bluuebunny/crossref_metadata_2025 huggingface dataset:
P956Improved quality of life and symptomatic atrial fibrillation reduction in patients treated with a standardized ablation index workflow
Authors: Gupta D , Vijgen J , De Potter T , Scherr D , Van Herendael H , Knecht S , Kobza R , Berte B , Sandgaard N , Albenque J , Szeplaki G , Stevenhagen Y , Taghji P , Wright M , Duytschaever M
Published: June 2020

Background/Introduction

The use of a standardized ‘CLOSE’ ablation workflow for pulmonary vein isolation (PVI), with defined inter-tag distance (ITD) with targeted ablation index (AI) values, has been shown in single centre reports to result in good outcomes. The effect of this approach on patients’ quality of life (QoL) has not been studied.

Purpose

To evaluate the effects of paroxysmal atrial fibrillation (PAF) ablation by the CLOSE workflow on QoL and symptomatic AF reduction in the multicenter VISTAX study.

Methods

329 patients with PAF (61.5% male, 61.3 ± 10.1 year) were treated at 17 European centres by point-by-point radiofrequency ablation using the CLOSE protocol to achieve PVI.  An ITD ≤6mm and AI values of ≥400 on the posterior wall and ≥550 on the anterior wall were targeted. The AI value on the posterior wall was lowered as per investigator discretion in case of safety concerns. Patients were monitored for atrial arrhythmia recurrences via weekly and symptom-activated transtelephonic monitoring (TTM), for 12 months post procedure. Patients completed an Atrial Fibrillation Effect on Quality-of-life (AFEQT) questionnaire at their baseline and 12-month follow up visits.

Results

Majority (83.3% [274/329]) of patients experienced freedom from symptomatic atrial recurrence through 12 months. Of the 70 documented recurrences, 34 (49%) were documented by trans-telephonic monitoring only. All domains captured on the AFEQT questionnaire showed improvement with the overall score improving by 25.7, which exceeded the threshold of clinically meaningful improvement (±5) (Table). Patient reported most improvements in PAF control and symptoms relieved. The overall AFEQT score improvement was seen both in patients with or without documented atrial arrhythmia recurrence, with improvement by 21.5 and 26.8, respectively.

Conclusion

PAF ablation using a standardized CLOSE workflow resulted in consistent improvements in QoL. The improved QoL was observed regardless of atrial arrhythmia recurrence likely reflecting the low residual arrhythmia burden in patients with documented recurrence identified only on TTM.

AFEQT Scores Through 12 Months AFEQT Domain Baseline 12 Months Change from Baseline* Daily Activities 59.2 85.3 26.0 Treatment Concerns 62.2 88.1 26.0 Controlling PAF 50.2 87.8 37.5 Symptoms 63.7 89.0 25.1 Symptoms Relieved 52.0 88.4 36.3 Overall AFEQT Score 61.3 87.2 25.7 *only includes patients who completed both baseline and 12 month AFEQT questionnaire
P1415Wide antral circumferential pulmonary vein isolation ablation using a novel balloon cryoablation catheter
Authors: Martin A P , Fowler M , Lever N
Published: June 2020

Background

Pulmonary vein isolation using cryotherapy is an established treatment for the management of patients with paroxysmal atrial fibrillation. Ablation using the commercially available balloon cryocatheter has been shown to create wide antral pulmonary vein isolation. A novel balloon cryocatheter (BCC) has been designed to maintain uniform pressure and size during ablation, potentially improving contact with the antral anatomy. The extent of ablation created using the novel BCC has not previously been established.

Purpose

To determine the anatomical extent of pulmonary vein isolation using electroanatomical mapping when performing catheter ablation for paroxysmal atrial fibrillation using the novel BCC.

Methods

Nine consecutive patients underwent pre-procedure computed tomography angiography of the left atrium to quantify the chamber dimensions. An electroanatomical map was created using the cryoablation system mapping catheter and a high definition mapping system. A bipolar voltage map was obtained following ablation to determine the extent of pulmonary vein isolation ablation. A volumetric technique was used to quantify the extent of vein and posterior wall electrical isolation in addition to traditional techniques for proving entrance and exit block.

Results

All patients had paroxysmal atrial fibrillation, mean age 56 years, 7 (78%) male. Electrical isolation was achieved for 100% of the pulmonary veins; mean total procedure time was 109 min (+/- 26 SD), and fluoroscopy time 14.9 min (+/- 2.4 SD). The median treatment applications per vein was one (range one - four), and median treatment duration 180 sec (range 180 -240). Left atrial volume 32 mL/m2 (+/- 7 SD), and mean left atrial posterior wall area 22 cm2 (+/- 4 SD). Data was available for quantitative assessment of the extent of ablation for eight patients. No lesions (0 of 32) were ostial in nature. The antral surface area of ablation was not statistically different between the left and right sided pulmonary veins (p 0.63), which were 5.9 (1.6 SD) and 5.4 (2.1 SD) cm2 respectively. In total 50% of the posterior left atrial wall was ablated. 

Conclusion

Pulmonary vein isolation using a novel BCC provides a wide and antral lesion set. There is significant debulking of the posterior wall of the left atrium.

Abstract Figure.
P1162Atrial fibrillation and Cardiac resynchronization therapy - is this combination truly bad?
Authors: Graca Rodrigues T E , Nunes-Ferreira A , Cunha N , Santos R , Aguiar-Ricardo I , Rigueira J , Silverio Antonio P , Pereira S C , Morais P , Bernardes A , Pinto F J , Sousa J , Marques P
Published: June 2020

Introduction

 

Cardiac resynchronization therapy (CRT) significantly reduces mortality and hospitalizations in patients with heart failure and reduced ejection fraction (EF). Atrial fibrillation (AF) is a very common comorbidity in these patients, however, CRT benefit in AF patients has been controversial.

Purpose

 

To compare the prognostic impact of CRT in patients (pts) with and without AF.

Methods

Prospective, single-center study that included pts undergoing CRT implantsince 2015. Clinical and echocardiographicevaluation were made before CRT implant and between 6-12 months post-implant. Pts with EF elevation ≥10% or LV end-systolic volume (ESV) reduction ≥15% were classified as responders. Patients with EF elevation ≥ 20% or ESV reduction ≥30% were classified as super-responders. All the parameters were compared between patients with and without AF.Prognostic impact of CRT was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). From these patients, 166 patients (31%) had AF (73.5% males, mean age 72.2 ± 10.2 years, 37.3% ischemic, LVEF < 30% in 65.5%). The cardiovascular risk factors and comorbidities were similar in both populations (with and without AF), except for chronic kidney disease which was more frequent in AF pts(28% vs 17%, p = 0.012). 

The prevalence of complications and surgical revision were similar in both groups.

The CRT response rate was similar in both groups (50% in AF group vs 59.6%, p = NS) as was the super-response rate (22.4% in FA pts vs 31.5%, p = NS).

The 4-year survival rate of patients with AF was similar to non-AF (83.7% vs 84.3%). 

Conclusion

 

Despite the controversy about the efficacy of CRT in AF pts, in our population the long-term survival and CRT response rates were comparable between patients with and without AF.

Abstract Figure.
P1447Use of novel local impedance-based catheter in typical right atrial flutter ablation: preliminary data from a multicenter Italian study
Authors: Ducceschi V , Pandozi C , Arestia A , Rossi L , Bencardino G , Segreti L , Schillaci V , Auricchio C , Aperuta F , Malacrida M , Sangiuolo R
Published: June 2020

Funding Acknowledgements

NO FUNDING

Background

Many studies demonstrated the importance of an optimal tissue contact to obtain safe and effective lesions and to improve the clinical outcome in ablation of cavotricuspid isthmus (CTI) for typical right atrial flutter (AFL). Data about a novel technology able to measure local tissue impedance (LI) providing a measure of tissue characteristics and lesion formation is still lacking in right atrium or CTI working.

Purpose

This analysis explores the relationship between LI measures and ablation spot lesion locations during ablation of CTI in common AFL patients (pts).

Methods

Consecutive pts undergoing AFL ablation from the CHARISMA registry were included. A novel RF ablation catheter with dedicated algorithm (DirectSense - DS -) was used to measure LI at the distal electrode of this catheter. Each targeted spot was characterized in terms of LI parameters during RF delivery at the lateral, intermediate and posterior portions of the CTI. Successful single RF ablation was defined according with a reduction of voltage (RedV) by at least 50% or split in two separate potentials (SPL). Ablation endpoint was the creation of bidirectional conduction block across the isthmus.

Results

A total of 135 ablation spot lesions were delivered in 20 pts (median 5 [3-11] lesions per pt): 7 (5%) at lateral, 88 (65%) at intermediate and 40 (30%) at posterior portions of the CTI. Acute success was obtained in all cases and no complications were observed. The median ablation time was 26 [17 – 36] seconds per lesion. 100 (74%) and 51 (38%) ablation spots were effective according with RedV or SPL, respectively. The mean LI was 106 ± 15Ω prior to ablation and 93 ± 13Ω after ablation (p < 0.0001, mean absolute LI drop 14 ± 7Ω, mean percentage LI drop 13%±6). Effective ablation spots showed a higher absolute impedance drop (15 ± 7Ω at effective RedV vs 9.6 ± 8Ω at ineffective RedV, p = 0.0001; 15.6 ± 7Ω at effective SPL vs 12.5 ± 7Ω at ineffective SPL, p = 0.0173) or % impedance drop (14%±6 at effective RedV vs 9%±7 at ineffective RedV, p < 0.0001; 14.5%±6 at effective SPL vs 11.6%±6 at ineffective SPL, p = 0.0103) compared with ineffective sites. No significant differences were found in terms of starting LI, ending LI or LI drop among CTI areas. The percentage of LI drop was associated both with RedV (odd ratio 1.17 (95%CI: 1.08 to 1.26, p = 0.0001)) and with SPL (odd ratio 1.08 (1.02 to 1.14, p = 0.0132)).

Conclusion

In our preliminary experience, measured LI before and after RF delivery and LI drop appear to be consistent and homogeneous across different CTI ablation locations. The magnitude of the LI drop was associated with effective lesion formation and conduction block.
P1362Diagnostic accuracy of R-wave detection by insertable cardiac monitors
Authors: De Coster M , Demolder A , De Meyer V , Vandenbulcke F , Van Heuverswyn F , De Pooter J
Published: June 2020

OnBehalf

1.Department of Cardiology, Ghent University Hospital, Ghent, Belgium

Introduction

Insertable cardiac monitors (ICM) allow automatic arrhythmia detection but the diagnostic performance can be hampered by poor R-wave sensing leading to false positive recordings.

Purpose

This study assesses the prevalence and predictors of R-wave under- and oversensing among different ICM types. 

Methods

Patients implanted with an ICM at the University Hospital of Ghent between January 2017 and August 2018 were included. All ICM tracings recorded at ICM interrogation or transmitted by remote monitoring were reviewed for inadequate R-wave sensing leading to false arrhythmia alerts. Inadequate R wave sensing was defined as undersensing due to sudden reduction in R wave amplitude or oversensing due to the occurrence of artefacts. Patient and implant characteristics were retrieved from the medical record and implant reports.

Results

The study screened 135 patients (age 59 ± 19 years, 44% female) implanted with different ICM types: Reveal XT and LINQ n = 92 (68%), Confirm and Confirm Rx n = 35 (26%),  BioMonitor n = 8 (6%). ICM analysis was conducted in 112 patients (83%). Overall, false arrhythmia alerts due to inadequate R wave sensing occurred in 22 (20%) of the patients. Among these 22 patients, false diagnosis of bradycardia or pauses were documented in 64%, false high ventricular rates in 14% and false atrial fibrillation alerts in 22% of the patients. Of interest, in an additional 7 (6%) patients significant changes in R wave sensing occurred, although not causing false arrhythmic alerts. Occurrence of R-wave changes occurred in 19% of Reveal, 17% of Confirm and 50% of BioMonitor ICMs (p = not significant). Occurrence of R-wave changes among the different types of ICMs were not related to age, sex, BMI, time of the day, heart frequency or implant R-wave sensing.

Conclusion

Poor R wave sensing, leading to false arrhythmia detection, occurred in a significant number of ICM, and seems to occur independent of ICM type, patient or implant characteristics.

Abstract Figure.
P967Role of low voltage ablation in catheter ablation of patients with persistent AF- a single centre experience
Authors: Panagopoulos D , Nagy S , Kim S , Lampridou M , Linton N , Lefroy D , Whinnett Z , Ng F S , Koa-Wing M , Kanagaratnam P , Peters N S , Qureshi N , Lim P B
Published: June 2020

Funding Acknowledgements

Research grant from Abbott

Introduction

We have recently described a novel evaluation of AF voltage which correlates better with MRI-DE defined scar than sinus rhythm voltage. We evaluated the clinical efficacy of additional voltage-based substrate modification in the Persistent AF patient cohort in a single centre case series.

Methods

22 PsAF patients undergoing catheter ablation were recruited. Left atrial electroanatomical maps were created in AF before any ablation was performed in all patients. Mean peak to peak AF voltage mapping was undertaken using 8s segments of AF (<0.35mV).  PVI was then performed in all patients after which, further ablation lesions were delivered on the underlying scar tissue (transection, box formation or homogenisation).

Results

Of the 22 patients currently under follow up, 16 patients are more than 12 months after their initial procedure. 11/16 patients have had no recurrence and no patient is currently on anti-arrhythmic medication.

Conclusion

From our series, 69% of PsAF patients remain arrhythmia free at one year follow up post blanking period with a single procedure. Ablation of low voltage areas appears to infer incremental benefit in the Persistent AF population.

Table 1 Mean Age, yrs 64 ± 9 Male 19 (86.3) Diabetes mellitus 1 (4.5) Hypertension 7 (31.8) TIA/CVA 2 (9) Left ventricular EF ≥55% 22 (100.0) LA size (diameter, according to British Society of Echocardiography Guidelines) Normal -Mild 12 (54.5) Moderate - Severe 10 (45.5) Mean AF duration, months 24.2 ± 20.8 Current antiarrhythmic strategy Amiodarone 3 (13.6) Sotalol 1 (4.5) Current anticoagulation Warfarin 3 (13.6) Direct oral anticoagulants 19 (86.3) Values are mean ± SD or N (%) or duration in months ± SD AF = atrial fibrillation; CVA= cerebrovascular accident; EF = ejection fraction; LA = left atrium; TIA = transient ischaemic attack. Baseline characteristics of patients (n = 22)

Abstract Figure. Ablation sets and AF Voltage
P989Determinants of beat-to-beat left ventricular function during atrial fibrillation: a combined clinical-computational study
Authors: Lyon A , Van Mourik M J W , Linz D K , Cruts L , Heijman J , Bekkers S C A M , Schotten U , Crijns H J G M , Lumens J
Published: June 2020

Funding Acknowledgements

Netherlands Organisation for Scientific Research (NWO-ZonMw, VIDI grant 016.176.340)

Background

The rapid irregular atrial electrical activity during atrial fibrillation (AF) is associated with an irregular and variable left ventricular (LV) systolic pump function. The mechanisms determining LV function during AF remain incompletely understood.

Purpose

To assess the reliability of global longitudinal strain (GLS) as a measure of LV function during AF, and to elucidate how beat-to-beat changes in LV preload and afterload affect LV function during AF.

Methods

Beat-to-beat speckle-tracking echocardiography was performed in patients with persistent AF. A hundred consecutive beats in each patient were imaged during AF and we evaluated the relation between GLS in the image plane (4-chamber view) and (pre-)preceding cycle length (CL) in these patients. We used the CircAdapt cardiovascular system model to simulate cardiac mechanics and hemodynamics during AF for each individual patient 1) by imposing the exact irregular sequence of CL as measured in the patient and 2) by making the atrial myocardium non-contractile. These simulations enabled beat-to-beat quantification of preload (end-diastolic volume, EDV), afterload (systolic aortic pressure) and GLS during AF. 

Results

Clinical data and simulations both showed a negative non-linear relation between preceding CL and GLS (Panel A). Non-linearity was more pronounced at low preceding CLs (<750ms), while GLS at preceding CLs >750ms showed less dependence on CL. Simulating ventricular failure by a reduction in ventricular contractility led to a lower overall GLS and a loss of non-linear response at low CL (Panel A, right, diamonds). Increased GLS at high preceding CL (purple box) was explained by a higher preceding EDV (higher preload) (p < 0.002, Panel B), reflecting the Frank-Starling mechanism of contractile myocardium. At a given preceding CL, variability in GLS was explained by the afterload of the preceding beat, with a lower preceding afterload (systolic aortic pressure) leading to higher GLS (Panel C, yellow box, p < 0.002), but not by changes in preceding preload (Panel C, p non-significant). Preload of the pre-preceding beat also correlated with changes in GLS (Panel C, p < 0.005).  

Conclusions

During AF, GLS depends non-linearly on the preceding CL, with GLS measures performed at longer preceding CLs (>750ms in our cohort) showing a low beat-to-beat variability. Beat-to-beat hemodynamic changes in preceding afterload could explain differences in LV function at same preceding CL. Our combined clinical-computational study highlights the variability in GLS measurement during AF and provides new insight into the potential hemodynamic mechanisms determining LV function in AF patients.

Abstract Figure.
P1115Cardiac SABR for ventricular tachycardia - initial UK experience
Authors: Lee J , Bates M , Shepherd E , Thornley A , Kelland N , Greenhalgh D , Atherton P , Peedell C , Hatton M
Published: June 2020

OnBehalf

United Kingdom Cardiac SABR consortium

Background

Stereotactic Ablative Body Radiotherapy (SABR) is a novel non-invasive treatment for Ventricular Tachycardia (VT) refractory to standard catheter ablation. 3 UK hospitals have started compassionate use cardiac SABR programmes, and are working in close collaboration.

Purpose

To report initial UK experience for treatment of refractory VT with cardiac SABR.

Methods

All patients had undergone prior unsuccessful invasive ablation with VT recurrence despite anti-arrhythmic drug (AAD) use. High-resolution CT imaging with 3D reconstruction was combined with 12 lead ECGs of VT and prior invasive +/- non-invasive electrophysiology mapping data to define a cardiac target. Treatment margins were modified to account for cardiac/respiratory motion and to minimise off target treatment to other organs as per clinical SABR practice. Single fraction high dose treatment (20-25 Gy) was delivered by CT guided Linear Accelerator. Patients were assessed regularly with clinical review and remote device monitoring.

Results

3 patients have been treated so far with aetiologies of prior myocarditis, non-ischaemic dilated cardiomyopathy and ischaemic cardiomyopathy. All patients successfully received planned SABR treatment in <1 hour with no peri-procedural complications. Current follow up is to 4 months. Clinical course was variable – patient 1 had a flare of VT post-SABR requiring temporary escalation of AADs before VT was suppressed, patient 2 had initial suppression of VT but died from decompensated heart failure with further VT after 4 weeks, patient 3 had further VT with a different exit site and underwent repeat invasive ablation and escalated AAD use to achieve VT suppression.

Conclusions

Cardiac SABR shows promise for VT control, but further experience and trials are needed. Integration of imaging and electrophysiology data to generate accurate targets appears critical. The effect of SABR seems to develop over several weeks after therapy. Patient selection and timing of SABR delivery is important with acknowledgement that competing causes of death exist in patients with refractory VT entering a compassionate use program.

Abstract Figure. Example SBRT plan
P336Relationship between polymorphism of NOS3 gene and primary cardiac conduction disorders
Authors: Chernova A , Nikulina S , Shulman V , Tretyakova S , Maksimov V , Voevoda M
Published: June 2020

Background

 Inherited cardiac conduction diseases (CCD) are rare but are caused by mutations in a myriad of genes. Nitric oxide (NO) derived from endothelial NO synthase (NOS3) is crucial to ССD. Nitric oxide is a reactive free radical which acts as a biologic mediator in several processes, including neurotransmission and cardiac activities. Nitric oxide is synthesized from L-arginine by nitric oxide synthases. Multiple transcript variants encoding different isoforms have been found for this gene. 

Material and methods: 

A family examination was performed for 69 patients with atrioventricular block (AVB). The control group was formed by 220 patients without clinical ECG manifestations of cardiac diseases. All the examinees underwent ECG, echocardioscopy, electrophysiological examination of the heart.

Results

 by results of research, it has been established that the frequency of carriers of a homozygous genotype on rare allele (4b/4b) among patients with AVB (26.1%±5.3) was higher in comparison with the controls (3.2%±1.2). The obvious tendency to decrease in carriers of a homozygous genotype on extended allele (4a/4a) among patients with AVB (47.8%±6.0) in comparison with the control group (71.4%±3.0) has also been noted. 

Conclusions

 In this work we revealed association between hereditary disturbances of cardiac conduction, such as AVB and polymorphism of NOS3 gene, using clinical - genetic material for the first time.
P1027Left atrial hypertension invasively measured during pulmonary vein isolation as a predictor of atrial fibrillation recurrence
Authors: Manfrin M , Mugnai G , Chierchia G B , Bilato C , Rauhe W G
Published: June 2020

Background

The clinical role of left atrial hypertension (LAH) in patients with atrial fibrillation (AF) and its role as predictor in those undergoing pulmonary vein (PV) isolation is still unknown.

Purpose

The aim of the present study was to analyse the prevalence of LAH in patients with nonvalvular AF and preserved left ventricular ejection fraction having undergone PV isolation and its implication for AF catheter ablation.

Methods

Consecutive patients with drug resistant AF who underwent PV isolation at San Maurizio Regional Hospital of Bolzano (Italy) as index procedure were retrospectively included in this analysis. Left atrial hypertension was defined as the LA mean pressure >15 mm Hg.

Results

A total of 98 consecutive patients (71 males, 72%; mean age 60.3 ± 8.4 years) with drug resistant, non valvular AF and preserved LV ejection fraction having undergone index PV isolation procedure were included in the analysis. Eleven patients (11%) underwent radiofrequency ablation and 87 (89%) cryoballoon ablation. The mean LA pressure was 10.7 ± 4.5 mmHg; LAH occurred in 24 (24%) patients. At a mean follow up of 14.6 ± 7.1 months (median 14 months), the success rate without antiarrhythmic therapy was 71.4% (70/98; considering the blanking period). On multivariate analysis, LAH remained the only independent predictor of definitive AF recurrence (HR 3.02, 1.36-6.72, p = 0.007).

Conclusion

Left atrial hypertension was found in 24% of patients undergoing PV isolation and was found to be significantly related to both early and late AF recurrences.

Univariate and multivariate Cox regressi Univariate analysis Multivariate analysis Early Recurrence (during BP) HR 95%CI P value HR 95%CI P value Age (years) 1.06 1.02-1.10 0.005 1.05 1.00-1.09 0.03 LA volume (ml/m2) 1.02 1.00-1.05 0.04 1.02 1.00-1.05 0.05 LA hypertension 2.46 1.32-4.57 0.004 1.97 1.03-3.79 0.04 Recurrence after the BP HR 95%CI P value HR 95%CI P value Age (years) 1.05 1.00-1.11 0.04 1.04 0.98-1.09 0.15 LA hypertension 3.51 1.62-7.60 0.001 3.02 1.36-6.72 0.007 BP recurrence 1.83 0.84-3.99 0.13 AF atrial fibrillation. BMI: body mass index. LA: left atrium. CAD: coronary artery disease. BP: blanking period. HR: hazard ratio. CI: confidence intervals.
P402Analysis of right atrium remodeling by cardiac magnetic resonance in patients with atrial fibrillation and its association with left atrium
Authors: Gunturiz Beltran C , Borras-Amoraga R , Alarcon F , Garre P , Figueras R , Caixal G , Cozzari J , Trotta O , Tolosana J M , Arbelo E , Roca I , Brugada J , Guasch E , Mont L
Published: June 2020

Funding Acknowledgements

none

Background

Atrial fibrillation (AF) causes changes in atrial anatomy and this remodeling leads to the arrhythmogenic substrate. Most studies with cardiac magnetic resonance-late gadolinium enhancement (CMR-LGE) have focused on the left atrium (LA); The role of the right atrium (RA) in AF is unknown.

Purpose

To evaluate RA remodeling parameters and its comparison with LA in patients with AF.

Methods

Observational study. We included 109 patients: 9 healthy volunteers, 55 paroxysmal AF, 45 persistent AF. All of them had a CMR-RTG 3.0 T. Image post-processed with segmentation of both atria. Comparison of mean parameters of RA and LA (T test), correlation between them (R Pearson). Multivariate analysis (Cox regression) to study predictive factors.

Results

AF patients had a mean age of 58.5 ± 10.5 years, 70(70%) were men, without structural heart disease 80(80%), and associated atrial flutter 11(11%). The RA parameters were compared by subgroups. We found differences in (healthy/paroxAF/persistAF): area(cm2) 94.0 ± 15.9 /125.3 ± 20.8/ 152.8 ± 24.4 (p <0.0001); volume (ml) 76.7 ± 19.6/ 107.0 ± 25.6/ 150.9 ± 37.6 (p <0.0001); and total fibrosis (%) 3.7 ± 4.3/ 16.5 ± 14.1/ 19.4 ± 15.9 (p 0.014).

RA was higher than LA in all subgroups. There was more fibrosis in RA in paroxysmal/persistent AF. Both types of AF had at least a moderate correlation for area, volume and fibrosis (table).

Finally, RA sphericity was the only predictor factor of AF recurrence after ablation among RA remodeling parameters (HR 1.1 95%CI [1.0 -1.3], p = 0.049).

Conclusions

Area, volume and fibrosis progressively increased from healthy to paroxysmal AF, and then to persistent AF. RA was higher than LA and it also had more fibrosis in patients with AF. The size and fibrosis between both atria had at least moderate correlation. The RA sphericity was a predictor of post-ablation AF recurrences.

COMPARISON/CORRELATION RA LA p R PEARSON(RA/LA) p HEALTHY VOLUNTEERS Volume (ml) 76.7 ± 19.6 37.0 ± 9.4 <0.0001 0.457 0.254 Total Fibrosis (%) 3.7 ± 4.3 5.0 ± 6.1 0.278 0.837 0.005 PAROXYSMAL AF Volume (ml) 107.0 ± 25.6 69.5 ± 26.5 <0.0001 0.422 0.001 Total Fibrosis (%) 16.5 ± 14.1 8.0 ± 8.6 <0.0001 0.485 <0.0001 PERSISTENT AF Volume (ml) 150.9 ± 37.6 103.2 ± 28.5 <0.0001 0.582 <0.0001 Total Fibrosis (%) 19.4 ± 15.9 10.5 ± 11.7 <0.0001 0.571 <0.0001

Abstract Figure. Correlation of area and fibrosis RA/LA
P1016Correlation between cardiac magnetic resonance-late gadolinium enhancement and electro-anatomical map for right atrium
Authors: Gunturiz Beltran C , Borras-Amoraga R , Alarcon F , Garre P , Figueras R , Caixal G , Tolosana J M , Arbelo E , Roca I , Prat S , Perea M J , Brugada J , Guasch E , Mont L
Published: June 2020

Funding Acknowledgements

none

Background

 Electroanatomical map (EAM) detects areas of low voltage as a surrogated marker of fibrosis areas, being the reference technique for its detection. Cardiac magnetic resonance with Late Gadolinium enhancement (CMR-LGE) allows non-invasive detection of atrial fibrotic areas. CMR-LGE studies have focused on the left atrium since now.

Purpose

We need to validate this test to extend its use to the right atrium (RA), since it is involved in the arrhythmogenic substrate of several arrhythmias, and probably also in atrial fibrillation (AF).

Methods

 Prospective observational study. Fifteen patients undergoing a first AF ablation procedure were included. All patients had a pre-procedural LGE-CMR performed. The blood pool-normalized intensity signal (image intensity ratio-IIR) was calculated for the right atrial wall, and values projected in a shell. IIR values validated for the left atrium were used to identify dense and intermediate fibrosis, and healthy tissue (>1.32, 1.2-1.32, <1.2, respectively). During the procedure but before ablation, a point-by-point high density EA bipolar voltage map of RA was obtained with a multipolar catheter. Standard voltage thresholds of 0,1 mV and 0,5 mV were used to characterize fibrotic and healthy tissue in EAM. For each RA, the EAM was projected into the IIR shell, and the correlation between bipolar voltage and normalized IIR values for each shell point was quantified. Then, we also obtained its concordance (categorical variables) according to the label automatically assigned by EAM/CMR with the pre-set thresholds: healthy tissue/ intermediate fibrosis/dense fibrosis.

Results

 A total of 8,830 points were obtained, mean per patient 588 (± 509) points. A global weak negative correlation was found between the EA bipolar voltage map (EAM) and IIR (CMR) (r= -0.16, p < 0.0001)(figure). LGE-CMR identified more healthy tissue than EAM (81.0% vs 60.6% respectively), then CMR underestimated the fibrotic tissue in RA. Finally, we analyzed the concordance and we obtained that the degree of accuracy between both measurements was 55.7%.

Conclusion

 There was an inverse correlation between the bipolar voltage EAM and IIR (CMR) of low grade but with statistical significance. CMR underestimated fibrotic tissue in RA with respect to its identification by EAM.

Abstract Figure. Correlation between bipolar voltage-IIR
P400Spatial relationship between atrial fibrillation drivers identified by dipole density mapping and left atrial fibrosis
Authors: Ammar-Busch S , Forkmann M , Tose Costa Paiva B , Mitlacher M , Mahnkopf C
Published: June 2020

Background

 Atrial fibrillation (AF) is a complex arrhythmia and several mechanisms that might coexist have been proposed. Recent technical advances opened the way to better mapping possibilities and might contribute to target more specific components of the AF substrate.

Objective

 The aim of this study was to evaluate a spatial correlation between AF drivers as determined by a novel non-contact unipolar high-resolution system and atrial fibrosis assessed by cardiac magnetic resonance imaging (MRI). 

Methods

 Patients undergoing a first ablation procedure for persistent AF were included. Prior to ablation, a Late Gadolinium-Enhancement (LGE) MRI was performed to detect the fibrotic atrial tissue. The procedure was performed using a new non-contact unipolar high-resolution system allowing a 3D anatomy reconstruction with a continuous dipole density mapping.

Three different wave front patterns were analyzed in the left atrium (LA):  1) focal activity (FA), 2) localized rotational activation (LRA) and 3) localized irregular activation (LIA). The spatial distribution of these AF drivers was analyzed prior to AF ablation. 

Results

 A total of 49 patterns in 6 patients were identified, among them 22 FA, 14 LRA and 13 LIA. The posterior (n = 14), anterior wall (n = 13) and roof (n = 8) were identified as predominant driver sites. 31/49 (59%) drivers had a strong correlation with late enhancement in MRI. Most of the LIA, LRA and FA were embedded infibrotic areas (LIA 10/13 (77%); LRA 9/14 (64%) and FA 12/22 (54%). The postero-inferior LA showed the best correlation between drivers and fibrosis, the antero-septal LA the weakest one. 

Conclusion

 There is a significant overlap between AF driver regions identified by dipole density mapping and atrial fibrosis assessed by MRI. Most of AF drivers are embedded in fibrotic areas, particularly in case of localized irregular activity and at the posterior LA.

Abstract Figure.
P1504Monitoring of TLE procedure using TEE practical utility Experience from 927 procedures
Authors: Nowosielecka D , Tulecki L , Tomkow K , Kleinrok A , Jachec W , Polewczyk A , Kutarski A
Published: June 2020

Background

Monitoring of the process of transvenous lead extraction using continuous TEE was delivered for the purpose of earlier recognition of cardiac or venuos wall tear  (behind hemodynamic and respiratory monitoring etc). But our experience indicates that it may be providing much more very important information for operator about present occurrences invisible for fluoroscopy monitoring and to warm about threatening disaster.

Objective

The goal of this study was to describe frequency of menaces visible in TEE before after effects will reveal.

Methods

 During last 4,5 years 1019 TLE were performed but due to different reasons complete TEE monitoring was performed in 910 patients; 1705 leads (1-4 leads, aver 1,66, with mean implant duration 100,7 mth) were extracted using as first line non-powered mechanical tools. There were 20 major complications (2,0%) but no procedure related death. We obtained 98,7% procedural and 97,9% clinical success. Results are presented in the table.

Conclusions

TEE cautioned about dangerous poling or torsion of the heart structures and permitted immediate explanation of the reasons of drop of blood pressure, brought information about arising cardiac tamponade, about rapid blood clothing in epicardial space and the onset of cave-in RV wall before significant drop of blood pressure. Uncomplicated course after rescue sternotomy seems be result of timeous it execution.

Abstract Figure.
P1087Prevalence and significance of mitral regurgitation in atrial fibrillation coexisting with HFpEF and HFmEF
Authors: Lupasteanu I , Vijan A , Delcea C , Stanescu C , Bari S , Daha I , Dan G A
Published: June 2020

Background

Recent data has acknowledged atrial induced functional mitral valve regurgitation (MR) in the setting of atrial fibrillation (AF) and/or heart failure with preserved ejection fraction (HFpEF)  as a distinct type of secondary MR, holding prognostic significance. However, evidence on its prevalence is still scarce, especially in the phenotype of mid-range ejection fraction heart failure (HFmEF).

Purpose

The aim of this study is to evaluate the occurrence of left atrial (LA) enlargement and MR in AF patients with or without heart failure with preserved or mid-range ejection fraction.

Methods

This retrospective study included 750 consecutive patients with AF admitted to a tertiary hospital from January 2018 to June 2019. We excluded patients with primary valvular disease and HF with reduced EF. MR presence and severity were assessed by evaluating the valve morphology, colour flow imaging and, when feasible, vena contracta and PISA methods. We measured LA anteroposterior diameter and used LA dilatation as a surrogate marker for mitral annulus dilatation.

Results

We evaluated 584 AF patients: mean age 72.22 ± 10.10 years; 58,73% females; 79.75% had HF: 73.13% of them had HFpEF and 26.87% had HFmEF.

Compared to those without HF, patients with HF had a relative risk (RR) of associating LA enlargement of 5.37 (95%CI = 3.05-9.48, p < 0.001) and a RR of associating MR of 1.47 (95%CI 1.08-2.00, p = 0.01). Mean LA diameter was higher in the HF group, compared to non-HF (47.06 ± 7.26 mm vs 40.91 ± 7.10 mm, p < 0.001). MR severity was more likely associated with HF (RR = 1.68, 95%CI = 1.46-1.94, p < 0.001).

When comparing results between the two HF subgroups, patients with HFmEF had a higher mean LA diameter than those with HFpEF (48.52 ± 5.68 mm vs 46.36 ± 7.57 mm, p = 0.011), without associating a significant difference in the MR prevalence (72.97% vs 73.98%, p = 0.94).

The presence of a dilated LA was directly correlated with MR in the HF group (RR = 1.94, 95%CI = 1.18-3.20, p = 0.023), but not in those without HF (RR = 1.04, 95%CI = 0.57-1.90, p = 0.89).

In HF patients, permanent AF associated the highest prevalence of LA dilatation (96.67%) and MR (81.73%) in contrast to paroxysmal AF (81.10%, p < 0.01, respectively 63.43%, p = 0.0002).

Conclusions

LA dilatation, the presence and severity of MR correlated with AF and HF, especially in permanent AF patients. In patients without HF, LA dilatation did not correlate with the presence of MR.

MR prevalence was similar in patients with HFmEF and HFpEF, irrespective of a higher degree of LA dilatation in HFmEF.

Our results suggest that the pathophysiological mechanisms involved in LA enlargement and MR are different for different phenotypes of AF in patients with or without HF.
P341Life-threatening events in patients with non-compaction cardiomyopathy and mutations in ion channel genes
Authors: Rineiska N , Komissarova S , Chakova N , Niyazova S
Published: June 2020

Purpose

to analyze life-threatening events during follow-up in patients with non-compaction cardiomyopathy (NCCM) who have mutations in the genes responsible for the functioning of ion channels.

Methods

the study included 64 unrelated pts (aged 38.63 ± 14.72 years, 34/53.12% male, LVEF 43.02 ± 8.65%) with criteria of NCCM confirmed by imaging techniques (echocardiography (Jenni) and cardiovascular magnetic resonance (Petersen).  Mutation search was carried out by the next generation sequencing (NGS). Pathogenic mutations or rare substitutions with possible clinical significance were found in 12 unrelated pts in the ion channel genes: KCNH2, KCNJ2, CACNA1C, RYR2, HCN4, TRPM4, PKP2, TRPM4. Mutations in other genes (PLN, DSP, NOTCH1, RBM20) were detected in 4 pts (1 pathogenic and 3 VUS).

Results

mutations in genes associated with long QT syndrome (LQTS) were found in 5 pts with NCCM: c.3107G > A (p.Gly1036Asp), с.2653С>T (p.Arg885Cys) in KCNH2 gene (16.7%); c.T28076 (p.F936C) in CaCNA1C gene (8.3%); c.1165G > C (p.Asp389Asn) in KCNJ2 gene (8.3%). There was no prolongation of the QTc interval > 480 msec on ECG; frequent episodes of nonsustained  ventricular tachycardia (VT) were recorded on 24-hour ECG-monitoring.

During the follow-up period (median follow-up of 2.4 years), two pts with mutations in KCNH2 genes with suddenly developed sustained VT were implanted with ICD. A 32-year-old patient with a mutation in CACNA1C gene and ST-elevation myocardial infarction of thromboembolic genesis underwent PCI. 58-year-old patient with widening of QRS > 130 msec and frequent paroxysms of nonsustained VT was implanted with CRT-D. An ICD was implanted in a 60-year-old patient with a mutation c.12665_12667del(p.4223del) in the RYR2 gene and suddenly developed a sustained VT. In the remaining two pts with RYR2 gene mutations c.12272C > T (p.Ala4091Val), c.12944G > A(p.Gly4315Glu), frequent episodes of nonsustained VT were recorded, which were corrected medically. Orthotopic heart transplantation and Accucinch transcatheter direct mitral valve annuloplasty system implantation were performed in two pts with ventricular tachyarrhythmias and severe systolic and diastolic dysfunction of the left ventricle with mutations c.3224T > C (p.Leu1075Pro), c.1459_1494del36 (p.Lys487_Leu498del) in the TRPM4 gene. In other pts with mutations in HCN4 (8.3%), DPP6 (8.3%), PKP2 (8.3%) genes ventricular tachyarrhythmias were treated with antiarrhythmic drugs.

Conclusion

the presence of mutations in the genes controlling the functioning of ion channels is an additional risk factor for adverse events in patients with NCCM.
P468Pre-diabetes a new risk factor for stroke in non-valvular atrial fibrillation
Authors: Kezerle L , Tsadok M A , Akriv A , Feldman B , Leventer-Roberts M , Ohana R , Haim M
Published: June 2020

Funding Acknowledgements

Pfizer Israel

Background

Diabetes mellitus is a well-established independent risk factor for embolic complications in patients with non-valvular atrial fibrillation (NVAF). The association between prediabetes and risk of ischemic stroke, however, has not been studied separately in patients with NVAF.

Purpose

To evaluate whether pre-diabetes is associated with increased risk of stroke and death in patients with NVAF

Methods

We conducted a prospective, historical cohort study using the Clalit Health Services (CHS) electronic medical records database. The study population included all CHS members ≥ 21 years old, with a first diagnosis of NVAF between January 1 2010 to December 31 2016 and a minimal follow-up period of 1 year. We compared three groups of patients:  prediabetes, those with established DM, and normoglycemic individuals

Results

A total of 44,451 cases were identified. The median age was 75 years and 52.5% were women. During a mean follow up of 38 months, the incidence of stroke per 100 person-years in the three study groups was: 1.14 in non-diabetics, 1.40 in pre-diabetics and 2.15 in diabetics. In both univariate and multivariate analyses, pre-diabetes was associated with an increased risk of stroke compared with non-diabetics (Adjusted Hazard Ratio (HR) = 1.19 {95% CI 1.01-1.4}) even after adjusting for CHA2DS2-VASC individual risk factors and use of oral anti-coagulants while diabetes conferred an even higher risk (vs non-diabetics { HR = 1.56, 95% CI ;1.37 - 1.79}). The risk for mortality was higher for diabetics (HR =1.47,  95% CI ;1.41, 1.54}) but not for pre-diabetics (HR = 0.98 ,CI 95%; 0.92 - 1.03). Conclusion: In this observational cohort of patients with incident newly diagnosed patients with NVAF, pre-diabetes was associated with an increased risk of stroke even after accounting for other recognized risk factors.

Abstract Figure. Kaplan-Meier for stroke-free survival
73Hemoglobin a1c levels and the risk of ischemic stroke and mortality in individuals with diabetes mellitus and atrial fibrillation
Authors: Kezerle L , Tsadok M A , Akriv A , Feldman B , Leventer-Roberts M , Ohana R , Haim M
Published: June 2020

Funding Acknowledgements

Pfizer Israel

Background

Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Whether the risk of stroke in AF patients remains the same among the wide spectrum of disease is yet to be determined.

Aim

Among individuals with AF and DM, to assess the incidence rates and risk of ischemic stroke and mortality by baseline HbA1C levels.

Methods

We conducted a prospective, historical cohort study using the Clalit Health Services (CHS) electronic medical records database. The study population included all CHS members ≥ 21 years old, with a first diagnosis of NVAF between January 1, 2010 to December 31, 2016 and a minimal follow-up period of 1 year. Among those patients identified as diabetics, we compared three groups of patients according to HBA1C levels at the time of AF diagnosis: <7.0%, between 7-9% and ≥ 9%.

Results

A total of 44,451 cases were identified. The median age was 75 years (IQR 65-83) and 52.5% were women. During a mean follow up of 38 months, the incidence of stroke per 100 person-years in the three study groups was: 1.9 in patients with HBA1C <7%, 2.37 in the intermediary group and 2.72 in those with HBA1C >9%. In both univariate and multivariate analyses, higher levels of HBA1C were associated with an increased risk of stroke compared with a dose-dependent response when compared to individuals with HBA1C <7% (Adjusted Hazard Ratio (AHR) = 1.32 {95% CI 1.12-1.55}for levels between 7-9% and AHR 1.64 {95% CI 1.28-2.09}) even after adjusting for CHA2DS2-VASC individual risk factors and use of oral anti-coagulants. The risk for overall mortality did not differ significantly between groups, with a slight elevation in the HBA1C >9% group after adjusted analysis {aHR = 1.17 (1.07- 1.28)} Conclusion: In this observational cohort of patients with incident newly diagnosed nonvalvular atrial fibrillation, HBA1C levels were associated with an increased risk of stroke in a dose-dependent manner even after accounting for other recognized risk factors for stroke in this population.

Abstract Figure. Kaplan-Meier for stroke-free survival
P1026Second-generation visually guided laser balloon ablation system for pulmonary vein isolation: Learning curve, safety and efficacy: The MERLIN registry
Authors: Heeger C H , Phan H L P , Meyer-Saraei R M S , Fink T F , Sciacca V S , Liosis S L , Brueggemann B B , Grosse N G , Fahimi B F , Sano M S , Kuck K H K , Ouyang F O , Vogler J V , Eitel C E , Tilz R R T
Published: June 2020

Funding Acknowledgements

Cardiofocus

Background

Radiofrequency (RF) based pulmonary vein isolation (PVI) results in favourable clinical outcome, although its complexity demands a long learning curve. Balloon-based systems, have been developed to possibly solve these limitations. The second-generation laser balloon (LB2) offers optimized features for improved tissue contact and visibility.

Purpose

We determined safety, efficacy and learning curve of the LB2 for PVI.

Method

A total of 45 consecutive patients (89% persistent AF) were prospectively enrolled and divided in three groups (T1, T2, T3) of n = 15 patients per group. All patients underwent PVI using the LB2 by two operators. The operators were experienced in RF and cryothermal procedures, but not in laser ablations.

Results

A total 174/177 PVs (98%) were successfully isolated. The median procedure time significantly declined from 132 (114, 158) to 119 (102, 127) and 91 (86, 105) min in T 1–3, respectively (P = 0.0009). Similarly, the median fluoroscopy time significantly decreased from T1 until T3 (22 (17, 27) vs. 21 (16, 24) vs. 13 (10, 17) min, respectively, P = 0.045. Adverse events occurred in 6.7% with a trend towards a lower complication rate with increasing experience.

Conclusion

The LB2 was safe and effective for PVI even for operators without any previous experience in laser balloon based PVI. Procedure time LA dwelling time and fluoroscopy time decreased after a learning curve of 15 cases.