bluuebunny/crossref_metadata_2025 huggingface dataset:
Usefulness of heart failure categories based on left ventricular ejection fraction
Authors: Christersson M , Gustafsson S , Lampa E , Almstedt M , Cars T , Arefalk G , Sundstrom J
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): This study was sponsored by AstraZeneca.

Introduction

Heart failure, a common disease with a mortality on par with many cancers, is one of the costliest diseases to society in the western world. Current heart failure guidelines are based on categories of left ventricular ejection fraction (LVEF) and have recently introduced a narrow category with mid-range/mildly reduced ejection fraction (HFmrEF; LVEF 41-49%) between the previous categories with reduced (HFrEF; LVEF ≤40%) and preserved (HFpEF; LVEF ≥50%) ejection fraction. The grouping of continuous variables into narrow categories can be questioned if the variability is high.

Purpose

To determine the shape of the LVEF distribution and quantify the stability of LVEF categories over time in a large real-world heart failure population, in order to establish the usefulness of LVEF categories for treatment decisions.

Methods

Population-based observational cohort study of all new cases of chronic heart failure in Region Stockholm, Sweden, from 2016-01-01 until 2020-12-31. All available values of LVEF were collected over time and patients were followed until death or end of study. Mixed models were used to quantify within-person variance in LVEF, and Multistate Markov models, with death as an absorbing state, to quantify the stability of LVEF categories.

Results

During the study period, 8,455 patients were diagnosed with heart failure. LVEF values followed a perfect normal distribution. The standard deviation of the within-person variance in LVEF was 7.4%. Regardless of initial LVEF category, age or sex, the mean time spent in any LVEF category before transition to another category (mean sojourn time) was on average less than 0.6 years (Figure 1). The one-year probabilities of transitioning between states were substantial (Figure 2). Patients with HFmrEF had a probability of 1/4 of remaining in that category one year later; the probability of patients with HFrEF of remaining in that category one year later was 1/4 for women and 1/3 for men; and patients with HFpEF had a probability of remaining in that category of 2/3 for women and 1/2 for men.

Conclusion

In patients with heart failure, LVEF has considerable variability over time. Hence, LVEF has limited use for categorisation of the heart failure population into narrow categories.
Effects of physical exercise on health-related quality of life in coronary heart disease patients. a systematic review and meta-analysis
Authors: Toval A , Bakker E A , Granada-Maia J B , Nunez De Arenas-Arroyo S , Solis-Urra P , Molina-Garcia P , Eijsvogels T M H , Martinez-Vizcaino V , Esteban-Cornejo I , Ortega F B
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): - HEARTY-BRAIN - Effects of Exercise on Brain in Patients with Coronary Heart Disease: The Heart-Brain Connection. Andalusian Plan for Research Development and Innovation (PAIDI). University of Granada. Funding: 116.000 €. PI: F. Ortega. 2021-2021. - VASCULACTIVE. Effects of exercise on brain vascularization in coronary heart disease patients. Spanish Ministry of Economy and Competitiveness (I+D+I RETOS). University of Granada. Funding: 121.000 €. PI: F. Ortega. 2021-2023.

Background

Coronary heart disease (CHD) is the most prevalent type of cardiovascular disease in the world, and a leading cause of mortality and morbidity. Previous research showed that patients with CHD have a decrease in health-related quality of life (HRQoL) during the course of the disease. Physical exercise may attenuate the decline in HRQoL observed in CHD patients.

Purpose

To determine the effect of exercise training interventions on HRQoL in CHD patients.

Methods

A systematic search of controlled trials (CTs) assessing the effects of exercise training on HRQoL in CHD patients was performed in Web of Science, PubMed, Scopus, EMBASE, Cochrane Register, SportDiscus, PsycINFO and Google Scholar from inception to 30 June 2022. A meta-analysis with fixed and random effects was performed on controlled trials (comparing at least one exercise group with one non-exercise group and including a global score of HRQoL assessments before and after the interventions. All statistical analyses were performed using R-Studio.

Results

A total of 26 CTs met all the eligibility criteria and were included in the review (25 randomized CTs and 1 non-randomized CTs). HRQoL was mostly assessed by the SF-36 instrument (11/26) and the MacNew Heart Disease Health-Related Quality of Life questionnaire (8/26). Six out of the 26 studies reported the total score of quality of life and were included in the meta-analysis, which resulted in 8 exercise interventions and 591 participants with a mean age of 61 years, and 33% was women. There was a small (effect size 0.20) borderline overall effect of exercise on HRQoL in CHD patients (95% confidence interval: fixed effect, 0.05–0.36; random effect, -0.06-0.46. The percentage of total variability attributed to between-study heterogeneity [I2] = 44%, P=0.09 (Figure 1).

Conclusions

Findings from this meta-analysis suggest that supervised exercise training may cause a modest improvement in HRQoL in CHD patients. Future studies should explore which type and loads of exercise lead to larger improvements.
Left atrial strain significance in prediction of early atrial fibrillation recurrence after cardioversion and ablation
Authors: Sabanovic-Bajramovic N , Iglica A , Begic E , Begic A , Dzubur A , Naser N , Bajramovic S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

The fibrosis of the LA, which is characteristic of AF, causes mechanical dysfunction of the LA and may also be present in patients without LA enlargement. LA strain represents a surrogate marker of this mechanical dysfunction. Early detection of LA dysfunction may be crucial in identifying patients who are more likely to experience AF recurrence following cardioversion and ablation. Before cardioversion and ablation, the probability of AF recurrence might be predicted, which could lead to better patient selection, an individualized therapeutic strategy with reduced risk and focused follow-up.

Purpose

The aim of this study was to evaluate the additional predictive value of LA function assessed by using strain echocardiography for early AF recurrence after cardioversion and ablation.

Methods

94 patients diagnosed with symptomatic persistent atrial fibrillation (EHRA symptom score ≥3 (mean age 59.4 ± 12.2 years, 58% male, 42%female), preserved LV ejection fraction were prospectively analyzed. In 39 (41,5%) patients pharmacological cardioversion was done after saturation with antiarhythmic drugs,in 27 (28,7%) patients planed electrical cardioversion was done after medical saturation with antiarrhythmic drugs and failure of pharmacological cardioversion, and in 28 (29,8%) patients planed RF ablation was performed. Complete echocardiography evaluation including strain and volume index LA was performed before cardioversion and ablation. The rhythm evaluation was done in the first month after cardioversion and RF ablation (35±5 days). The primary endpoint was persistent AF recurrence.

Results

29 (30,8%) patients had AF recurrence in the overall study population, independently of duration of AF or method of rhythm control. Peak atrial longitudinal strain (PALS) ≤15% had the highest incremental predictive value for AF recurrence (HR =8.42, 95% CI: 3.17–25.12, p < 0.001). In patients with non-dilated LA, PALS≤15% remained an independent predictor of AF recurrence (HR = 5.32, 95% CI: 1.77–17.42, p = 0.005).

Conclusion

This study shown that, in addition to LA dilatation, LA function as determined by PALS can provide a prognostic value for early AF recurrence after cardioversion or ablation. PALS also predicted AF recurrence in patients with nondilated LA. These findings highlight the additional prognostic usefulness of LA strain and recommend its implementation in the systematic assessment of AF patients prior to the choice of rhythm/rate control.
5 years incident stroke, heart failure, acute myocardial infarction, and death in patients having undergone atrial fibrillation ablation according to BMI
Authors: Toennesen J , Pallisgaard J P , Rasmussen P V R , Ruwald M R , Zoerner C Z , Riis-Vestergaard L R V , Middelfart C M , Gislason G G , Hansen M L H
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Novo Nordisk

Introduction

Both atrial fibrillation (AF) and obesity have reached epidemic proportions. Obesity is an established risk factor in acute myocardial infarction (AMI), de novo AF, and AF recurrence after ablation. AF increase the risk of stroke, heart failure (HF), and death. The link between body mass index (BMI) and incident stroke, HF, AMI, or death in an AF ablation population is unknown.

Purpose

To examine incident stroke, HF, AMI, or death by BMI.

Method

Using Danish nationwide registries, all Danish patients above 18 years who underwent first-time AF ablation from January1st 2010 to December31st 2018 were identified and included at the date of ablation. Underweight patients (BMI < 18.5) were excluded. Exposure of interest was BMI and patients were stratified as normal-weight (BMI 18.5-24.9), overweight (BMI 25.0 – 29.9), obese (30.0 – 34.9), and morbidly obese (BMI ≥ 35.0). The primary endpoint was combined of either first-reached incident stroke, HF, AMI, or death. The 5-year cumulative incidence of the primary endpoint stratified by BMI, was estimated using the Aalen-Johansen estimator. The relative rates were examined using normal-weight as reference in both univariate- and multivariate-Cox models adjusted for prior HF, hypertension, age, diabetes, prior stroke, prior atherosclerotic vascular disease, and sex.

Results

The study cohort consisted of 7,701 patients. Median age [IQR] decreased from 64 [57, 70] to 60 [53, 66] in normal-weight and morbidly obese respectively. The prevalence of HF, ischemic heart disease, diabetes, and hypertension increased by BMI while prior stroke remained stable. Use of oral anticoagulants remained stable at around 98%.

In total 1,285 patients reached the primary endpoint. By decreasing order, the most frequent endpoints were HF (564, 44%), AMI (431, 34%), stroke (199, 15%), and death (91, 7%).

The cumulative incidence of the primary endpoint increased incrementally from 15%, 16%, 19%, and 21% from normal-weight to morbidly obese respectively (Figure 1).

In the univariate analysis, the Hazard ratio (HR, [95% confidence interval]) increased incrementally from 1.03 [0.90 to 1.18], 1.28 [1.10 to 1.49], 1.43 [1.17 to 1.74] in overweight to morbidly obese respectively (Figure 2).

In the multivariate analysis no significant differences were found. The HRs were 0.94 [0.82 to 1.08], 1.05 [0.89 to 1.23], 1.01 [0.82 to 1.24] in the overweight to morbidly obese respectively (Figure 2).

Conclusion

When identifying obese and morbidly obese AF ablation patients in clinical practice, the risk of either stroke, HF, AMI, or death is higher compared to normal-weight AF ablation patients, but only due to the underlying comorbidities.
Predictors of stroke or systemic embolism in patients with non-valvular atrial fibrillation with CHA2DS2-VASc score of 0
Authors: Park Y , Choi H , Bae M H , Cho H J , Park B E , Kim H N , Kim N K , Lee J H , Jang S Y , Yang D H , Park H S , Cho Y
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Anticoagulant therapy has been important for stroke prevention in patients with atrial fibrillation (AF). However, it was not recommended due to its relatively higher risk of bleeding than its lower risk of stroke in patients with a CHA2DS2-VASc score of 0.

Purpose

This study aimed to evaluate the predictors of stroke in AF patients with very low risk of stroke.

Methods

Between 1990 and 2020, 542 patients with non-valvular AF (NVAF) with a CHA2DS2-VASc score of 0 followed up for at least 6 months were enrolled. Patients whose only risk factor was female were included as a CHA2DS2-VASc score of 0 in this study. The primary outcome was stroke or systemic embolism.

Results

The mean age at AF diagnosis was 49.9 years, and 398 (73.4%) were men. During the mean follow-up of 4.7 years, the primary outcome rate was 0.78%/year (stroke, 0.70%/year; systemic embolism, 0.08%/year), and major bleeding and all-cause death occurred in 0.31%/year and 1.02%/year, respectively. The proportions of age ≥50 years at diagnosis, left ventricular end-diastolic dimension (LVEDD) of ≥46 mm, and non-paroxysmal AF in patients with stroke or systemic embolism were significantly higher than in those without. Cox proportional hazard model, age of ≥50 years at diagnosis (hazard ratio [HR] 6.710, 95% confidence interval [CI] 1.811–24.860, P-value=0.004), LVEDD of ≥46 mm (HR 4.513, 95% CI 1.038–19.626, P-value=0.045), and non-paroxysmal AF (HR 5.575, 95% CI 1.621–19.175, P-value=0.006) were identified as independent predictors of stroke or systemic embolism. Patients with all three independent predictors had a higher risk of stroke or systemic embolism (4.21%/year), whereas those without did not have stroke or systemic embolism.

Conclusion

The annual stroke or systemic embolism rate in NVAF patients with CHA2DS2-VASc score of 0 was 0.78%/year. Age at AF diagnosis, LVEDD, and non-paroxysmal AF were independent predictors of stroke or systemic embolism in patients considered to be at very low risk of stroke.
Effects of antiarrhythmics on atrial high rate episodes and progression to clinical atrial fibrillation (ANTI-AHRE)
Authors: Simovic S , Taleski J , Todorovic Z , Kircanski B
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial High Rates Episodes (AHRE) are associated with progression to clinical atrial fibrillation (AF), stroke, increased risk of MACE and increased mortality (1-4). Although oral anticoagulation should be initiated in patients with CHADs-VASc score ≥ 2 and episode duration ≥ 24h, treatment of AHRE with antiarrhythmics was not investigated so far.

Purpose

This study aimed to assess the effects of antiarrhythmic treatment on AHRE and its impact on the progression to clinical AF and AHRE burden.

Methods

This study included patients with AHRE duration ≥ 24h detected by dual-chamber pacemakers, without a previous diagnosis of AF and treatment with antiarrhythmics. Nominal settings with high atrial rate criterion programmed to 200 beats/min were used for AHRE detection. Patients were randomized to the Intervention (n=169) and Control Group (n=138). Patients in the Intervention Group received antiarrhythmic treatment (Ic antiarrhythmics (n=54), beta-blockers (n=58) and amiodarone (n=57)). The primary endpoint was progression to clinical AF and the secondary endpoint was AHRE burden.

Results

A total of 307 were included in the study, with a mean age of 71.4±8.15, 166 (54.07%) females and a mean follow-up 20.84±5.04 months. The baseline characteristics did not differ significantly between groups. During the follow-up, 50 patients (36.23%) from the Control group developed clinical AF. In groups of patients treated with Ic antiarrhythmics, beta-blockers and amiodarone, clinical AF developed in 11 (20.37%), 25 (25.86%) and 5 (8.77%) patients, respectively (p<0.001). Average time to clinical AF progression was significantly longer in groups of patients treated with antiarrhythmics (Ic antiarrhythmics, beta-blockers and amiodarone) compared to the Control group (17.7, 17.2, 19.0 vs 15.9 months, respectively, p<0.001). The Kaplan-Meier plot of freedom from clinical AF is given in Figure 1. Amiodarone prolonged the time to clinical AF progression significantly compared to beta-blockers (p=0.017), while a trend was observed compared to Ic antiarrhythmics (p=0.057). No significant differences between Ic antiarrhythmics and beta-blockers were observed in time to clinical AF progression (p=0.567). The AHRE burden was significantly lower in the Intervention group compared to the Control group (6.9% vs 15.4%, p<0.001). Amiodarone was superior in lowering the AHRE burden when compared to Ic antiarrhythmics and beta-blockers (2.1% vs 5.6% and 7.8%, respectively, p<0.001), while no significant differences were observed between Ic antiarrhythmics and beta-blockers (p=0.18)

Conclusion

Initiating antiarrhythmics for AHRE episodes leads to a lower AHRE burden and progression to clinical AF. Randomized clinical trials are needed to investigate further the early antiarrhythmic treatment of AHRE without clinical AF.
Implementation of CLOSE protocol for pulmonary vein isolation in paroxysmal atrial fibrillation by young electrophysiologists in real world clinical practice
Authors: Chatzikyriakou S , Xaplanteris P , Sofianos D , Goethals P , Purnode P , Rassias I , Theodorakis G , Foading B
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Paroxysmal atrial fibrillation (AF) is widely treated by radiofrequency (RF) catheter ablation. The CLOSE protocol has been proposed and accepted to guide a successful, safe and durable pulmonary vein isolation in patients with paroxysmal AF. However, the reproducibility of the protocol in real clinical practice and on less experienced hands is less established.

Objective

To assess the acute effectiveness, safety and reproducibility of RF catheter ablation based on the CLOSE protocol for pulmonary vein isolation in paroxysmal AF patients, performed by young electrophysiologists with less than 5 years of experience.

Methods

Fifty consecutive patients (25 men, aged 61±11 years) with symptomatic paroxysmal AF were enrolled during the period 2020- 2021. RF catheter ablation based on the CLOSE protocol, using a conventional contact force sensing catheter (Thermocool SmartTouch ST D/F) and a circumferential multipolar catheter (Lasso) after double transseptal puncture (2 SL0 long sheaths), under general anesthesia and oesophageal temperature monitoring was performed in all patients.

Results

Pulmonary vein isolation demonstrated by entrance and exit block was achieved in all patients. Total procedure time was 147 ± 29 minutes, exposure X-ray time was 5.36 ± 4.46 minutes and exposure dose was 922 ± 1616 cGy*cm2. Left pulmonary veins (LPVs) first pass isolation (94%) was numerically higher than the right pulmonary veins (RPVs) first pass isolation (82%). There were not safety issues. In comparison with the results reported by the authors of the CLOSE protocol, the procedure time was similar (p= 0.84), however, the exposure X-ray time and the exposure dose were significantly lower in our study (p<0.0001 and p=0.01, respectively). The rates of first pass isolation of left and right pulmonary veins did not differ when compared to the respective rates reported by the CLOSE protocol authors (82% vs CLOSE 100% for RPVs and 94% vs CLOSE 97% for LPVs, p> 0.05 for both).

Conclusions

RF catheter ablation in paroxysmal AF patients using the CLOSE protocol is highly effective, safe and reproducible not only by experienced but also by young electrophysiologists. Adaptation of an ablation strategy for pulmonary vein isolation based on the CLOSE protocol may improve the workflow of the procedure and the training curve of young electrophysiologists without compromising the efficacy and safety.
Arrhythmic substrate in pulmonary vein isolation reprocedures in the era of the close protocol
Authors: Acosta Martinez J , Gonzalez De La Portilla-Concha C , Frutos Lopez M , Sanchez Brotons J A , Arana Rueda E , Pedrote A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

The CLOSE protocol was developed as a radiofrequency ablation strategy that would result in the safe creation of durable pulmonary vein isolation (PVI) leading to improved outcomes. The aim of the protocol is to enclose the PVs with stable, contiguous and ablation index (AI) guided lesions.

Purpose

We analyze the arrhythmic substrate found in patients undergoing PVI reprocedure after a first CLOSE-PVI procedure and compare it to that observed in PVI reprocedure in patients who underwent a first non-CLOSE-PVI procedure.

Methods

Patients undergoing a PVI-reprocedure after a first CLOSE-PVI procedure (35W, AI 450 for the anterior wall and 350 for posterior wall) were prospectively included (CLOSE-group). During the reprocedure a detailed electroanatomical map with multielectrode catheters was obtained in all patients. The number of reconnected PVs and segments was assessed. In patients with left atrial flutter (AFl), the circuit was defined by activation and entrainment mapping. These data were compared to those observed in a historic control group of PVI reprocedures after a first non-CLOSE-PVI procedure (non-CLOSE-group; 21 reprocedures among 157 first PVI procedures).

Results

Among 352 patients undergoing a first CLOSE-PVI, 27 (74.1% male, 57±8.6 years) underwent a PVI reprocedure. 74% (20 patients) showed at least 1 PV reconnected vs 100% in non-CLOSE group; p=0.012. Among the 7 patients without PV reconnection (PVR) perimitral AFl was found in 2 patients and a roof dependent AFl was observed in 1 patient. In the remaining 4 patients no specific substrate or trigger was observed. Among patients showing PVR, no differences were observed in terms of mean number of reconnected PVs [2(1-2) vs 2(1-3) respectively; p=0.751] or segments [2(1-2) vs 2(2-4) respectively; p=0.895) compared to the non-CLOSE group.

Conclusion

PVR remains the main substrate in patients undergoing atrial fibrillation (AF) ablation reprocedure after a first CLOSE-PVI. However, a significantly higher proportion of patients showed persistent PVI without a specific arrhythmic substrate or trigger for AF; which makes it necessary to define new strategies to improve rhythm control in these patients.
Integrated ALARA approach to atrial fibrillation radiofrequency ablation: combined use of transesophageal echocardiography, 3D mapping system and X-Ray sparing fluoroscopy settings
Authors: Buia V , Vitali-Serdoz L , Walascheck J , Xhakupi H , Hoefler D , Rittger H , Bastian D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

3D mapping guided ablation of atrial fibrillation (AF) demonstrated its value in increasing procedural safety and reducing the total patient and team radiation exposure. An ALARA (as low as reasonably achievable) approach can be reached through the use of transesophageal echocardiography (TEE) to guide transeptal puncture, a 3D mapping system and low fluoroscopy settings of the X-Ray System.

Purpose

Investigation of radiation exposure during an ALARA optimized AF Ablation with 3D mapping System

Methods

We included 112 consecutive patients in the years 2021-2022 undergoing radiofrequency (RF) AF Ablation with 3D mapping system.

Fluoroscopy was routinely performed with a Siemens Arctic Zee X Ray System at factory low setting of 1 to 3 pulses per second, pulse width of 6,4 ms, collimation and with the secondary radiation grid in situ.

Fluoroless 3D mapping of right atrium, His region, superior vena cava, septum and coronary sinus was performed in all cases except 5 patients with pace-maker or ICD. The wire, connected with alligator clip to the 3D mapping system and the transseptal puncture sheath were fluoroless positioned in the superior vena cava. Thereafter, double transseptal puncture was guided by TEE and fluoroscopy if necessary. Only in one case intracardiac echo (ICE) was used to guide the transeptal puncture.

93% of the procedures were performed with a BRK needle connected with an alligator clip to the 3D mapping system, a - RF-needle was used in 8 (7%) patients.

All further steps were performed with a contact -force catheter and a multipolar diagnostic catheter with use of radiation only if necessary. Usually, after mapping of the left atrium the staff worked without lead protection for the rest of the procedure.

Circumferential pulmonary vein isolation (PVI) was performed in all cases adding a substrate modification in re-do procedures.

Results

One hundred and twelve patients (age 63±10 years) with paroxysmal (n=48, 43%) oder persistent (n=64, 57%) AF scheduled for RF catheter ablation were included.

We performed the transseptal maneuver with a very low fluoroscopy exposure (mean 40±95s, DAP 5±13 cGy*cm2), moreover, the mean total radiation time of the complete PVI was under a minute (mean 51 ± 112s, DAP 7±17 cGy*cm2). A completely fluoroless procedure was possible in 52 (46%) procedures. No major complications occured.

Conclusion

In the years 2021 and 2022 we were able to perform 112 RF ablation procedures using an ALARA approach with a combined TEE- guided transseptal double puncture, a 3D-mapping system and low-fluoroscopy settings of X-Ray System achieving a mean radiation exposure of under a minute without compromising the safety and efficacy of the RF PVIs.
A single-center single-shot devices experience for pulmonary vein isolation
Authors: Kirstein B , Heeger C H , Phan H L , Eitel C , Feher M , Vogler J , Popescu S S , Hatahet S , Keelani A , Breithaupt C , Wolf C , Kuck K H , Tilz R R
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) is the gold standard for treatment of atrial fibrillation (AF). Single-shot devices have been introduced to provide a faster and more simplified approach to achieve PVI. We sought to evaluate our single-center experience with different single-shot devices for the treatment of AF.

Methods

Evaluation included 25 propensity score matched patients (age, gender, AF-type, CHADSVAsc score) for each single-shot device (i) Arctic Front 4th generation cryoballon (CB G4), (ii) PolarX cryoballoon, (iii) X3 laserballoon, (iv) single-access pulsed field ablation (PFA) as part of our prospective observational AF registry who underwent first-time ablation for symptomatic AF. The first 20 cases (learning curve) with each technology and those with pre/post mapping were rejected from the analysis. Procedures were performed by the institute´s standard operational procedures. Procedural characteristics and safety data were compared.

Results

A total of 100 symptomatic AF patients (66±8 years, 57% paroxysmal AF, 42% female, CHADSVasc Score 1.2±1) underwent first-time PVI with a single-shot device. Acute PVI rates were 96-100%. Treatment with either cryoballoon systems revealed similar procedure characteristics between vendors. Balloon-based procedures were associated with longer procedure times between 54-57 min. Using a single-access PFA approach, procedure (26 [25-30] min) and fluoroscopy times (5 [IQR 5;7] min) were significantly reduced (p<0.001). Significantly smaller amounts of contrast medium were needed in laser and PFA procedures in comparison to both cryoballoons (p<0.001). Adverse event rates did not differ between technologies. Details are given in Table 1-3 and Figure 1.

Conclusion

In our prospective ablation registry, first-time AF ablation using single-access PFA outperformed other common single-shot devices. Procedure and fluoroscopy times were significantly reduced by approximately 50% in comparison to balloon-based technologies (p<0.001). A comparable safety profile was found between PFA, cryo- and laser energy.
Short and midterm outcome of intraprocedural sinus node dysfunction requiring stimulation during ablation of persistent atrial fibrillation
Authors: Pu L , Ulbrich S , Gaspar T , Huo Y , Richter U , Zedda A M , Mayer J , Ebert M , Richter S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Ablation within the superior, antero-lateral portions of the right atrium has been described as a risk for sinus node dysfunction (SND) because of direct damage to the sinus node. The sinoatrial nodal artery arises from the right coronary artery in the majority of people and courses close to the superior posterior aspect of the interatrial septum. Rare cases of SND were observed periprocedurally during atrial fibrillation/flutter ablation. We sought to report on clinical characteristics, ablation set and acute and midterm rhythm outcome of patients who develop acute SND during/immediately after exclusively left atrial ablation.

Methods

We performed a retrospective analysis of AF/Aflutter ablation patients between January 2017 and December 2019 to characterize those who required temporary pacemaker (TPM) implantation due to acute sinus node dysfunction (sinus arrest, sinus bradycardia <35 beats/min with hemodynamic compromise) following atrial ablation.

Results

Of 1,072 patients, at nine patients [0,8%] intraprocedural temporary pacemaker implantation was necessary due to severe SND and hemodynamic compromise. The reasons for implantation were identified as sinus arrest (n=6) or severe sinus bradycardia (n=3). Eight of nine patients were male [89%], age 73 +11.2, 6/9 [67%] persistent AF, 2/9 [22%] Aflutter. The ablation set consisted of: pulmonary vein (PV) isolation in all patient (n = 9), left atrium(LA)-substrate modification in 8. In detail: roof line ablation (n = 3), mitral annulus-right superior PV line ablation ( n=8), mitral annulus-left superior PV line (n = 3). No patient had an ablation within the the right atrium. Four of nine [22%] pts. received permanent PM before discharge, performed 5 days postablation (range 3-7 days). At 3-month device interrogation, all patients were atrially paced, with a pacing proportion of >40% in 3/4 [0,3%] patients.

Conclusion

Acute sinus node dysfunction is a rare complication of sole left atrial ablation outside the pulmonary veins. However, a relevant fraction of these patients requires permanent implantation with substantial pacing proportion during midterm follow up.
An international two-centre experience with the third generation laser balloon system: safety, efficiency, and efficacy
Authors: Martignani C , Bartoli L , Spadotto A , Massaro G , Piemontese G P , Angeletti A , Ziacchi M , Phan H L , Keelani A , Eitel C , Vogler J , Biffi M , Kuck K H , Tilz R R , Heeger C H
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Endoscopic laser balloon systems (ELBS) are a new tool for pulmonary vein isolation (PVI). The third generation ELBS underwent significant structural improvements compared to its predecessors. These include a novel feature (RAPID mode), potentially allowing an automized and high-speed circumferential energy delivery for PVI. However, there is a lack of data on its use.

Objective

We analyzed the safety, efficiency, and efficacy of the third-generation ELBS in a cohort of patients who underwent ablation of atrial fibrillation in a German and an Italian centre.

Methods

We prospectively enrolled all consecutive patients who underwent PVI using the third-generation ELBS between June 2019 and November 2022. All the procedures were performed by four operators. For each pulmonary vein (PV), we always attempted to obtain a complete circumferential lesion using only the RAPID mode. When this was not feasible, the operator treated the remaining gaps with point-by-point laser delivery.

Results

We included 163 patients in our study (mean age 61.9 ± 11.4, persistent atrial fibrillation 30.6%, female patients 30.6%). The operators identified and successfully isolated 655 pulmonary veins. There was an anatomical variation of the PVs in 41 (25.1%) patients, of whom 19 had either a left or a right common trunk, and 23 had a supernumerary right PV. 424 PVs (64%) were isolated for at least 80% of their circumference using the RAPID mode, 389 (59.4%) were treated using it for a minimum of 90% of their circumference, and finally, 289 (44%) were isolated using only RAPID. The operators could perform the procedure using only the RAPID mode in 35 (21.5%) patients. We observed a mean total procedural and fluoroscopic times of 95.7 ± 44.5 min and 13.9 ± 8.4, respectively. 5 (3%) periprocedural complications occurred. There were three episodes of transient phrenic nerve palsy (the most extended episode resolved two months after discharge). One episode of pericardial tamponade occurred, with a subsequent need for pericardiocentesis. Finally, there was one periprocedural transient ischaemic attack (TIA). During energy delivery, eight pinhole balloon ruptures occurred.

Eighty-five patients were followed up for at least six months (mean follow-up 12.2 ± 4.4 months). Among these, 26 (30.5%) presented a recurrence after the blanking period. Among baseline features, persistent AF was not a predictor of recurrence.

Conclusion

This is one of the largest cohorts of patients treated with third-generation ELBS. In our two-centre experience, the system proved efficient, safe, and effective and the RAPID mode showed good applicability.
Pulmonary vein isolation and additional selective ablation of low voltage areas and atrial late potentials for persistent atrial fibrillation (SOLVE-AF-Study)
Authors: Jadidi A , Mueller-Edenborn B , Eichenlaub M , Lehrmann H , Allgeier J , Trenk D , Neumann F , Westermann D , Arentz T
Published: May 2023

Funding Acknowledgements

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

Introduction

Novel catheter ablation technologies (e.g. RF with contiguous lesions) for pulmonary vein isolation (PVI) achieve high (80-85%) arrhythmia freedom rates at 12 months in both paroxysmal and persistent AF. However, success rates are importantly reduced (45-50%) in persistent AF patients presenting atrial cardiomyopathy with additional low voltage areas in the left atrial body.

Aim

SOLVE-AF study is a prospective randomized multicenter study, in which the standard approach "circumferential PVI" is compared to "additional ablation of low voltage areas and ablation of slow conducting "atrial late potentials (ALPs)" during sinus rhythm (SR)".

Methods

320 patients with persistent AF will be included. Patients undergo left atrial high definition voltage mapping in SR. 160 patients with low voltage areas (<0.5mV at >5cm2) within the LA body will be randomized to "circumferential-PVI" vs. "additional low-voltage-guided ablation". The remaining 160 without low voltage substrate (registry group) will undergo "circumferential-PVI". Arrhythmia recurrences (defined as AF/AT >30 sec) will be assessed at 6 and 12 months (7-day-Holter and event-recorder) following ablation therapy (top panel).

Results

Currently, 120 patients have been included into the registry group and 120 patients with low voltage substrate have been randomized. Results of the SOLVE-AF-pilot study including a total of 210 patients (110 registry patients without LA-LVS and 100 patients with LA-LVS who were assigned to PVI-only versus additional substrate-based ablation) at the University-Heart-Center-FR-BK favor "PVI plus substrate-based ablation" in those patients who do present significant low voltage areas (see KM-curve bottom panel).

Conclusions

Results from the pilot trial suggests improved arrhythmia freedom rate with PVI plus additional substrate-based ablation during sinus rhythm. Final results of the prospective randomized multi-center trial SOLVE-AF are expected in June 2024.
Identification of atrial complex electrograms by short-coupled extrastimuli in paroxysmal and persistent atrial fibrillation
Authors: Silva E , Lobo Torres I , Fernandez Garcia M , Gomez Lopez A , Fernandez Rivero R , Cano Calabria L , Fernandez-Armenta Pastor J
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): - Health Council of the Andalusian Regional Government through the project "PI-0057-2017".

- European Regional Development Fund/European Social Fund.

Introduction

Electrogram fractionation during atrial fibrillation (AF) and sinus rhythm have been studied as marker of atrial remodeling and potential target for ablation.

Objective

The aim of our study was to analyze the response to closely coupled atrial extrastimuli and try to identify areas of hidden slow conduction (HSC) that can promote reentry and AF maintenance in paroxysmal and persistent AF.

Methods

Twenty consecutive patients with paroxysmal AF and persistent AF (10:10) underwent first PVI procedure. During sinus rhythm triple short coupled extrastimuli was delivered. Locations showing double or highly fragmented electrograms in response to triple extrastimuli were defined as positive electrogram (HSC-EGM) (Figure 1). Increase in duration (delta) of the bipolar EGM was recorded. Two consecutive high-density maps were acquired using a multipolar catheter during AF, sinus and paced rhythms. Spatial correlation of HSC-EGM and complex atrial fractionation (CFAEs) during AF were evaluated.

Results

Patients with persistent AF showed a higher number and percentage of HSC-EGM than paroxysmal AF (13,9% vs 3,3%, p<0.001) (Figure 2). Delta of EGM duration was 53 ± 22 ms compared to 16 ± 14 ms in sites with a negative response (p<0.001). The number of HSC-EGM distinguished with extrastimuli was lower than that of CFAEs during AF (19 vs 56 per map, p<0.01). The reproducibility of the extension and distribution of HSC-EGM in the repeated maps was superior to that of the CFAEs. The distribution of the HSC-EGM was comparable with those found in the initial map (p=0,32), however, there were significant differences in the distribution of CFAEs between the first map and the remap (p=0.003).

Conclusion

HSC-EGM in response to triple extrastimuli are more frequent in persistent AF. This type of evoked response could reveal the presence of slow conduction areas and could be considered a potential target for ablation of persistent atrial fibrillation. More studies are needed to confirm this hypothesis.
Heterogeneity in voltage and activation time in the left atrium of atrial fibrillation patients undergoing pulmonary vein isolation
Authors: Meijer I , Keshtkar S , Kong X , Jiang C , Ma C , Camara O , Marquering H , Arrarte Terreros N , De Groot J
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ITEA 3 Symphony project

Introduction

Electro-anatomical maps are standardly used to visualize anatomy and electrophysiological properties of the left atrium during pulmonary vein isolation (PVI) in atrial fibrillation (AF) patients. We sought to describe heterogeneity in atrial voltage and activation time, as a proof-of-principle, to study its association with treatment outcome. Therefore, we projected all data-points from electro-anatomical maps to the CT scan meshes of the left atrium and calculated median voltage and activation time in patients with paroxysmal or persistent AF undergoing first PVI ablation. We hypothesize that the variation and heterogeneity in these parameters throughout the left atrium carry important prognostic and diagnostic information and can be used to discern different subtypes of AF.

Methods

We included AF patients who underwent PVI for the first (cohort I) and second time (cohort II) during 2021-2022. Electro-anatomical maps during sinus rhythm were acquired before and after the ablation procedure and were projected on the patient-specific CT-scan-derived mesh of the left atrium. Patients underwent 6 to 12-month follow-up and were classified as persistent (AF lasting longer than 7 days and usually requiring electrical cardioversion) and paroxysmal (self-terminating AF episodes, lasting shorter than 7 days, mostly shorter than 24 hours). We determined bipolar voltages and activation times for persistent and paroxysmal AF patients in each cohort. In addition, we compared global left atrial voltage and activation times pre- and post-PVI.

Results

Our study population consisted of 24 patients: 14 patients in cohort I and 10 patients in cohort II. Summary of baseline and voltage and activation times can be found in Figure 1. In both cohorts, patients with persistent AF showed a trend towards a lower median LA voltage (Figure 1), but not a longer median atrial activation time. Paroxysmal patients showed more heterogeneity (wider IQR) in both voltage and activation times compared to persistent AF patients. Figure 2 displays a typical example of an electro-anatomical reconstruction of a paroxysmal AF patient pre- and post-second-PVI where the local heterogeneity can be observed - after the ablation, higher voltages and shorter activation times were observed.

Conclusion

We provide a proof-of-principle demonstrating that with the use of conventional electro-anatomical maps, important information on heterogeneity and variance in local voltage and activation time can be quantified. This quantification can help discern different AF subtypes and might contribute to understanding different arrhythmogenic substrates and treatment outcome differences.
Atrial myocardial substrate has a significant influence on local impedance data - clinical experience from high power short duration and standard radio frequency ablations
Authors: Herold V , Reents T , Maurer S , Bahlke F , Kottmaier M , Krafft H , Lengauer S , Tutarel O , Hessling G , Deisenhofer I , Bourier F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Local impedance is a new clinically used RF ablation parameter used to predict RF lesion creation. By now, data about the influence of atrial substrate on local impedance is still scarce. The aim of this study was to investigate local impedance data of different atrial tissues (healthy myocardium vs. Low Voltage areas) and the importance of local impedance drops during HPSD and standard RF ablation in atrial tissue.

Methods

A total of n=1319 clinical RF applications in n=51 clinical left atrial ablation procedures were analyzed regarding underlying RF ablation parameters (RF power, duration, contact force, global and local impedance data). 3D mapping data were used to differentiate RF ablations in low voltage areas (<=1.0mv) from those in healthy atrial myocardium (>1.0mV). Local and global impedance baseline values and drops, RF electrogram amplitude attenuation, as well as RF data were calculated and registered for statistical analysis.

Results

Local impedance drops were significantly higher during RF application in healthy myocardium when compared to low voltage areas (18,6 vs. 16,6 Ohm, p<0.01). Baseline local impedance was significantly higher in healthy atrial myocardium when compared to low voltage areas (105,4 vs. 99,1 Ohm, p<0.01). There was no significant difference in global impedance values between low voltage areas and healthy atrial myocardium (p=0.34). These findings were confirmed in HPSD (60W, 10s) as well as in standard (30-40W, 30-60s) RF applications. Impedance drops were significantly larger in HPSD when comapred to standard RF ablation (p<0.01). Detailed boxplot results are presented in the Figure.

Conclusions

Local impedance drop is a good predictor of RF lesion creation in HPSD as well standard RF ablations. Interestingly, different local impedance but not global impedance values were observed in healthy and low voltage areas. In clinical practice, local impedance may be a useful parameter to identify atrial substrate.
Initial experience and early outcomes of posterior wall ablation using pulsed-field ablation
Authors: Kueffer T , Madaffari A , Muehl A , Seiler J , Thalmann G , Servatius H , Tanner H , Haeberlin A , Baldinger S H , Kozhuharov N A , Noti F , Reichlin T , Roten L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The success rate of pulmonary vein isolation (PVI) is lower in patients with persistent compared to paroxysmal atrial fibrillation (AF). In patients with persistent AF, additional isolation of the posterior wall is under investigation to improve ablation success. Pulsed field ablation (PFA) might be superior to conventional methods for posterior wall isolation due to its safety profile and might allow for posterior wall ablation (PWA) rather than posterior wall isolation (PWI) based on its efficiency.

Purpose

To report our initial experience with PWA using a multipolar PFA catheter.

Methods

Consecutive patients with PWA during their first PFA procedure for AF between May 2021 and October 2022 at our institution were included. For PWA, the multipolar PFA ablation catheter was used in flower configuration only. With the wire in each of the pulmonary veins and the sheath angulated posteriorly, we first performed 2 x 2 sets of anchor lesions with the catheter rotated by ~30° between sets. Next, with the wire retracted back into the device, single sets of two applications were delivered in an overlapping fashion and without catheter rotation between lesion sets to cover the entire posterior wall between the superior and inferior pulmonary veins. Finally, completeness of PWA was verified by 3D electro-anatomical mapping.

Results

PWA using PFA was performed in 163 patients (mean age 67 years, 71% male). In 55 patients (34%), PWA was added to PVI during the first AF ablation procedure and the remaining 108 patients (66%) had undergone a median of two (interquartile range 1-3) previous AF ablation procedures using either cryoablation and/or radiofrequency ablation. Of all patients, 45 (28%) had paroxysmal, 93 (57%) persistent AF, and 22 patients (15%) left atrial reentry tachycardia. Median procedure duration and fluoroscopy time were 120 (70-190) min, and 18 (9-36) min, respectively. 3D-EAM showed no residual electrical signal (>0.05 mV) on the posterior wall at the end of the procedure in any patient. No cardiac tamponade, stroke, phrenic nerve injuries, atrio-esophageal fistula, or clinically manifest coronary spasm occurred.

A repeat ablation was performed in seven patients (4%) and 3D-EAM showed persisting posterior wall isolation in six (86%) and recurrent roof dependent atrial flutter in one patient. Despite PWA, low-voltage signals were found in four (67%) cases on the superior aspect of the posterior wall.

Conclusions

Left atrial PWA can be performed safely and efficiently using PFA. Early data on the durability of PWA are promising. The impact of PWA on arrhythmia-free outcome needs to be evaluated in larger, prospective randomized trials.