bluuebunny/crossref_metadata_2025_split huggingface dataset:
5 years incident stroke, heart failure, acute myocardial infarction, and death in patients having undergone atrial fibrillation ablation according to BMI
Authors: Toennesen J , Pallisgaard J P , Rasmussen P V R , Ruwald M R , Zoerner C Z , Riis-Vestergaard L R V , Middelfart C M , Gislason G G , Hansen M L H 
Published: May 2023

Abstract

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

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

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

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

Results
The study cohort consisted of 7,701 patients. Median age [IQR] decreased from 64 [57, 70] to 60 [53, 66] in normal-weight and morbidly obese respectively. The prevalence of HF, ischemic heart disease, diabetes, and hypertension increased by BMI while prior stroke remained stable. Use of oral anticoagulants remained stable at around 98%.
In total 1,285 patients reached the primary endpoint. By decreasing order, the most frequent endpoints were HF (564, 44%), AMI (431, 34%), stroke (199, 15%), and death (91, 7%).
The cumulative incidence of the primary endpoint increased incrementally from 15%, 16%, 19%, and 21% from normal-weight to morbidly obese respectively (Figure 1).
In the univariate analysis, the Hazard ratio (HR, [95% confidence interval]) increased incrementally from 1.03 [0.90 to 1.18], 1.28 [1.10 to 1.49], 1.43 [1.17 to 1.74] in overweight to morbidly obese respectively (Figure 2).
In the multivariate analysis no significant differences were found. The HRs were 0.94 [0.82 to 1.08], 1.05 [0.89 to 1.23], 1.01 [0.82 to 1.24] in the overweight to morbidly obese respectively (Figure 2).

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

Abstract

Funding Acknowledgements
Type of funding sources: None.

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

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

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

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

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

Abstract

Funding Acknowledgements
Type of funding sources: None.

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

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

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

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

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

Abstract

Funding Acknowledgements
Type of funding sources: None.

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

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

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

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

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

Abstract

Funding Acknowledgements
Type of funding sources: None.

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

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

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

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

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

Abstract

Funding Acknowledgements
Type of funding sources: None.

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

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

Methods
We included 112 consecutive patients in the years 2021-2022 undergoing radiofrequency (RF) AF Ablation with 3D mapping system.
Fluoroscopy was routinely performed with a Siemens Arctic Zee X Ray System at factory low setting of 1 to 3 pulses per second, pulse width of 6,4 ms, collimation and with the secondary radiation grid in situ.
Fluoroless 3D mapping of right atrium, His region, superior vena cava, septum and coronary sinus was performed in all cases except 5 patients with pace-maker or ICD. The wire, connected with alligator clip to the 3D mapping system and the transseptal puncture sheath were fluoroless positioned in the superior vena cava. Thereafter, double transseptal puncture was guided by TEE and fluoroscopy if necessary. Only in one case intracardiac echo (ICE) was used to guide the transeptal puncture.
93% of the procedures were performed with a BRK needle connected with an alligator clip to the 3D mapping system, a - RF-needle was used in 8 (7%) patients.
All further steps were performed with a contact -force catheter and a multipolar diagnostic catheter with use of radiation only if necessary. Usually, after mapping of the left atrium the staff worked without lead protection for the rest of the procedure.
Circumferential pulmonary vein isolation (PVI) was performed in all cases adding a substrate modification in re-do procedures.

Results
One hundred and twelve patients (age 63±10 years) with paroxysmal (n=48, 43%) oder persistent (n=64, 57%) AF scheduled for RF catheter ablation were included.
We performed the transseptal maneuver with a very low fluoroscopy exposure (mean 40±95s, DAP 5±13 cGy*cm2), moreover, the mean total radiation time of the complete PVI was under a minute (mean 51 ± 112s, DAP 7±17 cGy*cm2). A completely fluoroless procedure was possible in 52 (46%) procedures. No major complications occured.

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

Abstract

Funding Acknowledgements
Type of funding sources: None.

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

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

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

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

Abstract

Funding Acknowledgements
Type of funding sources: None.

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

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

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

Conclusion
Acute sinus node dysfunction is a rare complication of sole left atrial ablation outside the pulmonary veins. However, a relevant fraction of these patients requires permanent implantation with substantial pacing proportion during midterm follow up.