bluuebunny/crossref_metadata_2025_split huggingface dataset:
Concomitant surgical ablation of atrial fibrillation: long-term outcomes
Authors: Muneretto C , Baudo M , Petruccelli R , Stara A , Moscatiello M , Rosati F , Benussi S 
Published: November 2020

Abstract

Introduction
Atrial fibrillation (AF) is the most common cardiac related arrhythmia, independently associated with an increased risk of death and high level of morbidity, such as stroke, heart failure, as well as frequent hospitalization and reduced quality of life. Surgical ablation is an effective therapy for patients with AF undergoing concomitant cardiac surgery.

Purpose
In this study we report the results of concomitant surgical AF ablation, in terms of efficacy and safety, with a long-term follow-up at 10 years.

Methods
Two-hundred fourteen (214) consecutive patients (female, 45.17%) underwent from 1999 to 2016 surgical ablation of AF concomitantly with other major cardiac procedures. Mean age was 67.4±9.82. Patients had persistent and long-standing persistent AF in 64.65% of cases. Primary endpoints were overall survival, freedom from stroke and freedom from AF.

Results
Perioperative mortality was 2.3% (5/214). Mean EuroSCORE II was 5.2±4.4. Concomitant mitral valve surgery was performed in 56.74% of patients, 31% of patients had a concomitant aortic valve surgery, while myocardial revascularization either isolated or associated with aortic valve was performed in 11.63% and 3.72% of cases respectively. Ablation was carried out by means radio-frequency box lesions set in 35.51% (76/214) of patients while pulmonary veins isolation with bipolar clamp and Cox-MAZE IV was performed in 51.86% (111/214) and 12.61% (27/214) of patients respectively. Left atrial appendage (LAA) exclusion was performed in 57 patients (26.51%) after careful echocardiographic investigation of diastolic and atrial function. Incidence of early postoperative (30 days) permanent pacemaker implantation was as low as 2.3%. The mean follow-up was 6.71±4.47 years. The New York Heart Association functional class (2.84 vs. 1.91, p&lt;0.001) and ejection fraction (54.4% vs. 56.6%, p&lt;0.001) were improved compared with the preoperative status. At 10 years Kaplan-Meier overall survival was 62.3%. Freedom from cardiac related death was 98%, while freedom from stroke was 98% at 10 years. Efficacy endpoint showed a freedom from AF at 10 years, according to HRS criteria of 66.7%. Fisher exact test comparing mitral surgery patients or ischemic CABG-patients showed no differences in terms of stroke rate (p=0.999), while postoperatively, there was a higher rate of stroke at thirty days in patients with postoperative AF (p=0.019).

Conclusions
Concomitant surgical ablation of AF was associated with a very low incidence of postoperative PM implantation and provides excellent results in terms of stable rhythm outcome at long-term. Postoperative AF significantly increased the risk of stroke in the early postoperative period.

Funding Acknowledgement
Type of funding source: None
Long-term results of simultaneous hybrid ablation of therapy-resistant atrial fibrillation
Authors: Baimbetov A , Bizhanov K , Yakupova I , Bairamov B , Medeubekov U , Madyarov V 
Published: November 2020

Abstract

Background
A hybrid technique using thoracoscopic epicardial and standard endocardial ablation of atrial fibrillation (AF) is a strategy used to treat AF patients with therapy-resistant symptomatic AF. We conducted comparative study of efficacy and safety of simultaneous hybrid ablation in patients with non-paroxysmal forms of AF and evaluated the factors that determine success and quality of life.

Methods
The study included 56 consecutive patients who underwent simultaneous hybrid ablation. First, epicardial ablation was performed using thoracoscopic access: to isolate the pulmonary veins and the posterior wall of the left atrium. After this, an endocardial electrophysiological assessment was carried out from the pulmonary veins to the left atrium and additional endocardial ablation was performed, where necessary. The next day, a loop ECG recorder was implanted subcutaneously in the thoracic region. Efficiency was evaluated using implanted loop ECG recorders. The average follow up was 24 months, the studied patients came to the clinic every 3 months to receive diagnostic reports from loop recorders. Recurrence was defined as AF, atrial flutter and other atrial tachycardia, recorded in reports of loop recorders lasting &gt;30 sec during follow up period.

Results
Continuous follow up was carried out in 56 patients, the average age of which was 57±9 years. Of these, 39 (70%) men, 6 (10%) paroxysmal, 38 (68%) persistent and 12 (22%) long-standing persistent AF. Within 24 months of follow up, 45 (80%) maintened a sinus rhythm. Most recurrenses were atrial flutter (8/11 patients). Success was associated with factors such as left atrial size, patient age and duration of arrhythmia. Patients with paroxysmal AF had the highest success, patients with long-standing persistent AF had the least success. 5 (9%) patients had complications associated with the procedure. Quality of life after ablation improved in patients with sinus rhythm.

Conclusion
The efficiency of simultaneuous hybrid AF ablation was 80% for 24 months of continuous follow up period associated with the type of AF. Quality of life improved significantly, complications associated with the procedure occurred in 9%.

Funding Acknowledgement
Type of funding source: None
The predictor role of worsening renal function in patients with new onset atrial fibrillation on direct oral anticoagulant
Authors: Bartoli L , Angeli F , Stefanizzi A , Paolisso P , Bergamaschi L , Toniolo S , Donati F , D'Angelo E.C , Magnani I , Foa' A , Rinaldi A , Martignani C , Biffi M , Pizzi C , Galie' N 
Published: November 2020

Abstract

Background
Chronic kidney disease (CKD) is an important outcome predictor in patients with atrial fibrillation (AF). Moreover, renal function at baseline is used to guide oral anticoagulant (OA) selection and dosing at initial treatment. The prognostic role of worsening renal function (WRF) during treatment with direct oral anticoagulants (DOACS) has been poorly explored.

Purpose
To estimate the prognostic role of WRF in terms of major adverse cardiovascular events (MACEs) in a series of patients with newly diagnosed non-valvular AF (NVAF) treated with DOACs.

Methods
Among all patients with newly diagnosed NVAF and indication for OA between January 2017 and December 2018, we enrolled those treated with DOACs. Renal function at baseline and during follow-up was assessed with estimated glomerular filtration rates (eGFR). eGFR was calculated as a mean value of Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. The hemorrhagic risk at baseline was estimated with the main available scores (HAS-BLED, ATRIA and ORBIT). WRF was defined as a decrease in eGFR of at least 20%. MACEs were evaluated according to the type of DOAC and the WRF. Major bleedings (MB) were defined according to the ISTH definition.

Results
The study population was constituted by 249 patients with newly diagnosed NVAF started on DOAC and followed for a median time of 14.1±8.6 months. Overall, WRF was observed in 58 cases (23.3%). Patients with WRF had significative higher rates of death (10.3% versus 3.1%, p=0.025) and MB (13.8% versus 4.7%, p=0.016). The incidence of bleeding events, acute coronary syndromes and stroke was not affected by WRF. Interestingly, CG formula better predicted the incidence of MB as compared to the other formulas (p=0.006). The type of DOAC did not significantly impact the observed renal impairment and had no effect on the occurrence of MACEs in patients showing WRF. The predictors of WRF were found to be age, female sex, low hemoglobin level and left ventricle end telediastolic volume. At multivariate analysis, WRF was identified as an independent predictor of MB (OR 3.1, 95% C.I, 1.12–8.58), regardless of the baseline bleeding risk.

Conclusion
This is the first prospective study to evaluate the impact of worsening renal function on cardiovascular events in patients with atrial fibrillation treated with DOACs. A significant WRF emerged as an independent predictor of death and MB. The specific DOAC did not affect either the entity of worsening renal function or the incidence of cardiovascular events.

Funding Acknowledgement
Type of funding source: None
Is there a role for half-dose anticoagulation in atrial fibrillation? Randomized comparison of 2 doses of edoxaban in 14,014 patients in ENGAGE AF-TIMI 48
Authors: Steffel J , Ruff C.T , Braunwald E , Park J.G , Murphy S , Antman E.M , Giugliano R.P 
Published: November 2020

Abstract

Background
In the phase 3 RCT ENGAGE AF-TIMI 48, both the higher-dose (HDER/edoxaban 60/30mg) and lower-dose edoxaban regimen (LDER/edoxaban 30/15mg) were non-inferior to well-managed warfarin for the prevention of stroke or systemic embolic events in patients with atrial fibrillation (AF). While LDER was associated with a 41% relative increase in ischemic stroke as compared to warfarin, LDER showed a larger relative reduction in bleeding events than HDER. An interaction tree analysis was performed to identify subgroups of patients likely to derive greater benefit from LDER vs. HDER based on a serious net outcome (SNO) that combines the most serious stroke and bleeding events: disabling/fatal ischemic stroke or life-threatening/fatal bleeding.

Methods and results
LDER (N=7002) had a higher risk for disabling/fatal ischemic stroke (HR 1.37, 95% CI 1.06–1.77; p=0.017), but fewer life-threatening/fatal bleeds (0.61 (0.44, 0.84), p=0.002) than HDER (N=7012). The SNO was similar with LDER vs HDER in the total population (0.95 (0.78–1.16), p=0.61). In the 30% of patients who had either malignancy or paroxysmal AF (Figure) the SNO was significantly lower with LDER vs HDER (HR 0.59 (0.40–0.86)), driven by large reductions in bleeding without an increase in ischemic stroke in this subgroup (figure). Meanwhile the remaining 70% of patients with neither malignancy nor paroxysmal AF tended to have a higher risk with LDER vs. HDER (HR 1.15 (0.91–1.46), P-interaction 0.003).

Conclusions
In our current post-hoc analysis we were able to demonstrate that the combined rate of serious stroke and bleeding events was similar in patients treated with LDER and HDER. Moreover, patients with a malignancy as well as those with paroxysmal AF derived a greater net benefit from LDER vs. HDER regarding serious AF-/anticoagulation-related outcome events. These results need to be viewed as hypothesis-generating which may, if confirmed, aid physicians in individualizing edoxaban dosing.

Funding Acknowledgement
Type of funding source: None
Clinical implications of assessment of apixaban levels in elderly atrial fibrillation patients: J-ELD AF Registry sub-cohort analysis
Authors: Suzuki S , Yamashita T , Akao M , Okumura K 
Published: November 2020

Abstract

Background
Randomized clinical trials demonstrated the efficacy and safety of apixaban in preventing stroke in patients with atrial fibrillation (AF). However, data on distribution of apixaban levels and their relationships with clinical outcomes are limited.

Purpose
To evaluate the distribution of blood apixaban concentration and its relationship with clinical outcomes.

Method
The J-ELD AF Registry is a large-scale, multicenter prospective observational study of Japanese non-valvular AF patients aged ≥75 years taking on-label dose (standard dose of 5 mg bid or reduced dose of 2.5 mg bid) of apixaban. Among the entire cohort (3,015 patients from 110 institutions), plasma apixaban levels at trough was measured by anti-Xa assay (Api-AXA) in 943 patients. The 943 patients were divided into 2 groups by the apixaban dose (standard dose [n=431] and reduced dose [n=512]) and each group was further divided into 2 groups with low and high Api-AXA levels compared with the median value.

Results
In patients with standard dose, the incidence rates (/100 person-years) of stroke or systemic embolism (1.48 and 1.99), bleeding requiring hospitalization (0.98 and 1.49), and total deaths (0.49 and 0.99) were comparable between low and high Api-AXA groups, respectively. In patients with reduced dose, although the incidence rates (/100 person-years) of stroke or systemic embolism (0.84 and 1.68) were comparable, bleeding requiring hospitalization (0.42 and 4.64), and total deaths (2.52 and 6.65) were significantly higher in high Api-AXA group than in low Api-AXA group. Multivariable Cox regression analysis revealed that in patients with reduced dose, high Api-AXA level was independently associated with bleeding requiring hospitalization (HR 12.12, 95% CI: 1.56–94.22, P=0.017) and insignificantly with total deaths (HR 2.15, 95% CI: 0.83–5.55, P=0.116).

Conclusions
High trough apixaban level in patients with standard dose was not associated with adverse events, while that in patients with reduced dose was associated with bleeding requiring hospitalization and total deaths. Measurement of apixaban levels may be informative in elderly patients indicated for reduced dose possibly with the intent of risk stratification and decision making.

Funding Acknowledgement
Type of funding source: Other. Main funding source(s): Bristol-Myers Squibb K.K.
Short coupling with high burden of atrial ectopy in twenty-four hour holter recording predicts recurrence of atrial arrhythmia after atrial fibrillation ablation
Authors: Okajima T , Imai H , Murase Y , Kano N , Ogawa Y , Kawaguchi K 
Published: November 2020

Abstract

Background
Atrial arrhythmia recurrence is experienced in up to 20% of patients after initially receiving a catheter ablation for atrial fibrillation (AF). Therefore, it is important to define predictors of atrial arrhythmia recurrence. Atrial ectopy (AE) with short coupling interval (S-AE) has been reported to be a trigger of AF. On the other hand, high burden of AE has been reported to be a useful predictor of atrial arrhythmia recurrences after AF ablation. Thus, the combination of the incidence of S-AE and AE burden during a 24-hour Holter recording could be a useful predictor of atrial arrhythmia recurrence after AF ablation.

Purpose
To investigate this hypothesis, we performed a retrospective case-controlled study.

Methods
We enrolled 180 patients who underwent their first catheter ablation procedure for AF and performed a 24-hour Holter recording between 90 to 365 days after their ablation procedure. Patients who performed an additional ablation procedure before the Holter recording were excluded. Finally, we analyzed 173 patients (age: 65±10 years, female: 28.3%, non-paroxysmal: 27.7%). The Holter recordings were analyzed by the same experienced technicians. We defined AE as a narrow QRS complex occurring &gt;25% than prior R-R interval, and S-AE as AE occurring &gt;55% earlier than expected. The relationship between the characteristics of AE during the Holter recording and atrial arrhythmia recurrences was investigated.

Results
The Holter recordings were performed at a median of 103 (IQR: 98–138) days after ablation. The median number of AE were 144 (IQR: 54–699) beats per day, and S-AE was recorded in 49 patients (28.3%). Forty-two patients (24.3%) had a recurrence of atrial arrhythmia during a median 488-day follow up period. Patients with S-AE had a recurrence of atrial arrhythmia more frequently than those without S-AE (44.9% vs 16.1%, p&lt;0.001). We found the cut-off point of AE burden as 241 beats per day by the receiver operating characteristic curve with 74% sensitivity and 70% specificity to predict atrial arrhythmia recurrence. We divided the patients into four groups according to the presence or absence of S-AE and high AE burden. In the Kaplan-Meier analysis, patients with S-AE and high AE burden had the highest atrial arrhythmia recurrence rate (Log-rank test: p&lt;0.001). In the Cox multivariate analysis, S-AE with high AE burden was an independent predictor of atrial arrhythmia recurrence (HR: 4.27, 95% CI: 2.32–7.85, p&lt;0.001).

Conclusion
For AF patients who underwent their first catheter ablation, S-AE (&gt;55% earlier than expected) with high AE burden (&gt;241 beats per day) during the 24-hour Holter recording predicted recurrences of atrial arrhythmia. These results can help to develop follow-up strategies after AF ablation.

Funding Acknowledgement
Type of funding source: None
A comparison of rate control and rhythm control in tachycardia induced cardiomyopathy patients with persistent atrial flutter
Authors: Oka S , Kai T , Hoshino K , Watanabe K , Nakamura J , Abe M , Watanabe A 
Published: November 2020

Abstract

Background/Introduction
Tachycardia induced cardiomyopathy (TIC) is a potentially reversible dysfunction of the left ventricle (LV) caused by tachyarrhythmias. Early recognition of TIC and treatment of the culprit arrhythmia using pharmacological therapy or catheter ablation results in the recovery of LV function. For atrial flutter (AFL)-induced TIC, rhythm control strategy, such as catheter ablation has been recommended. On the other hand, the efficacy of rate control strategy has remained unclear due to the difficulty of control with arrhythmic medications. However, not all patients can take rhythm control treatments due to their backgrounds.

Purpose
The aim of this cohort study was to establish whether rate control strategy using β-blocker is as effective as invasive rhythm control strategy for the recovery of LV function in patients with TIC due to AFL.

Methods
We prospectively assessed 47 symptomatic non-ischaemic heart failure (HF) patients with left ventricular ejection fraction (LVEF) below 50% and suspected TIC induced by persistent AFL. Patients were divided into rhythm control strategy group (n=22, treatment: catheter ablation, electrical cardioversion) and rate control strategy group (n=25, treatment: bisoprolol). As a sub-group study, the rate control strategy group was divided into the strict rate control group (n=12, average heart rate below 80 bpm) and lenient rate control group (n=13, average heart rate below 110 bpm). The primary outcome was the recovery of LV function, defined as an increase of LVEF over 20% or to a value of 55% or greater after 6 months.

Results
There were no significant differences in baseline AFL heart rate, New York Heart Association class, LVEF, estimated glomerular filtration rate, and brain natriuretic peptide between the two groups. A greater proportion of patients who showed the recovery of LVEF after 6 months belonged to the rhythm control strategy group (90.9% vs. 52.0%, p=0.004). The cumulative incidence of HF re-hospitalization was significantly higher in the rate control strategy group than in the rhythm control strategy group (hazard ratio: 4.90, 95% CI: 1.06–22.69). As a result of sub-group study, LVEF recovery was greater in the strict rate control group compared to the lenient rate control group (75.0% vs. 30.8%, p=0.027)

Conclusion
Rate control strategy was significantly inferior to rhythm control strategy for the recovery of LVEF in TIC patients with persistent AFL. Rhythm control should be the first choice in the management of TIC with AFL, and strict rate control should be an alternative if rhythm control is not available.
Primary outcomes

Funding Acknowledgement
Type of funding source: None
Clinical risk predictors for bradycardia, supraventricular tachycardia and epilepsy necessitating therapy in patients with unexplained syncope monitored by insertable cardiac monitor
Authors: Onuki T , Shoji M , Kikuchi M , Asano T , Suzuki H , Tannno K , Shinke T 
Published: November 2020

Abstract

Background
Insertable cardiac monitors (ICMs) allow for lengthy monitoring of cardiac rhythm and improve diagnostic yield in patients with unexplained syncope. In most cardiac syncope cases, sick sinus syndrome, atrioventricular block, and paroxysmal supraventricular tachycardia (SVT) are detected using ICMs. On the other hand, epileptic seizures are sometimes diagnosed as unexplained syncope because in these situations, the loss of consciousness is a similar manifestation. Thus, the population of patients with unexplained syncope monitored by ICMs includes epileptic patients. Clinical risk factors for bradycardia, SVT and epilepsy that necessitate therapy in patients with unexplained syncope are not well known. If these risks can be clarified, clinicians could provide more specific targeted monitoring.

Purpose
We aimed to identify these predictors.

Methods
We retrospectively reviewed medical records of consecutive patients who received ICMs to monitor unexplained syncope in three medical facilities. We performed Cox's stepwise logistic regression analysis to identify significant independent risk factors for bradycardia, SVT, and epilepsy.

Results
One hundred thirty-two patients received ICMs to monitor unexplained syncope. During the 17-month follow-up period, 19 patients (10 patients had sick sinus syndrome and 9 had atrioventricular block) needed pacemaker for bradycardia; 8 patients (3 had atrial flutter, 4 had atrial tachycardia, and 1 had paroxysmal atrial fibrillation) needed catheter ablation for SVT; and 9 patients needed antiepileptic agents from the neurologist.Stepwise logistic regression analysis indicated that syncope during effort (odds ratio [OR] = 3.41; 95% confidence interval [CI], 1.21 to 9.6; p=0.02) was an independent risk factor for bradycardia. Palpitation before syncope (OR = 9.46; 95% CI, 1.78 to 50.10; p=0.008) and history of atrial fibrillation (OR = 10.1; 95% CI, 1.96 to 52.45; p=0.006) were identified as significant independent prognostic factors for SVT. Syncope while supine (OR = 11.7; 95% CI, 1.72 to 79.7; p=0.01) or driving (OR = 15.6; 95% CI, 2.10 to 115.3; p=0.007) was an independent factor for epileptic seizure.

Conclusions
ICMs are useful devices for diagnosing unexplained syncope. Palpitation, atrial fibrillation and syncope during effort were independent risk factors for bradycardia and for SVT. Syncope while supine or driving was an independent risk factor for epilepsy. We should carefully follow up of patients with these risk factors.

Funding Acknowledgement
Type of funding source: None