bluuebunny/crossref_metadata_2025_split huggingface dataset:
Clinical risk prediction for left atrial appendage thrombus among patients with atrial fibrillation
Authors: Segan L , Nanayakkara S , Spear E , Shirwaiker A , Chieng D , Sugumar H , Ling L H , Prabhu S , Lee G , Morton J , Kalman J , Voskoboinik A , Kistler P 
Published: October 2022

Abstract

Background
Exclusion of left atrial appendage thrombus (LAAT) by transoesophageal echocardiography (TOE) is recommended in patients with inadequate anticoagulation prior to direct cardioversion (DCR) or catheter ablation for atrial fibrillation/flutter (AF/AFL). LAAT risk factors in this population remain poorly defined.

Purpose
Determine LAAT predictors in AF/AFL patients undergoing pre-procedural TOE.

Methods
We evaluated available clinical and transthoracic echocardiographic (TTE) parameters in AF/AFL patients undergoing TOE between 1999–2022 in our institution in Melbourne, Australia. Regression analysis identified predictors of LAAT, which were applied to a weighted score developed in the derivation cohort (70%) and validated in the remaining 30%.

Results
Of 627 patients (age 62±12 years, 27% female, AF 84%,AFL 16%, left ventricular ejection fraction (LVEF) 44±20%), 24% had LAAT and 13.8% dense spontaneous echo contrast precluding DCR. Anticoagulation was NOAC 56.5%, warfarin 32.1% and none in 11.4%. In the LAAT cohort, thrombus resolution occurred in 39% on serial transoesophageal imaging with a median time to resolution of 131 days (IQR 54–398).
Diabetes (p=0.004), prior stroke (p=0.009), coronary disease (p=0.015), renal impairment (p&lt;0.001) and CHADS2VASc &gt;2 (73% vs. 55%, p&lt;0.001) were higher in the LAAT cohort. Age (p=0.093), gender (p=0.689), BMI (p=0.828), anticoagulant type (p=0.316) and diabetes (p=0.107) were not univariate predictors, whereas anticoagulation duration (&lt;30 days), creatinine and TTE markers of remodeling (LVEF, LAVI, RVSP and TAPSE) were independent predictors on univariate and multivariate regression; CHADS2VASc was not significant after adjustment (p=0.090). The weighted risk model included continuous (age, creatinine, LVEF, LAVI, TAPSE and RVSP) and categorical (anticoagulation duration) variables with excellent predictive performance: AUC 0.872 (95% CI 0.798–0.946), PPV 91%, NPV 70% and accuracy 80%.

Conclusion
A novel LAAT risk model comprising clinical and echocardiographic parameters enhances risk prediction over CHADS2VASc in AF/AFL and may guide the need for pre-procedural TOE imaging.

Funding Acknowledgement
Type of funding sources: None.
Risk of stroke and transient ischemic attack after elective cardioversion of atrial fibrillation: a nationwide study in Finland
Authors: Itainen-Stromberg S , Lehto M , Halminen O , Putaala J , Haukka J , Mustonen P , Linna M , Kalatsova K , Aro A , Hartikainen J , Airaksinen K E J 
Published: October 2022

Abstract

Background
Cardioversion is routinely used to restore sinus rhythm in patients with atrial fibrillation (AF). Elective cardioversion (ECV) is associated with an increased risk of thromboembolic complications even during adequate oral anticoagulation (OAC).

Purpose
The aim was to analyze the incidence of ischemic stroke and transient ischemic attack (TIA) after first-ever ECV of AF in patients using guideline-recommended OAC.

Methods
This nationwide register-based study includes all (N=9625) AF patients undergoing their first-ever ECV between 2012 and 2018 in Finland. Data was obtained from the Finnish health care registers, including both primary and special health care. The risk of stroke and TIA within 30 days after ECV were estimated in patients using OAC.

Results
The mean age of patients was 68 (±9.9) years, 61.2% were men, and the mean CHA2DS2-VASc score was 2.6 (±1.6, range 0–9). Warfarin was used in 6245 (64.9%) and non-vitamin K oral anticoagulants in 3380 (35.1%) cardioversions, of which 1453 (15.1%) was rivaroxaban, 1246 (12.9%) apixaban, 635 (6.6%) dabigatran, and 46 (0.5%) edoxaban. Twenty-nine (0.3%; 95% confidence interval [CI] 0.2–0.4%) ischemic strokes or TIAs occurred within 30 days after ECV (median 3 days, interquartile range 2.0–8.5) (Figure 1 and Table 1). In warfarin-treated patients experiencing stroke or TIA, the mean INR value before ECV and at the time of stroke or TIA were 2.5 (±0.5) and 2.5 (±0.5), respectively. One of the patients had INR-value &lt;2.0 before ECV and at the time of stroke and one patient had INR value &lt;2.0 before ECV.

Conclusion
In our nationwide study, the rate of stroke and TIA after first-ever ECV was low (0.3%) in all OAC groups.

Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District
Long-term efficacy and health consumption before and after ablation of AF
Authors: Englund A , Tabrizi F , Scheel S 
Published: October 2022

Abstract

Background
Atrial fibrillation (AF), the most common arrhythmia worldwide, is associated with increased morbidity and mortality. Catheter ablation of AF is the most effective treatment option for symptomatic patients. The long-term efficacy is however not very well studied nor is health consumption before and after an ablation of atrial fibrillation.

Purpose
To study the long-term efficacy and health consumption before and after an ablation of AF in 1453 consecutive patients undergoing ablation in our institution.

Methods
Consecutive patients undergoing radiofrequency ablation for AF were included prospectively. 4 mm irrigated ablation (Biosense Webster) catheters and Carto® were used for all procedures. After a mean period of 4 years a survey measuring arrhythmia symptoms was sent out to all patients who were treated with an ablation of AF between 1st of January 2010 and 31st of December 2016. Data was collected from local registries, the national registry for catheter ablations and the national health registry. Health consumption measured as in-hospital visits two years before and after the procedure was assessed.

Results
877 (72.7%) patients had no further symptomatic arrhythmia four years after the procedure. Among the 329 patients who still reported symptoms 237 (72%) had milder, 65 (20%) had unchanged and 20 (8%, 1.3% of total) had worsened symptoms after e ablation.
The total number of in-hospital visits 2 years before and after the ablation was 4067. There were 2594 in-hospital visits before and 1473 after the ablation, a decrease by 43%. The majority of the these were arrhythmia related, 2264 and 908, respectively, a decrease by 60%. Seven patients had a stroke before the ablation and five after. The median length of stay was 1 day both before and after the ablation.

Conclusion
Health consumption is significantly decreased after an ablation for AF. The long-term effect is good with freedom of symptomatic AF of approximately 70% after four years.

Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Biosense Webster Inc
Prediction of difficulty in cryoballoon ablation with a 3D deep learning model using polygonal mesh representation
Authors: Nakasone K , Nishimori M , Kiuchi K , Shinohara M , Fukuzawa K , Takami T , Nakamura T , Sonoda Y , Takahara H , Yamamoto K , Suzuki Y , Tani K , Iwai H , Nakanishi Y , Hirata K 
Published: October 2022

Abstract

Background
Cryoballoon ablation (CBA) is a useful treatment for pulmonary vein isolation (PVI). Some cases, however, are difficult to treat and may require multiple freezing procedures and/or touch-up ablation. Although several predictors of CBA difficulty have been reported, no report has been able to assess the spatial location and morphology of the left atrium (LA) and pulmonary veins (PVs). A polygonal mesh is a collection of vertices, edges, and faces that defines the shape of a polyhedral object, and is able to represent a spatial location with a small amount of information. We hypothesized that a deep learning model that learns mesh representation datasets could more accurately detect the CBA difficulty and that we could establish a novel evaluation method in CBA.

Purpose
The aim of this study was to create a model to predict CBA difficulty with a 3D deep learning model using polygonal mesh representation.

Methods and results
All the 140 patients who underwent CBA for drug-resistant atrial fibrillation between January 2015 and January 2022 were included. A 28-mm cryoballoon (Arctic Front Advance, Medtronic) was used in all cases. We defined CBA difficulty as requiring a touch-up ablation procedure to create complete PVI. We converted the volume data in DICOM format of the computed tomography images of PVs and LA to obj file format (shown in Figure 1), which supports the definition of the geometry for object surfaces using polygonal meshes. Next, we developed a deep learning model that could learn polygonal meshes and classify whether the CBA required touch-up ablation or not. Only a training dataset is used to train the deep learning model, and finally, a test dataset is used to evaluate the model metrics. The accuracy, area under the ROC curve, recall, precision, and f1-score of the deep learning model using the test dataset was 86.5%, 87.7%, 66.7%, 75.0%, 70.6%, respectively.

Conclusions
We developed a 3D deep learning model that can detect a difficulty in CBA using polygonal mesh representation. By predicting difficult cases in advance, we will be able to develop strategies to increase the success rate.

Funding Acknowledgement
Type of funding sources: None.
Use of an active esophageal cooling device in zero-fluoroscopy settings without intracardiac echocardiography
Authors: Joseph C , Cooper J , Schricker A , Sala D , Woods C 
Published: October 2022

Abstract

Background
Active esophageal cooling is increasingly being utilized during radiofrequency (RF) ablation to achieve pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF). In addition to data showing decreases in severe esophageal injury with active esophageal cooling, placement of a commercially available cooling device can be identified on intracardiac echocardiography (ICE), allowing implementation in zero-fluoroscopy settings. In the case of procedures that do not have ICE available, an alternative method to determine proper placement of an esophageal cooling device is needed in zero-fluoroscopy settings..

Purpose
To describe a large single-center approach to visualizing an active esophageal cooling device into a 3D mapping system.

Methods
We reviewed data on patients treated with RF ablation for PVI procedures over the time frame 1/1/2020 to 12/31/21. Active esophageal cooling was phased in towards the end of 2020. For all cases, transseptal puncture was performed with the use of transesophageal echocardiography (TEE). After successful transseptal puncture, the TEE probe was removed, and either a single-sensor LET probe or an active esophageal cooling device was placed. For the active cooling device, the distal tip was cut, and an SL-1 (0.032 inch, 150 cm length) guidewire was placed through the central lumen of the cooling device (used for gastric suctioning and enteral feeding). The guidewire was pinned via a pin block to the 3D mapping system (EnSite, Abbott). Unipolar configuration was used to generate a 3D map, which was then visualized during device placement. Placement was confirmed after visualizing the guidewire tip on the 3D map passing below the coronary sinus (Figure 1).

Results
A total of 417 cases were performed over the study timeframe. The mean age of patients was 65±10 years, and 40% were female. A total of 5 complications were recorded (3 pericardial effusions, 1 pseudoaneurysm, and 1 air embolism). A total of 156 patients received LET monitoring, and 261 received active esophageal cooling. The mean procedure length was 109±24 minutes for cases utilizing LET monitoring, and 93±11 minutes for cases utilizing active esophageal cooling. Visualization of the active esophageal cooling device on the cardiac mapping system was possible in all cases.

Conclusions
We describe here the largest series to date utilizing active esophageal cooling in a zero-fluoroscopy, zero-ICE setting. With increasing efforts to reduce fluoroscopy, this approach allows pursuit of zero-fluoroscopy even in systems without the availability of ICE, while maintaining procedural speed and safety.

Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Attune Medical
Heart failure and the risk of left atrial thrombus formation in patients with atrial fibrillation and atrial flutter: insights from the LATTEE registry
Authors: Wybraniec M , Mizia-Szubryt M , Gawalko M , Uzieblo-Zyczkowska B , Gorczyca-Glowacka I , Kaufmann D , Wojcik M , Hiczkiewicz J , Fijalkowski M , Szymanska A , Haberka M , Michalski B , Tomaszuk-Kazberuk A , Kozinski M , Mizia-Stec K 
Published: October 2022

Abstract

Background
The aim of the study was to evaluate the prevalence of left atrial thrombus (LAT) on transesophageal echocardiography (TEE) in patients with atrial fibrillation and atrial flutter (AF/AFl) with reference to the presence of heart failure (HF) and its subtypes.

Methods
The research is a substudy of multicenter, prospective, observational Left Atrial Thrombus on Transesopahgeal Echocardiography (LATTEE) registry, which comprised 3109 consecutive patients with AF/AFl undergoing TEE prior to direct current cardioversion or catheter ablation. TEE parameters, including presence of LAT, were compared between patients with and without HF, as well as different subtypes of HF, including HF with preserved (HFpEF), mid-range (HFmrEF) and reduced ejection fraction (HFrEF).

Results
HF was diagnosed in 1336 patients (43%). HF patients had higher prevalence of LAT than non-HF patients (12.8% vs. 4.4%, P&lt;0.001). The rate of LAT increased with the more advanced type of systolic dysfunction (HFrEF vs. HFmrEF vs. HFpEF: 20.3% vs. 10.5% vs. 7.4%, P&lt;0.001; Figure 1). Univariate analysis revealed that HFrEF (OR 4.13, 95% CI: 3.13–5.46) but not HFmrEF or HFpEF predicted the presence of LAT. Multivariable logistic regression indicated that left ventricular ejection fraction (unit OR=0.94 per 1%, 95% CI: 0.93–0.95) was an independent predictor of LAT formation. Receiver operator characteristic analysis showed LVEF ≤48% predicted presence of LAT (AUC=0.74, P&lt;0.0001).

Conclusion
The diagnosis of HFrEF, but not HFpEF, confers a considerable risk of LAT presence despite widespread utilization of adequate anticoagulation in the assessed population. TEE should be considered in these patients prior to cardioversion or catheter ablation despite adequate oral anticoagulation.

Funding Acknowledgement
Type of funding sources: None.
Body mass index from the RE-LY trial: further evidence of the obesity paradox
Authors: Jacobs M , Ezekowitz M , Nagarakanti R , Eikelboom J , Khan O , Reiss J , Liu H , McAndrew T , Francese D , Arce J , Brueckmann M , Connolly S , Yusuf S 
Published: October 2022

Abstract

Background
The obesity paradox has been reported in 3 post-hoc analyses evaluating the direct oral anticoagulants (DOAC) against warfarin (W): apixaban (ARISTOTLE), rivaroxaban (ROCKET), and edoxaban (ENGAGE-AF).

Purpose
To evaluate the obesity paradox in a post-hoc analysis of the RE-LY trial, comparing dabigatran 110 mg BID (D110), 150 mg BID (D150), and W by body mass index (BMI).

Methods
Baseline characteristics were evaluated using World Health Organization (WHO) criteria of overweight and obese (BMI ≥25 kg/m2) and under and normal weight (BMI &lt;25 kg/m2). Stroke and systemic embolism, ischemic stroke, major bleeding, mortality, and intracranial hemorrhage were evaluated using BMI as a continuous variable and by the WHO criteria using a cox proportional hazard model.

Results
BMI was available in 99.9% of patients randomized; 74% had a BMI ≥25. At baseline, patients with a BMI ≥25 were younger (70.9 vs 73.1, p&lt;0.001) and had fewer prior strokes (11.5% vs 15.6%, p&lt;0.001), but higher mean creatinine clearance (78.3 vs 57.0, p&lt;0.001) and rates of diabetes (25.8% vs 16.1%, p&lt;0.001) (Table 1). Independent of drug assignment, patients with a BMI ≥25 had lower rates of stroke and systemic embolism (HR 0.65 [95% CI 0.54–0.79], p&lt;0.001), ischemic stroke (0.75 [95% CI 0.60, 0.94], p=0.01), major bleeding (HR 0.79 [95% CI 0.69,0.89], p&lt;0.001), mortality (HR 0.60 [95% CI 0.53, 0.67], p&lt;0.001) and intracranial hemorrhage (HR 0.53 [95% CI 0.38, 0.73], p&lt;0.001) compared to those with a BMI &lt;25. Using BMI as a continuous variable combining all outcomes at 3 years, endpoint rates declined as BMI approached 25 in all 3 treatment groups. The exceptions were intracranial hemorrhage for D110 and D150 and stroke in D150 patients, where rates were low independent of BMI. No significant interaction between BMI and treatment was observed in individual outcomes except for the D110 vs. D150 comparison for major bleeding, in favor of D110 for patients with BMI ≥25 (HR 0.77 [95% CI 0.65, 0.91] and HR 1.12 [95% CI 0.86, 1.47], interaction p=0.0190).

Conclusions
In RE-LY, independent of drug assignment, patients with a higher BMI had improved outcomes, demonstrating the obesity paradox. As BMI increased towards 25, outcome rates improved except for intracranial hemorrhage rates for both D110 and D150 and ischemic stroke rates for D150, which were low independent of BMI. Patients treated with D110 with a BMI ≥25 kg/m2 had significantly lower rates of bleeding compared to D150.

Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Sharpe Strumia Foundation
Watchman device migration and embolization: a report from the NCDR LAAO registry
Authors: Friedman D , Zimmerman S , Tan Z , Freeman J , Curtis J 
Published: October 2022

Abstract

Background
Incomplete anchoring of the Watchman left atrial appendage closure (LAAO) device can result in substantial device migration or device embolization requiring percutaneous or surgical retrieval.

Purpose
To report rates and characteristics of in-hospital and post-discharge Watchman device migration and embolization events in the United States.

Methods
We performed a retrospective analysis of Watchman procedures (January 2016 through March 2021) reported to the National Cardiovascular Data Registry LAAO Registry. We excluded patients with prior LAAO interventions, no device released, and missing device information. In-hospital events were assessed among all patients and post-discharge events were assessed among patients with 45-day follow-up.

Results
Of 120,278 Watchman procedures, device migration or embolization occurred in 0.07% of patients (n=84) during the index hospitalization and surgery was performed in 39 patients. The in-hospital mortality rate was 14% among patients with device migration or embolization and 20.5% among patients who underwent surgery. In-hospital migration or embolization was more common: at hospitals with a lower median annual procedure volume (24 vs. 41 procedures, p&lt;0.0001), with first-generation Watchman versus next-generation Watchman FLX devices (0.08% vs. 0.04%, p=0.0048), with larger LAA ostia (median 23 mm vs. 21 mm, p=0.004), and with a smaller difference between device and LAA ostial size (median difference 4 mm vs. 5 mm, p=0.04). There were no differences by age, sex, hospital type, hospital size, or teaching versus non-teaching status. Of 98,147 patients with 45-day follow-up, device migration or embolization after discharge occurred in 0.06% (n=54) patients and cardiac surgery was performed in 7.4% (n=4) of cases. The 45-day mortality rate was 3.7% (n=2) among patients with post-discharge device migration or embolization. Post-discharge migration or embolization was more common among men (79.7% of events but 58.9% of all procedures, p=0.0019), taller patients (177.9 cm vs. 172 cm, p=0.0005), and those with greater body mass (99.9 kg vs. 85.5 kg, p=0.0055); in contrast to in-hospital events, there were no differences in hospital volume, device characteristics, or LAA characteristics.

Conclusions
Watchman device migration or embolization is rare but associated with high mortality (Figure 1) and frequently requires surgical retrieval. A substantial proportion of all device migration or embolization cases occur after discharge and different patient and procedure characteristics are associated with in-hospital versus post-discharge cases. Given the morbidity and mortality associated with device migration or embolization, risk mitigation strategies and on-site cardiac surgical back-up are of paramount importance.

Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health
Importance of bilateral vagus nerve stimulation for effective atrioventricular node denervation during cardioneuroablation
Authors: Stiavnicky P , Wichterle D , Jansova H , Stojadinovic P , Haskova J , Peichl P , Cihak R , Kautzner J 
Published: October 2022

Abstract

Background
The progression of parasympathetic denervation of the atrioventricular node (AVN) during cardioneuroablation (CNA) can be evaluated by extracardiac vagal stimulation (ECVS). The right vagus nerve is usually used for stimulation (R-ECVS) because the right jugular vein is easily accessible. However, the AVN node is predominantly under the control of the left vagus nerve.

Purpose
To highlight the importance of left vagus stimulation (L-ECVS) for effective AVN denervation.

Methods
Both R-ECVS and L-ECVS (frequency: 50 Hz; pulse width: 0.05 ms; output 1 V / 1 kg; max. 70 V, duration 5 s) was attempted in 80 patients (age: 41±12 years, 45% men) undergoing CNA with stepwise strategy consisting of ablation of right anterior ganglionated plexus (RAGP) followed by ablation of posteromedial left ganglionated plexus (PMLGP). The study objective was the AVN response to L-ECVS (evaluated as the max. R-R interval during stimulation train) at the point when AVN non-reactivity to R-ECVS was achieved.

Results
A total of 59 patients were suitable for the analysis. Of the remaining 21 patients, left (n=14) or right (n=2) jugular veins were not accessible, AVN non-reactivity to L-ECVS was achieved before non-reactivity to R-ECVS (n=4), or AVN denervation was not achieved at all (n=1). At baseline, the AVN response was identical for R-ECVS (max. R-R median: 6.9 s, interquartile range [IQR]: 5.7–8.2 s) and L-ECVS (median: 7.1 s, IQR: 6.0–8.3 s), P=0.44. AVN non-reactivity to R-ECVS was present already at baseline (n=2); was achieved after ablation of RAGP (n=14), after ablation PMLGP (n=38), or after extensive ablation (n=5). At the point of AVN non-reactivity to R-ECVS, the response of AVN to L-ECVS was as follows: none (n=25), 2: 1 AV block (n=13) or complete AV block (n=21). The corresponding median of max. R-R interval was: 1.2 s, IQR: 0.6–4.8 s distributed as shown in Figure 1.

Conclusions
In 34/59 (58%) patients, significant AVN response to L-ECVS persists after reaching AVN non-reactivity to R-ECVS. Stimulation of both vagal nerves tightens the procedural endpoint and may increase the clinical efficacy of CNA, especially in patients with dominant AVN disorder.

Funding Acknowledgement
Type of funding sources: None.