bluuebunny/crossref_metadata_2025_split huggingface dataset:
Risk factors for progression of paroxysmal to persistent atrial fibrillation following successful PV isolation
Authors: Mohanty S , Trivedi C , Della Rocca D.G , Gianni C , Salwan A , Macdonald B , Mayedo A , Bassiouny M , Gallinghouse G.J , Burkhardt J.D , Horton R , Al-Ahmad A , Di Biase L.D , Natale A 
Published: November 2020

Abstract

Background
Progression from paroxysmal (PAF) to persistent atrial fibrillation (PerAF) following effective PV isolation (PVI) has important clinical implications, as it is relevant for subsequent management of the arrhythmia.

Objective
We evaluated risk factors responsible for progression of PAF to PerAF following successful PVI.

Methods
Consecutive AF patients that received their first catheter ablation as well as the first redo at our center were identified (n=1352). Patients were included in group 1 if the diagnosis was PAF at both first and redo procedure (PAF to PAF) and group 2 if PAF at index progressed to PerAF at redo. All patients received PVI plus isolation of LA posterior wall and SVC at the first procedure.

Results
A total of 822 patients remained as PAF at redo, whereas 530 (39%) progressed from PAF to PerAF. Clinical characteristics of the study population are presented in table 1. In multivariate analysis, BMI (OR 1.02, 1.01–1.04, p=0.04), hypertension (1.4, 1.08–1.8, p=0.01), heart failure (1.67, 1.03–2.69, p=0.03), LA size (2.75, 2.29–3.31, p&lt;0.001) were independent predictors of progression of PAF to PerAF. Data on serum-transthyretin level was available for 37 and 48 patients in group 1 and 2 respectively. It was &lt;18 mg/dL (normal) in 33 (68.7%) patients in group 2 vs 6 (16.2%) in group 1 (p&lt;0.001).

Conclusion
In our patients, after successful PVI, progression of PAF to PerAF was mediated by independent risk factors such as high BMI, heart failure, hypertension, larger LA size and lower LVEF.

Funding Acknowledgement
Type of funding source: None
Empirical superior vena cava isolation in patients undergoing redo- catheter ablation procedure after recurrence of atrial fibrillation
Authors: Spies F , Madaffari A , Voellmin G , Krisai P , Schaerli N , Reichlin T , Osswald S , Sticherling C , Kuhne M , Knecht S 
Published: November 2020

Abstract

Background/Introduction
Extra pulmonary vein (PV) foci may trigger AF recurrence after an initially successful PVI. Superior vena cava (SVC) catheter ablation (CA) may therefore offer a treatment target in order to improve success rates.

Purpose
The purpose of this study was to evaluate the potential benefit of empirical SVC isolation in addition to PVI in patients undergoing a second CA after index PVI.

Methods
We retrospectively analyzed consecutive patients scheduled for a second CA because of a recurrence of symptomatic AF. Redo-CA was performed with a 3D electroanatomic mapping system and point-by-point ablation using RF energy in the range between 25 W and 30 W. In case of persistent isolation of all PVs, only SVCI was performed. In case of reconnection of vein(s), a wider antral re-isolation was performed. Redo-PVI (PVI-group) or Redo-PVI plus SVC isolation (SVCI) (PVIplusSVCI-group) were performed at the discretion of the operator. No additional targets were allowed. The endpoint of all procedures was elimination of the PV signals confirmed by a circular mapping catheter at the level of the PV ostium and elimination of all signals in the SVC in case of SVCI. Recurrence of AF during a follow-up of 12 months is presented.

Results
We analyzed 191 patients (age 61±10 years, 30% female, BMI 27±5 kg/m2, LVEF 56±9%, PLAX 41±7 mm, paroxysmal 61%). Whereas 148 (78%) patients underwent Redo-PVI only, 31 patients (16%) underwent PVI plus SVCI, and in 12 patients (6%) SVCI only was performed. Baseline characteristics did not differ significantly between the two groups. In the PVI-group, 79% were recurrence-free compared to 65% (see Kaplan-Meier curve: log rank p=0.011) in the PVIplusSVCI-group. The RF time of the PVI group focusing on the wide antral re-isolation of vein(s) was significantly higher than for the PVIplusSVCI-group (819±494 s versus 458±444 s; p&lt;0.001).

Conclusion
Additional empirical SVCI at redo-PVI in patients with symptomatic AF recurrence does not lead to an increase in freedom from AF recurrence. Focusing on an additional “wider antral” re-isolation may be more effective.
Kaplan-Meier Survival Curves for Recurre

Funding Acknowledgement
Type of funding source: None
Long-term follow-up of thoracoscopic ablation for long-standing persistent atrial fibrillation
Authors: Harlaar N , Oudeman M.A.P , Trines S.A , De Ruiter G.S , Khan M , Zeppenfeld K , Tjon A , Braun J , Van Brakel T.J 
Published: November 2020

Abstract

Background
Catheter ablation in patients with long-standing persistent AF (LSPAF) remains challenging and often requires repeated procedures with variable results. We report long-term outcomes of a bipolar thoracoscopic pulmonary vein and left atrial posterior wall ablation for LSPAF, and compare continuous and interval rhythm monitoring.

Methods
Seventy-seven LSPAF patients who underwent thoracoscopic pulmonary vein and box isolation between 2009–2017 in two Dutch centers were included. Follow-up consisted of continuous rhythm monitoring using an implanted loop recorder or 24-h Holter at 3/6/12/24/60 months.

Results
Mean age was 59±8 years with a median AF duration of 3.8 [1.2–6.3] years. In the total cohort, at 2-year follow-up, 86.0% of patients were in sinus rhythm, 12.3% were in paroxysmal AF and 1.6% in persistent AF. At 5 years, 62.9% of patients were in sinus rhythm, 20.0% in paroxysmal AF, 14.3% in persistent AF and 2.9% was experiencing atrial flutter. Continuous rhythm monitoring was performed in 46% of patients. Comparing continuous and interval rhythm monitoring, freedom from any atrial arrhythmia episode at 2- and 5 years was 60.0% and 49.9% in the continuous group and 93.8% and 51.9% in the interval monitoring group, respectively (p=0.02, Breslow-Wilcoxon test). In patients with continuous rhythm monitoring the mean atrial arrhythmia burden was reduced from 99.1% preoperatively to 0.1% at the end of the blanking period and 7.3% at 2-year follow-up.

Conclusions
Thoracoscopic box ablation is highly effective in restoring sinus rhythm at medium term follow-up. However, it is not a curative treatment as demonstrated by the 50% arrhythmia-free survival at long-term follow-up. Whether this is due to the progressive nature of AF needs further investigation. Continuous rhythm monitoring shows earlier recurrence detection with a potential early treatment adaptation.

Funding Acknowledgement
Type of funding source: None
16-month outcomes following hybrid ablation for long-standing persistent atrial fibrillation in patients with dilated atria
Authors: Kaba R.A , Ashry A , Elbadri A , Gukop P , Li A , Sohal M , Bajpay A , Saba M , Sharma R.A , Gallagher M , Chandrasekaran V , Momin A 
Published: November 2020

Abstract

Introduction
Although catheter ablation therapy is a well-established treatment for cardiac dysrhythmias, the success rates for longstanding, persistent AF with dilated atria remain unsatisfactory. The minimally invasive hybrid technology is a novel form of therapy.

Methods
A prospective, single-center UK study to evaluate the hybrid ablation technique for patients with longstanding (&gt;1 year) persistent AF and dilated atria. Stage 1 was a minimally invasive epicardial approach for ablation of the posterior wall of left atrium (LA) and pulmonary veins (PVs). Stage 2 was a transcatheter approach via the femoral veins to isolate the endocardial aspect of the PVs +/− posterior wall. Occasionally, the sequence of the stages was reversed.

Results
Forty-one patients were enrolled for the study with a mean follow-up for 16±9 months. Mean age was 65±9 years and the mean BMI was 32±7. Males constituted 75% of the study cohort. Mean LA size was 48±7 mm and mean left ventricular ejection fraction (LVEF) was 51.9%, although 51.6% of patients had impaired LVSF (LVEF below 55%). 87.8% CI (0.7–0.9) of patients remained in sinus rhythm (SR) without repeat ablation, whereas only 12.2% CI (0.04–0.02) had redeveloped persistent AF. Although numerically different, there was no statistically significant difference in maintaining SR between patients with severely dilated LA (&gt;50 mm) and those without (70% vs. 90%, respectively; z=−1.39, p=0.165). Major perioperative complications during stage 1 ablation were low, with IVC injury in 1 patient and a mild stroke in 1 patient. Median LOS was 1 day (1–4 days) and there was no 30-day mortality after stage 1.

Conclusions
The hybrid ablation therapy has a conversion rate from longstanding persistent AF to SR of 87.8% at a mean follow-up of 16±9 months, without repeat ablation. LOS was short, with very few complications and no peri-operative mortality. The hybrid approach appears to be very encouraging for a condition with otherwise low success rates by conventional endocardial techniques alone.

Funding Acknowledgement
Type of funding source: None
Safety and efficacy of antithrombotic therapy according to stroke and bleeding risk in patients with atrial fibrillation and acute coronary syndrome or PCI: insights from AUGUSTUS
Authors: Harskamp R , Lopes R.D , Li Z , Wojdyla D , Goodman S.G , Aronson R , Windecker S , Mehran R , Granger C.B , Alexander J.H 
Published: November 2020

Abstract

Background
The AUGUSTUS trial showed that patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) and/or PCI treated with a P2Y12 inhibitor and apixaban resulted in less bleeding and comparable ischemic events compared with regimens that included a vitamin K antagonist (VKA), aspirin, or both. We assessed the effect of apixaban versus VKA and aspirin versus placebo according to patients' baseline risk of stroke and bleeding.

Methods
AUGUSTUS randomized 4614 patients in a two-by-two factorial design to open label apixaban or VKA and blinded aspirin or placebo. The primary endpoint was major or clinically relevant nonmajor (CRNM) bleeding over 6 months of follow-up. The effects were assessed stratified by baseline CHA2DS2-VASc and HAS-BLED score using Cox proportional hazards models.

Results
4386 patients were included for this analysis. The median age was 71 (64–77) years, 29.4% were female, 81.7% had a CHA2DS2-VASc score≥3, and 66.8% a HAS-BLED score≥3. As shown in the table, rates of bleeding were lower with apixaban (vs VKA) irrespective of baseline bleeding risk (p-value interaction: 0.23). Aspirin (vs placebo) was associated with increased bleeding irrespective of baseline risk (p-value interaction: 0.88). Apixaban use was associated with a lower risk of death or hospitalization without a significant interaction with stroke risk (p-value of interaction=0.53). No differences were found for ischemic outcomes.

Conclusion
An antithrombotic regimen including a P2Y12 inhibitor and apixaban is associated with less bleeding and hospitalization compared to a regimen with VKA, aspirin, or both with results consistent across CHA2DS2-VASc, and HAS-BLED scores. Our findings support the use of apixaban and a P2Y12 inhibitor without aspirin during the first 6 months for most patients with AF and ACS and/or PCI, regardless of stroke and bleeding risk.

Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The Augustus trial was sponsored by Bristol-Myers Squibb and Pfizer, Inc
Uninterrupted twice-daily direct oral anticoagulants are safer than once-daily ones for atrial fibrillation catheter ablation
Authors: Oshima T , Fujiu K , Yoshida Y , Matsunaga H , Matsuda J , Matsubara T , Saga A , Shimizu Y , Oguri G , Kojima T , Hasumi E , Komuro I 
Published: November 2020

Abstract

Background
In patients undergoing AF catheter ablation (CA), uninterpreted DOACs reduced bleeding events without increasing ischemic events compared with vitamin K antagonist, and the continuation of anticoagulants is recommended for AF ablation. However, in the past studies, patients received once-daily DOACs in the evening, not in the morning of the procedure day. Moreover, there has been no study comparing uninterrupted 4 DOACs; therefore, the safety and effect of uninterpreted DOACs taken just in the morning of AF ablation is unknown.

Objective
The purpose of this study was to compare bleeding complications and thromboembolism events between 4 DOACs in patients undergoing AF ablation.

Method
This study was the retrospective single-center cohort study of consecutive patients who underwent AF ablation between April 2014 to July 2019. All patients continued DOAC uninterruptedly including just in the morning of the procedure. The primary endpoint included major bleeding events within the first 30 days after CA. The secondary endpoints included the composite events of ischemic stroke, systemic embolism, myocardial infarction, and vascular death.

Result
A total of 713 patients (mean age 64±12 years, 72% male) were included in this analysis; enrolled patients were 88, 238, 218, and 169 respectively in dabigatran, rivaroxaban, apixaban and edoxaban group. At the baseline, the ratio of age ≥75 years and CHADS2 score was higher in apixaban group, though all other baseline variables were similar between them.
The primary endpoint was observed 0%, 2.1%, 0.45%, and 4.7% respectively in dabigatran, rivaroxaban, apixaban, and edoxaban group (P=0.013) without significant difference about secondary endpoint between them (P=0.3).
Comparing twice-daily vs once-daily DOACs, the primary endpoint was observed significantly lower in the twice-daily group than in once-daily group (0.32% and 3.2% respectively, P=0.0054), without any significant difference about secondary endpoint (0% and 0.73% respectively, P=0.26).

Conclusion
Taking DOACs also in the morning of AF ablation, uninterrupted twice-daily DOACs are safer than once-daily DOACs without increasing ischemic event, although twice-daily DOACs, especially apixaban, were used in higher aged patients.
Figure 1

Funding Acknowledgement
Type of funding source: None
Data for 3D left atrial printing acquired using open source and free software, with the aim to determine the proper size of left atrial appendage occlured
Authors: Hecko J , Jiravsky O , Chovancik J , Hudec M , Sramko M , Sknouril L 
Published: November 2020

Abstract

Background
The occlusion of the left atrial appendage is the treatment of choice in patients with high both thrombembolic and bleeding risks. The optimal method for size selection and occluder placement is still evolving. Based on published data, the ability to print a 3D atrial model might be helpful in these processes. Minimizing the cost of this approach may contribute to a massive extension of the methodology.

Aim
To present a process of data acquisition for 3D left atrial printing without the need of using a premium software.

Method
Patients indicated for percutaneous left atrial appendage closure are prepared according to standard recommendations. Afterwards, DICOM CT scans were used for our purpose. This data was transfered to the segmentation software. With the help of 3D Slicer 4.10 (slicer.org), the cardiac chambers were segmented from the contrast CT (DS CorCTA 1.0 B26f BestDiast 72%). The “Paint” function was specifically used for segmentation, marking each chambe. “GrowFromSeeds” utility was then used to automatically initialize chambers with the option of manual correction. Segments were subsequently transfered to the 3D model format (STL, 3MF). The difficulty was, that from the aforementioned contrast CT, we were only able to acquire the left atrial “cavity”, not reflecting the true dimensions of the walls. Therefore, we subtracted this shape from a cuboid. Then, using function “Hollow” in 3D Builder, we gradually removed the outer part of the cuboid around the subtracted cavity, resulting in a true left atrial wall. This enabled a valid sizing of the appendage. Since this procedure was part of a blinded study, a small cuboid marker (10x10x3mm) was added to the cast for patient identification and correct 3D printing.
For the printing itself, a flexible material with 30–35D hardness was used to simulate compliant cardiac tissue.

Conclusion
The segmentation of the left atrium using open source and free 3D software enables to minimize printing costs which may lead to extension of this method to everyday clinical practice.
Figure 1. Sequention of work

Funding Acknowledgement
Type of funding source: None
Impact of liver disease on oral anticoagulant prescription and major adverse events in patients with atrial fibrillation: analysis from a population-based cohort study
Authors: Proietti M , Marzona I , Vannini T , Colacioppo P , Tettamanti M , Foresta A , Fortino I , Merlino L , Lip G.Y.H , Roncaglioni M.C 
Published: November 2020

Abstract

Aims
Data on the impact of liver disease (LD) in patients with atrial fibrillation (AF) and the role of oral anticoagulant (OAC) drugs for stroke prevention, are limited. We analysed the impact of LD and OAC treatment in determining stroke, major bleeding, all-cause death and secondary bleeding outcomes.

Methods
A retrospective observational population-based cohort study. The study cohort is derived from the administrative health databases of Lombardy region (&gt;10 million inhabitants), Italy. All AF patients ≥40 years admitted to hospital from 2000 to 2018 were considered. AF and LD diagnosis were established using ICD9-CM codes. Use of OAC was determined with Anatomical Therapeutic Chemical (ATC) codes. Primary study outcomes were stroke, major bleeding and all-cause death.

Results
Among 393,507 AF patients, 16,168 (4.1%) had concomitant LD. LD AF patients were significantly less treated with OAC independent of associated clinical characteristics (OR: 0.96, 95% CI: 0.92–0.98). Concomitant LD was found associated with an increased risk in all the study outcomes (HR: 1.18, 95% CI: 1.11–1.25 for stroke; HR: 1.57, 95% CI: 1.47–1.66 for major bleeding; HR: 1.41, 95% CI: 1.39–1.44 for all-cause death. Use of OAC in patients with AF and LD resulted in a reduction in stroke (HR: 0.80, 95% CI: 0.70–0.92), major bleeding (HR: 0.86, 95% CI: 0.74–0.99) and all-cause death (HR: 0.85, 95% CI: 0.80–0.90), with similar results according to several clinically relevant subgroups. A net clinical benefit (NCB) analysis suggested a positive benefit/risk ratio in using OAC in AF patients with LD (NCB: 0.408, 95% CI: 0.375–0.472).

Conclusions
In AF patients, concomitant LD carries a significantly higher risk for all clinical outcomes. Use of OAC in AF patients with LD was associated with a significant benefit/risk ratio, even in high-risk patient subgroups.

Funding Acknowledgement
Type of funding source: None
Bleeding risks with frailty and multimorbidity in patients with atrial fibrillation. A nationwide analysis of 1.4 million subjects
Authors: Fauchier L , Bisson A , Bodin A , Herbert J , Clementy N , Pierre B , Angoulvant D , Hanon O , Babuty D , Lip G 
Published: November 2020

Abstract

Background
Frailty and multimorbidity are common in patients with atrial fibrillation (AF). The quantifiable frailty phenotype has been validated as predictive of mortality and disability, and patients can be categorised as frail and non-frail using the Claims-based Frailty Index (CFI). The Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and also a strong estimator of mortality. We evaluated whether frailty and multimorbidity are associated with the risk of major bleeding in patients with AF.

Methods
Based on the administrative hospital-discharge database, we collected information for all patients with AF between 2010 and 2019 in France. CCI and CFI were calculated for each patient, and their associated risks of bleeding compared to 4 bleeding risk scores (HAS-BLED, HEMORR2HAGES, ATRIA and ORBIT). The analysis focused on patients with events or with at least one year of follow-up. Predictive abilities of the scores were compared in the whole population, and then separately in the subgroup of elderly patients (&gt;75 yo).

Results
Among 1,372,567 patients with AF, 131,535 major bleeding events were recorded during a follow-up of 3.5±2.1 years (median 3.1, IQR 1.8–4.9) (yearly rate 2.7%). Bleeding occurred more commonly in patients with higher HAS-BLED, ATRIA, CCI and CFI scores. Those with high frailty and multimorbidity had markedly higher yearly incidences of bleeding events of 13.0% and 14.7%, respectively (vs low frailty and multimorbidity: 4.3%% and 4.1%, respectively; p&lt;0.001). The 4 bleeding risk scores significantly had lower c-statistics than CCI and CFI for predicting major bleeding (table). In elderly patients (n=853,833), the c-statistics were all lower than in the whole population and were lower for the 4 scores than for the CCI and CFI scores (0.463, 0.473, 0.443, 0.445, 0.622 and 0.620 for HAS-BLED, ATRIA, ORBIT, HEMORR2HAGES, CCI and CFI, respectively).

Conclusion
Multimorbidity and frailty, respectively assessed with CCI and CFI, demonstrated statistically better performances in predicting major bleeding than the 4 established bleeding risk scores in AF.

Funding Acknowledgement
Type of funding source: None
Cross sectional analytic study of the relationship between age and the distance from His bundle to slow pathway in atrioventricular nodal reentrant tachycardia (AVNRT) patients using 3D mapping
Authors: Srisakvarakul C , Boonyapisit W , Sriprom C 
Published: November 2020

Abstract

Background and objective
The incidence of atrioventricular nodal reentrant tachycardia (AVNRT) in elderly patients has increased due to an increased in life expectancy of the general population. Slow pathway (SPs) ablation is considered the treatment of choice for patients with AVNRT. This study is interested in the relationship of the distance from SPs to His bundle electrogram (HBEs) in various age groups because understanding of anatomy clearly could guide treatment patients by using radiofrequency ablation to be easier and safer.

Design and methods
A cross-sectional study was analyzed in patients diagnosed with AVNRT and underwent SPs ablation using EnSite NavX mapping system guided therapy. The distance from SPs to the lowest HBEs recorded was measured. Relationship between distance from SPs to HBEs and age was analyzed by Pearson correlation.

Results
A total 68 adults diagnosed with AVNRT (27.9% males, mean age 52.43 years old) were included. The mean distance from SPs to HBEs is shorter in the group older than or equal to 60 years old (n=24, mean age 70.70 years old) compared to the group younger than 60 years old (n=44, mean age 42.45 years old) (13.77 vs. 17.73 millimeter, p=0.024). Average fluoroscopy time was greater in the older group compared to the younger group (24.43 vs. 16.52 minutes, p=0.002) while the procedure time in both groups was not different (105.1 vs. 85.48 minutes, p=0.09). The distance from SPs to HBEs was negative correlation with age with the coefficient of −0.392 (p&lt;0.001). When dividing the age group into three age groups, the group that younger than 40 years old (n=15, mean age 29.73 years old), 40 to 60 years old (n=29, mean age 49.03) and older than 60 years old (n=24, mean 70.70 age), the average distance from SPs to HBEs was 20.77, 16.15 and 13.77 millimeter respectively. The mean distance from SPs to HBEs in the group younger than 40 years old is significant statistically different to the group that is older than 60 years old (p=0.006). Slow pathway ablation was successful in all patients in this study except for one patient who was 72 years old because frequent transient atrioventricular block occurred during ablation.

Conclusion
Distance from SPs to HBEs was negative correlation with age by measuring with 3-dimentional mapping.
Distance from SPs to HBEs in each groups

Funding Acknowledgement
Type of funding source: None