bluuebunny/crossref_metadata_2025_split huggingface dataset:
Predicting atrial fibrillation ablation success: a novel approach using pre-procedure sinus rhythm ecg and deep learning
Authors: Mohsen Y , Vatsaraj I , Loeffler S , Horlitz M , Stoeckigt F , Trayanova N 
Published: May 2024

Abstract

Introduction
Pulmonary vein isolation (PVI) has been the corner stone of the treatment of patients with atrial fibrillation (AF), yet its efficacy varies notably between patient groups. Specifically, it shows reduced efficacy in individuals with persistent AF and those with atrial fibrosis.
Recent advancements suggest that additional substrate modification could enhance outcomes in specific patient groups. Therefore, predicting the outcomes of lone PVI could help in stratifying patients who would benefit most from this additional substrate modification. Addressing this gap, our study explores the prognostication of PVI outcomes using pre-procedural 12-lead ECG recordings taken in Sinus rhythm, employing advanced deep learning techniques.

Methods
This retrospective study analyzed 209 patients with paroxysmal and persistent AF who underwent PVI. These patients were followed up for 12 months after the blanking period. Pre-procedural sinus rhythm 12-lead ECGs were processed using an innovative deep learning architecture, integrating Long Short-Term Memory and Convolutional Neural Networks with a cross-attention module. This multimodal deep learning model was trained using ECG and clinical covariates like age, sex, and BMI to predict binary outcomes – AF type (Paroxysmal or Persistent) and AF recurrence. The model's efficacy was evaluated through a 5-fold stratified cross-validation to ensure accuracy and reliability. Model was also tested using only ECG data.

Results
The multimodal deep learning model performed significantly better as compared to the model trained using ECG data only. The multimodal deep learning model achieved an accuracy of 75.56% and a sensitivity of 82% in prognosticating ablation outcomes. Additionally, the model demonstrated a significant capability in classifying AF into paroxysmal or persistent types with an accuracy of 86.67% and a recall of 89%.

Conclusion
Our deep learning approach in analyzing sinus rhythm ECG recordings shows promising results in predicting PVI outcomes and identifying AF types. This approach could offer a more accessible and cost-effective tool to stratify AF patients undergoing PVI, identifying those less likely to benefit from standard procedures. Such insights can assist physicians and patients in determining ablation candidacy and selecting the most appropriate ablation strategy and technique.Proposed StrategyDeep learning model approach
Secondhand tobacco smoke and risk of atrial fibrillation: an observational epidemiologic and gene-environment interaction analysis
Authors: Lee K , Rhee T M , Choi J M , Ahn H J , Kwon S , Lee S R , Choi E K , Oh S 
Published: May 2024

Abstract

Background
Second-hand tobacco smoke (SHS) is related to coronary artery disease and increases susceptibility to arrhythmia inducibility including atrial fibrillation (AF). However, epidemiologic evidence on the relationship between SHS and the risk of incident AF remains controversial.

Purpose
To evaluate the effect of SHS exposure on the long-term risk of AF and assess whether gene-environment interaction (synergism) exists by utilising the population-based data from the UK biobank.

Methods
We performed a nationwide population-based cohort study using the UK Biobank database. Participants with previous AF or current smokers were excluded. Participants were categorised into SHS-exposure and non-exposure groups. The risk of incident AF was assessed using the multivariable Cox proportional hazards model. We also evaluated the synergistic effect of SHS exposure and the polygenic risk score (PRS) of AF.

Results
Out of 400,493 participants, AF occurred in 23,471 (5.9%) during a median follow-up of 12.5 years. The SHS-exposure group (mean exposure 2.2 ± 5.2 hours/week) had a higher proportion of male participants with a younger age. The risk of incident AF was significantly increased in the SHS-exposure group (multivariable-adjusted hazard ratio [aHR] 1.06, 95% confidence interval 1.03-1.10, P &lt;0.001) compared to the non-exposure group, suggesting a dose-dependent manner (aHR of severe SHS-exposure group, 1.11 [1.03-1.20], P = 0.005). The risk of AF increases regardless of the exposure location (home, outside, or workplace). When SHS-exposure was combined with the high genetic risk of AF, significant additive interaction was observed on the risk AF (Synergy Index of SHS-exposure with 3rdtertile of AF PRS, 1.13 [1.02-1.25], P = 0.024).

Conclusion
Exposure to SHS is a significant predictor for an increased risk of AF, with a synergistic effect when combined with genetic predisposition. Minimising SHS exposure, especially in individuals with a heightened genetic susceptibility to AF, may hold potential benefits for reducing the future risk of AF.
Stroke risk assessment in different atrial fibrillation subtypes: CHA2DS2-VASc score and beyond
Authors: Cheng C C , Huang P S , Chen J J , Chang S N , Chiu F C , Wu C K , Hwang J J , Wang Y C , Tsai C T 
Published: May 2024

Abstract

Background
Patients with atrial fibrillation (AF) have been known to have an inhomogeneous risk of stroke, with several well-documented risk factors including hypertension, history of stroke, and diabetes mellitus that have been incorporated into the CHA2DS2–VASc score to stratify risk levels. Accumulating evidence has suggested that AF subtype, namely persistent AF and paroxysmal AF, also have an impact on stroke development.

Purpose
This study focused on the impact of AF subtype on stroke risk in a large, long-term follow-up cohort as to provide insight of the impact on ischemic stroke risks. Such findings may play a role in future ischemic stroke risk stratification in selected patients.

Methods
A total of 7346 AF patients were followed up for 10 years from January 2010 to December 2020 (mean follow-up time 2.74 years). Among these patients, 2460 (33.5%) had persistent or permanent AF (PerAF) and 4886 (66.5%) had paroxysmal AF (PAF). The study evaluated the risk of ischemic stroke between the two groups using Cox models adjusting for all components of the CHA2DS2–VASc score. Analyses were further stratified into the usage of oral anticoagulation (OAC) or no OAC.

Results
Comparing AF patients based on subtype, it was found that PerAF patients were older, had a higher prevalence of previous stroke, congestive heart failure, PAD, DM, and were more often prescribed anticoagulants. Univariate analysis found patients with PerAF at a higher risk for ischemic stroke (HR 1.262, p&lt;0.001). The results remained significant after multivariate analysis with factors of the CHA2DS2–VASc score (HR 1.234, p&lt;0.001). After stratifying patients according to anticoagulation prescription, PerAF and PAF patients were found to have similar rates of developing ischemic stroke in patients under DOAC.

Conclusions
Patients with PerAF have a higher risk of stroke during follow-up independent of components of the CHA2DS2VASc score. In patients with OAC use, there was no difference in stroke risk between AF subtypes.Stroke Risk in OAC-naive patientsStroke Risk in OAC-experienced patients
Assessment of mild cognitive dysfunction in patients with atrial fibrillation utilizing the R4Alz assessment test
Authors: Toumpourleka M , Meletidou M , Tachmatzidis D , Triantafyllou K , Antoniadis A P , Bakogiannis C , Giannopoulos G , Vassilikos V 
Published: May 2024

Abstract

Background/Introduction
The association between atrial fibrillation and cognitive dysfunction has accumulated a growing body of evidence in recent years. However, establishing such a diagnosis remains challenging, especially in mild oligosymptomatic patients. REMEDES for Alzheimer (R4Alz) is a novel test, designed to assess cognitive control decline at an early stage.

Purpose
We sought to evaluate the prevalence of early, mild cognitive dysfunction in patients with paroxysmal atrial fibrillation with the use of established and novel diagnostic tools.

Methods
This is a prospective cross-sectional study that enrolled consecutive patients with history of paroxysmal atrial fibrillation and matched healthy controls, from a tertiary cardiology department. Patients with history of stroke or known cognitive dysfunction of any type were excluded from the study. Demographic and clinical data were collected. All study participants were subjected to Montreal Cognitive Assessment (MoCA) and to R4Alz within the same day. Cognitive function and attention ability is assessed at three stages with R4Alz: working memory updating (R1), supervisory attention system (R2) and task/rule switching and control of inhibition (R3). The primary endpoint was the difference in cognitive function between patients with atrial fibrillation and controls. Secondary endpoints included the correlation between the two assessment tests in both groups. Statistical analysis was performed with R version 4.1.0 and a p-value&lt;0.05 was considered statistically significant.

Results
Fifty-five patients with atrial fibrillation and thirty-four controls were enrolled in the study (Mean age: 62.6 y, Female gender: 62.9%). MoCA scores (25.4 ± 4.11 for patients with atrial fibrillation vs 22.3 ± 3.72 for healthy controls, p-value &lt;0.001) (Figure 1) as well as scores of all stages of R4ALz {working memory (R1a, R1b, R1c), supervisory attention system (R2) and task/rule switching – inhibition control (R3a1, R3a2, R3b)} were indicative of mild cognitive dysfunction in patients with atrial fibrillation. The control group exhibited significantly better cognitive performance on all assessment tools (Table 1).Figure 1Table 1
A novel approach to invisible vein of Marshall: extending the utility of ethanol infusion into the vein of Marshall
Authors: Ishimura M , Yamamoto M , Kobayashi Y 
Published: May 2024

Abstract

Background
The utility of ethanol infusion into the vein of Marshall (EIVOM) is limited in patients without a visible vein of Marshall (VOM).

Methods
Our study included of 232 patients with atrial fibrillation undergoing MI ablation. We initially performed coronary sinus venography using a balloon catheter in all patients to assess VOM characteristics. EIVOM was attempt in those with adequately visible VOMs. In cases where the VOM was not visible, we utilized a guide-wire to locate its entrance, using the intravenous valve as a landmark.

Results
Venography initially identified the VOM in 140 of 232 patients (60%) (visible VOM group). Within this group, 68 patients (29%) did not require balloon inflation for VOM visualization, while 72 patients (31%), visibility was achieved through balloon inflation. In the remaining 92 patients (39%), the VOM remained invisible even after balloon inflation. Nevertheless, in 13 of these cases, the VOM was successfully located using a landmark technique (invisible VOM group). EIVOM was fully achieved in 96% (147 of 153 patients). Additionally, full MI line blocks were achieved in 91% of (A) the visible VOM group (122 of 134 patients), 92% of (B) the invisible VOM group (12 of 13 patients), and 81% in (C) the EIVOM (-) group (69 of 85 patients) (A vs. B, p = 0.88; A vs. C, p &lt; 0.05; B vs. C, p = 0.32).

Conclusion
A novel approach to locating invisible VOM extends the clinical utility of EIVOM and potentially improves success rate of MI ablation.Guide-wire insertion into invisible VOM
Does a higher body mass index influence additional presence of low voltage areas in the left atrium in patients with persistent atrial fibrillation?
Authors: Haxhikadrija P , Kirsch K , Surber R , Schulze P C , Grosse A 
Published: May 2024

Abstract

Introduction
Pulmonary vein isolation (PVI) is recommended during all atrial fibrillation (AF) catheter ablation procedures. In nearly half of patients with persistent AF, low voltage areas (LVAs), commonly defined as areas in left atrium (LA) with a bipolar electrogram amplitude of &lt; 0.5 mV, could be documented during electrophysiological study (EP). The remaining presence of these areas in LA after a PVI-only catheter ablation procedure is identified as a risk factor for recurrence of AF. Targeting and ablating (substrate modification) these areas reduces recurrency of AF. Pre-procedural identification of patients with additional LVAs is thus very important, until date very challenging and not established. Many markers are evaluated but it remains elusive. Extensive adipose tissue in obese patients leads to LA enlargement and remodeling via different mechanisms, leading to higher incidence of AF. The link between obesity and presence of LVAs in LA other than of pulmonary veins (PV) is to our knowledge not yet evaluated.

Aim of the study
Is to evaluate role of body mass index (BMI) in the presence of low voltage areas in left atrium besides pulmonary vein by comparing the BMI in patients with persistent AF with and without LVAs in LA, thus eventually identifying BMI as a possible pre-procedural marker of the presence of these areas.

Methodology
We analyzed data from 91 consecutive patients with persistent AF undergoing first time LA catheter ablation from 09/2021 until 10/2023 inside of the Jen-PACE study. In all patients a high-density 3D endocardial voltage mapping was carried out using EnSite Precision™/ Ensite X™ and the Advisor™ HD-Grid Mapping Catheter.

Results
The mean BMI was 29.6 ± 4.8, mean LV-EF was 53,4% ± 9.7, 24 patients (27%) were females, average age was 67 years. Depending on the presence of low voltage areas, the patients underwent either PVI only when no such areas were documented (61 patients, 67%) or PVI and substrate modification (30 patients, 33%) with documentation of LVAs. There was no statistical difference in the BMI between the two groups (29.9 ± 4.9 in patients with PVI only vs 29.0 ± 4.8 in patients with PVI + substrate modification; p=0.37). Furthermore, in a subgroup analysis of only adipose patients with a BMI higher than 30 (44 patients; 48%; mean BMI 33.8 ± 3.0), there was no significant difference in BMI between the two groups (34.2 ± 3.3 in PVI only vs 33.2 ± 2.4 in patients with PVI and substrate modification; p=0.2)

Discussion and conclusion
Even though a high BMI is generally related to a higher incidence of AF, a higher BMI was not observed in patients having additional low-voltage areas in LA compared to patients in whom such areas could not be identified. Electric remodeling caused by obesity could be rather diffuse than localized in specific areas in LA. BMI is not a pre-procedural marker for the presence of additional low voltage areas in LA.
Prevalence of diabetes mellitus diminished the efficacy of additional ablation following pulmonary vein isolation: a sub-analysis of the EARNEST-PVI trial
Authors: Matsuda Y , Masuda M , Mano T , Tsujimura T , Uematsu H , Higashino N , Tanaka N , Watanabe T , Inoue K , Hikoso S , Sunaga A , Nakatani D , Sotomi Y , Sakata Y 
Published: May 2024

Abstract

Introduction
Diabetes mellitus (DM) is a well-known cause of atrial remodeling in patients with atrial fibrillation (AF). Although additional left atrial ablation following pulmonary vein isolation (PVI) is a strategy to modify AF substrate, its efficacy has not been well elucidated in patients with DM. We hypothesized that the efficacy of additional ablation was different in patients with DM and in those without.

Purpose
The purpose of this study was to investigate the efficacy of additional ablation following PVI in patients with or without DM.

Methods
The EARNEST-PVI was a multicenter, prospective, randomized controlled trial. In this sub-analysis, 493 consecutive patients of persistent AF (age, 65 ± 9 years; female, 120 [24%] patients) who underwent the initial radiofrequency catheter ablation were analyzed. Patients were randomized to be treated with PVI only (PVI-alone) or PVI plus linear and/or complex fractionated atrial electrogram ablation (PVI-plus). Primary outcome measure was defined as AF recurrence during the 12 months follow-up periods.

Results
In total, 84 (17%) patients had DM. Primary outcome occurred in 120 (24%) patients. In patients without DM, freedom from AF recurrence was significantly higher in PVI-plus group than in PVI-alone group (80.0% versus 71.1%, p=0.03) (Figure 1A). Conversely, in patients with DM, freedom from AF recurrence was similar between PVI-plus group and PVI-alone group (75.4% versus 72.9%, p=0.70) (Figure 1B).

Conclusion
Additional ablation following PVI reduced AF recurrence after radiofrequency catheter ablation only in patients without DM.Figure 1
Feasibility and safety of left atrial roof ablation with the third-generation visually guided laser balloon
Authors: Yamasaki T , Kakita K , Pak M , Hattori T 
Published: May 2024

Abstract

Background
The roof area ablation beyond pulmonary vein (PV) isolation (PVI) using a cryoballoon has been widely performed for patients with atrial fibrillation (AF). However, the feasibility of roof area ablation using a visually guided laser balloon (VGLB) remains to be elucidated.

Purpose
This study aims to investigate the feasibility and safety of additional roofline creation by VGLB ablation alone in patients with AF.

Methods
A total of 30 patients with AF (paroxysmal AF=15, persistent AF=15) who underwent VGLB ablation from March 2023 to August 2023 were analyzed retrospectively. VGLB ablation was performed using a third-generation VGLB. After initial circular ablation, VGLB was inflated to a larger size to extend and fuse the isolation area at the roof portion during the superior PVs occlusion. The complete conduction block of the left atrial (LA) roof was assessed by the differential pacing methods and the high-resolution mapping system at the end of the procedure.

Results
Acute success in complete roofline creation was achieved in 70% of patients. The PVI time was 21.6±5.5 minutes, and additional roof ablation time was 8.7±3.5 minutes, respectively. The anatomical LA roof length was significantly shorter in patients with successful roofline generation than without (30.4±7.2mm vs. 42.9±4.0mm, P&lt;0.001). A cut-off value of 40.2mm for the LA roof length calculated by a receiver operating characteristic curve predicted a successful construction of the LA roofline with the highest sensitivity of 94.7%, specificity of 83.3%, and the area under the curve was 0.94 (95% confidence interval, 0.35-0.99). No complications occurred during laser energy titration at the roof area.

Conclusion
The roofline creation using a third-generation VGLB is possible with acceptable safety concerns. The length of the LA roof≤40.2mm was a predictor of the successful LA roofline generation.Fluoroscopic and endoscopic imageVoltage map after ablation
Impact of age on atrial arrhythmia recurrence following cryoballoon pulmonary-vein isolation
Authors: Boehmer A A , Rothe M , Wiedenmann L , Nussbaum E , Schneider K Y , Spork P , Keim C , Dobre B C , Kaess B M , Ehrlich J R 
Published: May 2024

Abstract

Background
Age is a major risk factor for development of atrial fibrillation (AF) and associated with increased recurrence rates in the setting of rhythm control. Current data tend to support catheter ablation in elderly patients, but it remains unclear whether there is an age limit for ablation and whether the potential benefits of catheter ablation justify the potentially increased complication rate in elderly.

Objective
To prospectively analyze the impact of age on efficacy and safety of cryoballoon ablation (CBA).

Methods
; We prospectively analyzed consecutive patients who underwent CBA in a single-center cohort between 2018 and 2023. Patients were stratified by age (&lt;75yrs versus ≥75yrs) and AF type. Primary efficacy endpoint was recurrence of atrial arrhythmia after 90-day blanking period. Linear and spline regression were used to assess the association between age and primary efficacy endpoint. Safety endpoints were death, stroke or procedure-related complications.

Results
873 patients underwent CBA (525 paroxysmal, 348 persistent AF). Median follow-up was 18-months. At 1-year, primary efficacy endpoint occurred in 19.6% (71/363) of young (&lt;75yrs) versus 27.8% (45/162) of elderly (≥75yrs) patients with paroxysmal AF (HR 0.62; 95%CI, 0.41-0.92; P=0.019; fig. 1A) and in 25.0% (57/228) of young versus 39.2% (47/120) of elderly patients with persistent AF (HR 0.57; 95%CI, 0.37-0.85; P=0.006; fig. 1B). A significant linear relationship between age and primary efficacy endpoint occurrence was found for both paroxysmal (P=0.01) and persistent AF (P=0.002; fig.2) while spline regression was non-significant (P=0.45/ P=0.12). No difference was observed regarding the incidence of safety endpoints between young and elderly patients (P=0.76).

Conclusion
Atrial arrhythmia recurrence rate after CBA increases linearly with age (thus not allowing determination of a clear "cut-off-age") and is highest in elderly patients (≥75 yrs) with persistent AF. Safety of CBA in elderly is comparable to patients of younger age.
Radiofrequency balloon ablation: 1-year outcomes of the AURORA registry
Authors: My I , Schmidt B , Rottner L , Lemoine M , Moser F , Ismaili D , Kirchhof P , Reissmann B , Ouyang F , Rillig A , Chun J , Metzner A , Bordignon S 
Published: May 2024

Abstract

Background and Objectives
A novel irrigated radiofrequency balloon (RFB) for pulmonary vein isolation (PVI) integrated into 3D mapping system was recently launched.

Methods
Patients ablated for paroxysmal atrial fibrillation (PAF) or persistent atrial fibrillation (persAF) at two German high-volume electrophysiology centers were included into the prospective AURORA registry. All patients underwent clinical follow-up (FU) at 90, 180 and 360 days following ablation including 24h Holter ECGs.

Results
A total of 101 patients were enrolled (50 from centre A, 51 from centre B) and 86 patients (48% male, 65 ± 11 years, 55% PAF, 59 ± 7% left ventricular ejection fraction (LVEF)) completed the follow-up. Mean ablation and procedure times were 26 ± 13 min and 71 ± 20 min, respectively. Dose area product was 1501 ± 1634 mGycm2. Acute PVI was achieved in 100%. Atrial fibrillation (AF) free survival after a mean FU of 361 (219-375) days was 78.4% for PAF and 75.4% for persAF. (p= 0.828). A multiple regression analysis did not reveal any clinical or procedural predictors of AF recurrence among sex, age, BMI, left atrial diameter, LVEF, ablation time, procedure time and single shot PVI. However, early recurrence of atrial tachyarrhythmia (ERAT) was an independent predictor for AF recurrence at 1-year (Hazard Ratio [HR]: 3.198; 95% confidence interval [95% CI]: 1.036 - 10.32, p value = 0.0433). Primary adverse events occurred in 3.5% of patients (1 postprocedural pharyngeal bleeding, 1 myocardial infarction, 1 non-cardiovascular death); no pericardial effusion, stroke or phrenic nerve paralysis were observed.

Conclusions
RFB-based PVI is clinically effective and safe. ERAT at the first follow-up visit is an independent predictor of late AF recurrence.