65.9 % at 24 months. After multiple procedures, freedom from ATa was 80%, during the follow-up.

Conclusion

Left ATs are more common compared to the right ATs and macroreentry is the major mechanism in both right- & left ATs. RF ablation of ATs had favourable long-term outcomes in patients with MV surgery.
microRNAs as the predictors for atrial fibrillation recurrence after catheter ablation: next-generation sequencing study
Authors: Sustr F , Machackova T , Pesl M , Trachtova K , Svacinova J , Starek Z , Spinarova L , Kianicka B , Slaby O , Novak J
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): This study was supported by Specific research of the Masaryk University (MUNI/A/1156/2021) and Institutional support project of St. Anne’s University hospital in Brno.

Background

Atrial fibrillation (AF) represents the most common arrhythmia. Catheter ablation (CA) of AF is indicated in patients with recurrent and symptomatic AF episodes fulfilling the criteria stated in the current guidelines. Despite the strict inclusion/exclusion criteria, AF recurrence after CA remains notably high. Thus, identifying a novel marker to more precisely select individuals that will profit from CA would be beneficial. microRNAs, i.e., small non-coding RNAs of the length of approx. 22 nucleotides are known to play crucial roles in the pathophysiology of AF and therefore represent promising biomarkers in the field.

Purpose

Aim of the study was to identify potential plasmatic microRNAs as novel biomarkers for predicting AF recurrence after CA.

Methods

Prospective monocentric and biomarker-screening study. Altogether 49 consecutive AF patients indicated for CA were enrolled. Before the CA, blood sampling was performed, and plasma was isolated. All patients then underwent CA and were followed up for 6 months. Within the close-up visit at the 6th month, 24-hour ECG Holter monitoring was performed to evaluate participants’ rhythm. For the next-generation sequencing (NGS), 5 patients with recurrent AF and 5 age- and BMI-matching patients without recurrent AF were randomly selected from the baseline cohort. NGS was performed using Illumina Instrument, and obtained data were then evaluated using edgeR and DESeq2 algorithms to identify all miRNAs present in the study samples. Filtering was performed to exclude microRNAs with low expression (i.e., base mean value at least 20 and more and expression detectable in all study samples). Comparison of the two groups (with and without AF recurrence) was performed using standard statistical tests with correction for multiple comparisons: differences with log2 fold change above 0,5 or below -0,5 with p < 0,05 were considered biologically and statistically significant.

Results

In total, 2069 various microRNAs were identified. Altogether 59 microRNAs statistically significantly differed between the groups. The most altered microRNAs were as follows: miR-29c-5p, miR-183-5p, miR-190b, miR-206, miR-326, miR-505-5p, miR-548b, miR-574-3p, miR-1294 and miR-1296-5p.

Conclusion

Using NGS, we have identified 59 potential microRNAs whose plasmatic levels are altered between individuals with and without early AF recurrence. If the results are confirmed on the larger patients’ cohort, these microRNAs will represent supportive biomarkers to identify AF patients benefiting from CA.
Left atrial thrombus in atrial fibrillation/flutter patients in relation to anticoagulation strategy: LATTEE registry
Authors: Gawalko M , Kaplon-Cieslicka A , Budnik M , Scislo P , Piatkowski R , Kochanowski J , Opolski G , Grabowski M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) and flutter (AFl) increase the risk of thromboembolism by promoting clot formation in the left atrium. Current guidelines recommend initiation of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) or, preferably, non-VKA-OACs (NOACs) in men and women with a CHA2DS2VASc score of ≥2 and ≥3, respectively. Effective OAC is also recommended 3 weeks before elective AF cardioversion or catheter ablation with pre-procedural ttransesophageal echocardiography (TEE) as an alternative. However, TEE before AF/AFl cardioversion or ablation is often performed even in anticoagulated patients, given that, in clinical practice, "effective" OAC may be difficult to achieve and/or verify.

Purpose

The aim of the study was to assess the prevalence of left atrial thrombus (LAT) in AF/AFl in relation to OAC strategy.

Methods

The Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry was a prospective, observational study enrolling consecutive patients with AF or AFl in whom TEE was performed before direct current cardioversion or catheter ablation, hospitalized in 13 cardiology departments in Poland. Patients’ recruitment process started from November 2018 in the coordinating centre and lasted 12 months since the beginning of the study in each participating centre or longer, i.e., until the inclusion of at least 200 patients at each participating centre (with the last patient enrolled in May 2020).

Results

Of 3109 patients enrolled, 88% were on chronic, 1.5% on transient OAC and 10% without OAC. Of patients on chronic OAC, 39% received rivaroxaban, 30% dabigatran, 14% apixaban and 18% vitamin K antagonists (VKA). Patients on apixaban were oldest, had worst renal function and highest both bleeding and thromboembolic risk, and more often received reduced doses. Overall, prevalence of LAT was 8.0% (7.3% on chronic OAC vs. 15% without OAC; p<0.01). In patients on VKA, prevalence of LAT was doubled compared to patients on non-VKA-OACs (NOACs) (13% vs. 6.0%; p<0.01), even after propensity score matching (13% vs. 7.5%; p<0.01) and in multivariable logistic regression (OR 1.9, 95% confidence interval 1.4-2.8). Prevalence of LAT in patients on apixaban was higher (9.8%) than in those on rivaroxaban (5.7%) and dabigatran (4.7%; p<0.01 for both comparisons). However, in propensity score matching and multivariable logistic regression, there was no difference in the risk of LAT between apixaban and other NOACs.

Conclusions

Prevalence of LAT in AF is non-negligible even on chronic OAC. In the real-world AF/AFl population, the risk of LAT seems higher on VKA compared to NOAC, and similar between different NOACs.
Real world outcomes of minimally invasive epicardial surgical left atrial appendage exclusion in atrial fibrillation patients with high risk of stroke and bleeding
Authors: Friedman DANIEL , Rose DAVID , Calkins HUGH , Digiorgi PAUL , Ramlawi BASEL , Awasthi Y , Ferguson M , Pulugan Z , Tiegland C , Brennan M
Published: May 2022

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): AtriCure, Inc

Introduction

The left atrial appendage (LAA) is the site of thrombus formation in patients with atrial fibrillation (AF) and first line therapy for reducing the risk of stroke is oral anticoagulation (OACs). A subset of patients with AF carry a very high risk of stroke and bleeding and are ineligible for OAC and percutaneous LAA occlusion; these patients may be suitable for minimally invasive thoracoscopic epicardial surgical LAA exclusion (LAAE) which can be used with a wide variety of LAA morphologies with a ~98% rate of complete exclusion. While use of LAAE is well studied as a concomitant procedure, there are relatively few data on its use as a stand-alone procedure.

Purpose

To compare real-world outcomes of LAAE versus no-LAAE in AF patients at high risk of stroke and bleeding who are not on OACs.

Methods

We performed an analysis of Medicare beneficiaries with AF who were not on OACs and received LAAE (ICD10-PCS code 02L74CK, Oct 2015 – Dec 31, 2017) in the absence of a concomitant surgical or catheter AF ablation procedure. Patients were propensity-matched (1:4) to otherwise similar patients who did not receive LAAE (control), using age, gender, race, region, AF type, CHA2DS2-VASc, HAS-BLED, and co-morbidities. The primary endpoint was hospital readmission for a thromboembolic event (ischemic stroke, systemic embolism, or transient ischemic attack). Kaplan Meier event rates were calculated and 95% CI were generated via bootstrapping.

Results

A total of 243 patients who underwent LAAE and 1.7M control patients met study criteria. In the matched cohort, the mean age was 75 years, 61% were men, 77% had non-paroxysmal AF, and the mean CHADS2-VASC and HAS-BLED scores were 5.5 and 4.2, respectively. The 1-year rate of thromboembolism in the LAAE and control arms were 7.3% (95% CI 4.3% -10.9%) and 13.6 (95% CI 11.0% -16.4%) (Figure), respectively, with an absolute and relative risk reduction of 6.2% (95% CI 2.0-10.3, p-value=0.001, NNT 17) and 0.54 (95% CI 0.29-0.68, p=0.001).

Conclusion

Among high-risk AF patients who were not on OAC, LAAE was associated with a clinically meaningful and significantly lower risk of TE. Additional studies are needed to confirm these finding.