bluuebunny/crossref_metadata_2025_split huggingface dataset:
Durable pulmonary vein (PV) isolation at repeat atrial fibrillation (AF) ablation procedure: a comparison between 4 ablation technologies
Authors: Morales G , Boghossian E , Rajendra A , Osorio J 
Published: November 2020

Abstract

Background
Durable PV isolation is the sought-after endpoint to obtain long term success after AF catheter ablation. Evolution in technology improves efficiency, safety and effectiveness in AF catheter ablation.

Purpose
To investigate the effectiveness of different catheter technologies in obtaining durable PV isolation in a real-world practice.

Methods
Retrospective analysis of prospectively collected data of patients undergoing repeat procedures for recurrence of AF or atrial flutter at our institution was performed. Incidence of all PVs being isolated at repeat procedure was recorded and patients 4 groups created based on catheter technology used during index AF ablation procedure (SF: multipored, irrigated catheter; ST: contact force sensor catheter; Cryo: 2nd generation cryobaloon; and STSF: multipored, irrigated, contact force sensing catheter).

Results
We identified 269 subjects undergoing repeat ablation from May 2014 to September 2019. Mean age was 67±9.7 years, 54.6% were males, 74.4% non-paroxysmal AF at the index procedure. The mean CHA2DS2Vasc score was 2.5±0.26, LA size 4.2±0.6 cm, EF 55.3±10%. The mean time from index to redo procedure was 374±331 days. At repeat procedure all veins were isolated in 24% (6/25) who were initially ablated using SF; 36% (8/22) with Cryo; 44% (47/108) with ST; and 74% (84/114) with STSF catheter. (Figure)

Conclusion
Patients undergoing index ablation with STSF catheter technology were significantly more likely to have all 4 PVs isolated at repeat procedure compared to previous generation technology.

Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Biosense Webster
Comparison between non-vitamin K antagonist oral anticoagulants versus warfarin for the risk of dementia in Asian patients with non-valvular atrial fibrillation
Authors: Lee S.R , Choi E.K , Park S.H , Han K.D , Oh S , Lip G 
Published: November 2020

Abstract

Background
Atrial fibrillation (AF) is a risk factor for dementia and oral anticoagulant (OAC) use is associated with a decreased risk of dementia in patients with AF.

Objective
We sought to find whether the risk of dementia would be different between patients treated with non-vitamin K antagonist oral anticoagulants (NOACs) and those treated with warfarin.

Methods
Using the Korean National Health Insurance database from January 2014 to December 2017, we identified OAC naïve non-valvular AF patients aged 40 years or older. For the comparison, warfarin and NOAC groups were balanced using the inverse probability of treatment weighting method (IPTW). The primary outcome was incident dementia. Patients were censored at the occurrence of dementia, discontinuation of index treatment, or the end of the study period (December 31, 2018).

Results
Among 72,846 of total study patients, 25,948 were treated with warfarin and 46,898 were treated with NOAC (17,193 with rivaroxaban, 9,882 with dabigatran, 11,992 with apixaban, and 7,831 with edoxaban). Crude incidence of dementia was 4.65 per 100 person-years in warfarin group and 4.98 per 100 person years in NOAC group. Baseline characteristics were well-balanced after IPTW (mean age 72 years, 93% CHA2DS2-VASc ≥2, 58% men). Compared to warfarin, NOAC showed a comparable risk of dementia (hazard ratio [HR] 0.944, 95% confidence interval [CI] 0.934–1.059), vascular dementia (HR 0.921, 95% CI 0.814–1.043) and Alzheimer dementia (HR 1.101, 95% CI 1.019–1.191). When comparing individual NOACs with warfarin, edoxaban was associated with a lower risk of dementia (HR 0.830, 95% CI 0.740–0.931). Rivaroxaban (HR 0.767, 95% CI 0.648–0.907) and edoxaban (HR 0.786, 95% CI 0.620–0.996) were associated with a lower risk of vascular dementia than warfarin. In subgroup analyses, NOAC was associated with a lower incidence of dementia than warfarin particularly in patients with prior stroke (HR 0.891, 95% CI 0.820–0.968) and in patients aged 65–74 years (HR 0.815, 95% CI 0.709–0.936).

Conclusion
In this large Asian population with AF, NOAC showed a comparable result with warfarin on the risk of dementia. Edoxaban was associated with a lower risk of dementia. NOAC appeared more beneficial especially in those with AF who had a history of prior stroke and aged 65–74 years.

Funding Acknowledgement
Type of funding source: None
Extensible artificial intelligence model predicts post-ablation AF recurrence using coronary sinus electrogram
Authors: Huang D , Zhang Z , Lin K , Zuo Z , Chen Q , Qian D , Zhu W , Li J 
Published: November 2020

Abstract

Background
Atrial fibrillation (AF) is a major public health problem with significant adverse outcomes and catheter ablation is a widely adopted treatment. The CABANA trial showed that catheter ablation reduced AF recurrence to a greater extent than medications. However, some of patients who underwent this procedure still experience relapse. Here, we present an innovative way to identify this subgroup using an artificial intelligence (AI) -assisted coronary sinus electrogram.

Hypothesis
Our hypothesis is that credible features in the electrogram can be extracted by AI for prediction, therefore rigorous drug administration, close follow-up or potential second procedure can be applied to these patients.

Methods
67 patients from two independent hospitals (SPH & ZSH) with non-valvular persistent AF undergoing circumferential pulmonary vein isolation were enrolled in this study, 23 of which experienced recurrence 6 months after the procedure. We collected standard 2.5-second fragments of coronary sinus electrogram from ENSITE NAVX (SPH) and Carto (ZSH)system before the ablation started. A total of 1429 fragments were obtained and a transfer learning-based ResNet model was employed in our study. Fragments from ZSH were used for training and SPH for validation of deep convolutional neural networks (DCNN). The AI model performance was evaluated by accuracy, recall, precision, F-Measure and AUC.

Results
The prediction accuracy of the DCNN in single center reached 96%, while that in different ablation systems reached 74.3%. Also, the algorithm yielded values for the AUC, recall, precision and F-Measure of 0.76, 86.1%, 95.9% and 0.78, respectively, which shows satisfactory classification results and extensibility in different cardiology centers and brands of electroanatomic mapping instruments.

Conclusions
Our work has revealed the potential intrinsic correlation between coronary sinus electrical activity and AF recurrence using DCNN-based model. Moreover, the DCNN model we developed shows great prospects in the relapse prediction for personalized post-procedural management.

Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): The National Natural Science Foundation of China
Sex differences in the predictors of recurrent atrial fibrillation after catheter ablation: insights from the Kansai Plus Atrial Fibrillation (KPAF) registry
Authors: Tanaka N , Inoue K , Kobori A , Kazutai K , Morimoto T , Kurotobi T , Morishima I , Kusano K , Yamaji H , Nakazawa Y , Tanaka K , Iwakura K , Fujii K , Kimura T , Shizuta S 
Published: November 2020

Abstract

Background
The impact of sex differences on the clinical outcomes of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is controversial. We previously reported that females experienced more frequent AF recurrences than males after the index and last RFCA procedures.

Purpose
To identify the risk factors associated with recurrent AF in females and males after RFCA of AF.

Methods
We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; 1369 [27.3%] females; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years.

Results
The incidence of AF recurrences after a single procedure was 43.3% in females and 39.0% in males. After a multivariate adjustment at baseline, the significant predictors of AF recurrence in females after the index RFCA were non-paroxysmal AF (hazard ration [HR],1.59; 95% confidence interval [CI],1.31–1.93, p&lt;0.0001), a history of AF ≥2 years (HR,1.47; 95% CI,1.24–1.74, p&lt;0.0001), coronary artery disease (HR,1.43; 95% CI,1.03–1.98, p=0.0035), and an estimated glomerular filtration rate (eGFR)&lt;60 mL/min/1.73m2 (HR,1.46; 95% CI,1.10–1.95, p=0.0086). On the other hand, significant predictors of AF recurrence in males after the index RFCA were non-paroxysmal AF (HR,1.54; 95% CI,1.37–1.73, p&lt;0.0001), a history of AF ≥2 years (HR,1.40; 95% CI,1.26–1.56, p&lt;0.0001), the number of antiarrhythmic drugs (HR,1.06; 95% CI,1.003–1.13, p=0.040), a left atrial diameter≥40mm (HR,1.13; 95% CI,1.007–1.27, p=0.038), and dilated cardiomyopathy (HR,1.55; 95% CI,1.07–2.26, p=0.021), however, an eGFR&lt;60 mL/min/1.73m2 was not associated with AF recurrence in males (HR, 1.00; 95% CI, 0.88–1.13, p=0.97).

Conclusion
The Kansai Plus Atrial Fibrillation Registry revealed a distinct sex difference in terms of the predictors of recurrent AF after RFCA. Non-Paroxysmal AF and a long history of AF were common risk factors both in females and males. However, renal dysfunction was a significant predictor of AF recurrence in females, while it was not a risk of recurrence in males.

Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development in Kyoto, Japan.
D-dimer for the prediction of left atrial appendage thrombosis: daydream or reality? A meta-analysis
Authors: Casula M , Fortuni F , Frassica R , Coccia M.G , Magrini G , Fabris F , Gnecchi M , Leonardi S , Savastano S , Rordorf R 
Published: November 2020

Abstract

Introduction
Left atrial appendage thrombosis (LAAT) is a dangerous condition that mainly affects patients with atrial fibrillation (AF) or those with mitral stenosis (MS), increasing their risk of stroke. Transesophageal echocardiography (TEE) is the gold standard for the diagnosis of LAAT but some technical issues and the suboptimal sensitivity in identifying small thrombi, especially within a side lobe, can limit its clinical usefulness. Reliable non-invasive diagnostic methods could be useful in clinical practice. D-dimer, a fibrin degradation product already commonly used in the diagnostic work-up of conditions such as venous thromboembolism, may have a role as a non-invasive marker of LAAT.

Purpose
To evaluate the diagnostic performance of D-dimer for the detection of LAAT in patients with AF and/or MS, using TEE as the reference standard.

Methods
We searched the literature for studies that evaluated the ability of D-dimer to predict LAAT. For each study a 2x2 table of D-dimer positivity and LAAT presence was constructed. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. Considering the different diagnostic thresholds used in the included studies, the overall sensitivity and specificity were calculated using a hierarchal summary receiver operating characteristic (HSROC) model and a SROC curve was generated.

Results
6 studies, evaluating 1380 patients of whom 154 had LAAT, were included in the analysis. The prevalence of LAAT in the studies ranged from 9% to 26%, with a median of 12%. The mean age was 60±13 years, 63% were male. The mean left atrial diameter was 43±3 mm. The D-dimer diagnostic threshold ranged from 200 mcg/l to 1150 mcg/l. The overall sensitivity calculated with the HSROC model was 85%±28% and the overall specificity was 82%±29%. The negative predictive value was 98%. Figure 1 shows the summary ROC curve: individual studies are depicted by a clear circle; the red circle marks the pooled sensitivity and specificity across the 6 studies. The red dot-dashed-curve marks the boundary of the 95% credible region for the pooled estimates of sensitivity and specificity.

Conclusions
Our analysis shows that D-dimer has a good diagnostic performance with a very high negative predictive value for LAAT and therefore it might be of clinical aid for ruling out the presence of LAAT in patients with AF and/or MS. Further studies are needed to determine the best diagnostic threshold.
Figure 1

Funding Acknowledgement
Type of funding source: None
Continuation or discontinuation of oral anticoagulants after an increase in HAS-BLED scores and the risks of clinical outcomes in patients with atrial fibrillation. a nationwide cohort study
Authors: Chao T.F , Liao J.N , Lip G.Y.H , Chen S.A 
Published: November 2020

Abstract

Background
The bleeding risk profile of patients with atrial fibrillation (AF) may change over time and the increment of HAS-BLED score (a validated bleeding risk score) is perceived to result in discontinuations of oral anticoagulants (OACs). The goal of the present study was to investigate the changes of HAS-BLED scores of AF patients initially with a low bleeding risk (HAS-BLED 0–2). Second, the impact of continuation or discontinuation of OACs on clinical outcomes after patients' bleeding risk profile worsened (ie HAS-BLED increased) were also studied.

Methods
The present study used the Taiwan nationwide health insurance research (NHIRD) database. From year 2000 to 2015, a total of 24,990 AF patients aged &gt;20 years with a CHA2DS2-VASc score &gt;1 (males) or &gt;2 (females) having a HAS-BLED score of 0–2 who were treated with OACs (warfarin or NOACs) were identified and followed up for changes of the HAS-BLED scores. The risks of clinical outcomes were compared between patients who continued or stopped OAC's once their HAS-BLED score increased to ≥3.

Results
Mean HAS-BLED score of study population continuously increased from 1.54 (SD 1.63) at baseline, to 3.33 (SD 1.36) at the end of follow up with increasing age and incident comorbidities (Figure A). At end of 1 year, 5,229 (20.9%) patients had an increment of their HAS-BLED score to ≥3, mainly due to newly diagnosed impaired renal function, occurrences of bleeding events and concurrent use of antiplatelet agents or NSAIDs. Among 4,777 patients who consistently had a HAS-BLED score &gt; =3, 1,062 (22.2%) stopped their use of OACs. Patients who kept on OACs (n=3,715; 77.8%) even after their HAS-BLED score increased to ≥3 were associated with a lower risk of ischemic stroke (aHR 0.601), major bleeding (aHR 0.780), all-cause mortality (aHR 0.876) and any adverse events (aHR 0.748) (Figure B).

Conclusions
For patients whose HAS-BLED scores increased to ≥3, the continuation of OACs (which occurred in the majority of patients) was associated with better clinical outcomes. An increased HAS-BLED score in AF patients is not a reason to withhold OACs, but reminds physicians to correct modifiable bleeding risk factors and follow up patients more closely. The low risk of bleeding despite continuing OAC in high HAS-BLED score patients may reflect the early reviews and careful follow-up of these “high risk” patients (as recommended in guidelines).

Funding Acknowledgement
Type of funding source: None
QRS voltage in precordial leads in patients with neurally mediated syncope
Authors: Blendea D , Cimpeanu M , Jelnean M , Chiorescu R , Crisan S , Pop S 
Published: November 2020

Abstract

Background
We have previously demonstrated that patients with neurally mediated syncope (NMS) who have an isolated QRS complex, of very low voltage (≤0.3mV cutoff), in one of the frontal leads on the 12-lead electrocardiogram have a threefold increase in the risk of syncope recurrence. The potential relationship between isolated low voltage (ILV) in precordial leads (Figure A) and recurrent NMS has not been yet explored.

Purpose
To prospectively evaluate whether the presence of ILV in the precordial leads predicts recurrence of NMS.

Methods
We included 135 patients with NMS (age 49±20) years, with a median of 4 syncopal episodes. During a median period of 15 months, 43 patients (32%) experienced recurrent syncope. The lowest QRS voltage (QRSmin) was determined separately for the frontal and precordial leads. The cutoff for precordial QRSmin that best discriminated between patients with recurrent and no recurrent syncope was ≤0.7mV (ROC curve AUC=0.65).

Results
Isolated low voltage in precordial leads was present in 49 (36%) of patients. The lead which displayed QRSmin in the precordial leads was V1 in 35 (71%) patients. The actuarial total syncope recurrence rate at 1 year was 26% (95% CI 16–42%) in patients with ILV in precordial leads, and 21% (95% CI 6–39%) in patients without ILV (log rank test P=0.043; Figure B). The significant relationship between the presence of ILV in precordial leads and syncope recurrence was retained in Cox multivariate analysis that included isolated very low voltage in frontal leads (≤0.3mV cutoff), as well as the number of syncopal episodes.

Conclusions
Isolated low QRS voltage in the precordial leads predicts recurrence of NMS independent of isolated low QRS voltage in the frontal leads.
Figure 1

Funding Acknowledgement
Type of funding source: None
Silent myocardial infarction among young sudden cardiac death victims
Authors: Vahatalo J.H , Pakanen L , Huikuri H.V , Perkiomaki J.S , Kaikkonen K.S , Junttila M.J 
Published: November 2020

Abstract

Background
Silent myocardial infarctions (SMIs) occur with atypical or no symptoms at all. The burden of SMIs among sudden cardiac death victims have recently been acknowledged. However, the prevalence of previously undetected SMI in young victims remains unclear.

Purpose
The aim of the present study was to determine the prevalence of autopsy verified SMI in SCD victims under 50 years old without a prior diagnosis of coronary artery disease (CAD).

Methods
Fingesture study consists of systematically collected consecutive victims of SCD in Northern Finland between years 1998–2017 (n=5,869). According to Finnish law, all unexpected deaths undergo medico-legal autopsy. The autopsies routinely included histological examinations, and a toxicology investigation was carried out if needed. The SMI was defined as focal scar detected by macroscopic evaluation of the dissected ventricles and histologic analysis of the myocardial samples with an absence of a history of previously diagnosed CAD. Pre-mortem clinical history was obtained from medical records, standardized questionnaire to the closest family members of the victims and police reports about the conditions of the death.

Results
Overall, 10.4% off all SCDs occurred among victims under the age of 50 years (610 victims). Most common underlying cause of SCD among young was CAD (44%). About 90% of the victims had no clinical diagnosis of CAD, however, 34% (78 victims) had previously undetected myocardial scar at autopsy indicating a previous SMI. The mean age of the young SMI victims was 44±4 and they were mostly men (87%). 24% of SCDs occurred during physical activity and 21% had SCD outdoors. The mean heart weight was 466±110 g and 67% had hypertrophied hearts. Three vessel disease was detected in 69% of the victims. Alcohol was detected in 17% of victims in toxicology investigations.

Conclusions
Previously undetected myocardial infarction is also common among young victims who experienced CAD associated SCD. Three vessel disease and cardiac hypertrophy were common autopsy findings among young SMI victims and about a fourth had SCD during physical activity.

Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Sigrid Juselius Foundation, Finnish Foundation for Cardiovascular Research
Fragmented QRS, a predictor of clinical events in patients on cardiac resynchronization therapy
Authors: Martinez Milla J , Garcia-Talavera C , Arroyo B , Camblor A , Garcia-Ropero A , Miracle A , Benezet-Mazuecos J , Rubio-Campal J.M , Romero-Daza A 
Published: November 2020

Abstract

Introduction
Cardiac resynchronization therapy with defrilator (CRT-D) has been shown to reduce mortality in HFrEF. The width and morphology of the QRS are essential when deciding on the implantation of these devices. QRS fragmentation (fQRS) has been shown to be a good predictor of cardiovascular events in certain patients, but its role in patients with CRT-D has not been studied. The aim of this study is to determine whether the presence of a fQRS at the time of CRT-D implantation can predict clinical events.

Methods
All patients who underwent CRT-D implantation from 2010 to 2017 were included. Patients' ECG were evaluated at the time of implantation, and the incidence of clinical events during follow-up was also assessed. fQRS was defined as the presence of an RSR' pattern with a notch in the R wave or in the ascending or descending branch of the S wave in two continuous leads on the ECG.

Results
We studied 131 patients (mean age 73 years, 76.5% male). The mean follow-up period was 37±26 months. No difference in baseline characteristics was found (Table 1); the proportion of fQRS was 48.9%. 25 patients (19.1%) had hospital admissions secondary to cardiovascular causes (heart failure, arrhythmic events, acute coronary syndrome, and death from other causes). We performed a multivariate logistic regression analysis aiming at an association between the presence of fQRS and the increased risk of hospital admissions due to cardiovascular causes OR 2.92 (95% CI: 1.04–8.21, P=0.04).

Conclusion
The presence of a fQRS at the time of implantation of a CRT-D is an independent predictor of hospital admissions due to cardiovascular causes. Therefore this could be a useful marker to identify the population at high risk of cardiovascular events, for this we consider necessary to conduct future studies and thus assess the value of the fQRS for the selection of patients requiring closer monitoring thus avoiding further hospital admissions.

Funding Acknowledgement
Type of funding source: None
Obesity accelerates cardiac senescence in heart failure with preserved ejection fraction
Authors: Verbrugge F.H , Reddy Y.N.V , Kapa S , Borlaug B.A 
Published: November 2020

Abstract

Background
Diastolic reserve decreases with aging. A recently developed artificial intelligence (AI) algorithm can predict age based on 12-lead electrocardiogram (ECG) analysis.

Purpose
This study aims to use a validated AI algorithm to assess cardiac senescence and investigate the impact of obesity on cardiac aging in heart failure with preserved ejection fraction (HFpEF).

Methods
This retrospective cohort study includes 403 patients with HFpEF, admitted for treatment with intravenous diuretics. ECG age was assessed by a convolutional neural network as previously validated. Patients were stratified according to the presence of obesity (body mass index &gt;30 kg/m2) and ECG age was compared between groups. The relationship between ECG versus calendar age and structural/functional alterations on echocardiography, as well as the risk of atrial fibrillation (AF) development, was evaluated.

Results
In 253 (63%) obese patients with HFpEF, calendar age was 8 years younger compared with their non-obese counterparts, but ECG age was only 3 years younger. ECG minus calendar age was higher in obese patients (P-value &lt;0.001; figure) and correlated moderately strong with weight, fat free, and fat mass (r=0.35–0.41; P-value &lt;0.001). Older ECG age was correlated with worse diastolic function, but not with left ventricular afterload (table). Calendar age correlated less strongly with diastolic dysfunction (table). ECG age did predict AF development, independently of calendar age, gender, and presence of obesity [HR (95% CI) = 1.31 (1.06–1.63) per 5-year; P-value=0.015].

Conclusions
Obesity accelerates cardiac senescence in HFpEF as reflected by more pronounced diastolic dysfunction and a higher AF risk, which was identified from ECG analysis by a validated AI algorithm.
Figure 1

Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Belgian American Educational Foundation (B.A.E.F.); Special Research Fund (BOF) of Hasselt University (Hasselt, Belgium).