Journal: Circ Arrhythm Electrophysiol

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Abstract

Vein of Marshall Ethanol Infusion: Feasibility, Pitfalls, and Complications in over 700 Patients.

Kamakura T, Derval N, Duchateau J, Denis A, ... Haïssaguerre M, Pambrun T

Background:
- Vein of Marshall (VOM) ethanol infusion is a relatively new therapeutic option for atrial tachyarrhythmias. We aimed to evaluate the feasibility, pitfalls, and complications associated with this procedure in a large cohort of patients. Methods - Successful ethanol infusion, VOM-related lesion extent, and serious complications were evaluated in 713 consecutive patients treated with VOM ethanol infusion. Results - While feasible in 88.9% of cases, VOM ethanol infusion failure mainly resulted from non-identification (6.2%), non-cannulation (1.5%), or ethanol infusion in the wrong vein (1.7%). The Vieussens valve was a helpful landmark and was visible in 63.2% of cases. Multivariable analysis identified previous coronary sinus ablation as the only predictor for non-identification. The mean area of VOM-related endocardial scarring was 10.2±5.3 cm2. VOM dissection (10.7%), iodine leakage (3.0%), and VOM morphology without visible branches (3.0%) were associated with smaller VOM-related scarring (5.0±3.9 cm2, 6.6±3.5 cm2 and 4.7±2.3 cm2, with a p <0.0001, p <0.044, and p <0.0001, respectively). Ethanol infusion in a wrong vein was associated with less mitral line block (72.7% vs. 95.8%, p=0.012). A total of 14 serious complications (2.0%) occurred: 7 tamponades, of which were 6 delayed and treated with pericardiocentesis (2 of these patients had per-procedural VOM perforation), 4 strokes, 1 anaphylactic shock, 1 atrioventricular block, and 1 left appendage isolation. Only 4 of these complications occurred during the procedure.
Conclusions:
- Although limited by previous coronary sinus ablation, VOM ethanol infusion is a highly feasible treatment for atrial tachyarrhythmia, with a low rate of serious complications.




Circ Arrhythm Electrophysiol: 18 Jul 2021; epub ahead of print
Kamakura T, Derval N, Duchateau J, Denis A, ... Haïssaguerre M, Pambrun T
Circ Arrhythm Electrophysiol: 18 Jul 2021; epub ahead of print | PMID: 34280029
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Abstract

Super and Non-responders To Catheter Ablation for Atrial Fibrillation: A Quality-of-Life Assessment Using Patient Reported Outcomes.

Farwati M, Wazni OM, Tarakji KG, Diab M, ... Saliba WI, Hussein AA

Background:
- Atrial fibrillation (AF) ablation targets improvement in quality of life (QoL). Data is scarce on predictors of QoL improvement following ablation. We aimed to investigate the clinical characteristics underlying differential response in QoL after AF ablation (with or without arrhythmia recurrence). Methods - All patients undergoing AF ablation (2013-2016) at our center were prospectively enrolled in a fully automated patient-reported outcomes registry. A large number of variables were collected including AF symptom severity scale (AFSSS) and AF burden (as indicated by AF frequency and duration scores). Patients were divided into 3 groups based on self-report of QoL improvement: remarkable (super responders), mild/moderate, and unchanged or worse (non-responders). Univariable and multivariable logistic regression models assessed clinical characteristics and QoL outcomes. Results - A total of 956 patients were included (25% females, mean age 63.9). Most patients (~80%) were super responders (n=761), 138 (14.4%) had mild/moderate improvement, and 57 (5.9%) were non-responders. The strongest predictors of remarkable QoL improvement were freedom of arrhythmia recurrence (OR 2.42, 95% CI 1.27-4.59, p-value = 0.007), and lower AF burden at 12 months. Similarly, higher AF burden was significantly associated with clinical \"non-response\". In patients with observed clinical recurrence-QoL mismatch, changes in AF burden at 12 months were the main predictors of QoL outcome, with lower burden predicting higher improvement in QoL and vice versa.
Conclusions:
- Most patients derive significant QoL benefit from AF ablation. Freedom from arrhythmia recurrence and lower AF burden predict remarkable QoL improvement following ablation.




Circ Arrhythm Electrophysiol: 18 Jul 2021; epub ahead of print
Farwati M, Wazni OM, Tarakji KG, Diab M, ... Saliba WI, Hussein AA
Circ Arrhythm Electrophysiol: 18 Jul 2021; epub ahead of print | PMID: 34279998
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Abstract

Propagation Vectors Facilitate Differentiation between Conduction Block, Slow Conduction and Wavefront Collision.

Yavin HD, Bubar ZP, Higuchi K, Sroubek J, Yarnitsky J, Anter E

Background:
- Differentiation between conduction block, slow conduction, and wavefront collision can be difficult using activation mapping alone, often requiring differential pacing. Therefore, a real-time method for determination of complex patterns of conduction may be desired. We hereby report a novel algorithm for displaying propagation vectors, allowing differentiation between complex patterns of conduction and facilitating real-time detection of block during ablation. Methods - In 10 swine, a chronic transcaval ablation line with an intentional gap or complete block was created, simulating conduction block, slow conduction and wavefront collision. The line was mapped during atrial pacing using Carto 3 and a novel high-resolution array that includes 48 mini-electrodes (surface area-0.9mm2, spacing 2.4mm) distributed over 6 splines (Optrell™, Biosense Webster). Propagation vectors were created from unipolar waveforms of adjacent electrodes along and across splines that were acquired at single beats. In order to examine the utility of propagation vectors for detection conduction block during ablation, a cavotricuspid isthmus line (CTI) was created during coronary sinus pacing with the array positioned lateral to the line. Results - Propagation vectors detected the gap in all 6 interrupted ablation line, while activation maps only identified gap in 3/6 lines; in the remainder, activation maps alone could not differentiate between conduction block, slow conduction or wavefront collision. Propagation vectors accurately determined block in all 4 contiguous ablation line, while activation maps suggested conduction block or was indeterminant due to wavefront collision in 2/4 lines. CTI block was detected during ablation by abrupt reversal of propagation vectors from a lateral to a septal direction and acute reconnection was detected by reversal of the propagating vectors back to a lateral direction.
Conclusions:
- Real-time propagation vectors enhance the ability of standard activation maps to differentiate between complex patterns of conduction, including determination of conduction block during ablation.




Circ Arrhythm Electrophysiol: 18 Jul 2021; epub ahead of print
Yavin HD, Bubar ZP, Higuchi K, Sroubek J, Yarnitsky J, Anter E
Circ Arrhythm Electrophysiol: 18 Jul 2021; epub ahead of print | PMID: 34279988
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Abstract

Anatomical Characteristics of the Left Atrium and Left Atrial Appendage in Relation to the Risk of Stroke in Patients with Versus without Atrial Fibrillation.

Smit JM, Simon J, El Mahdiui M, Száraz L, ... Maurovich-Horvat P, Bax JJ

Background:
- The left atrial appendage (LAA) has been regarded as an important source of cardiac thrombus formation and appears important in the contribution to thrombo-embolism in patients with atrial fibrillation (AF). Our aim was to evaluate the relationship between LAA morphology and previous stroke and/or transient ischemic attack (TIA) in two large and distinct patient cohorts with and without known AF. Methods - The study population consisted of patients with and without drug-refractory AF who underwent computed tomography (CT) prior to transcatheter AF ablation, or clinically indicated for suspected coronary artery disease (CAD). The CT data were used for volumetric assessment of the left atrium (LA) and LAA and to determine LAA morphology. The LAA was classified by 3 readers in consensus as chicken wing, swan, cauliflower or windsock, based on predefined morphology classification criteria. Results - In total, 1813 patients (mean age 59 ± 11 years, 42% female) who underwent CT were included in this analysis (908 patients with AF and 905 patients without known AF). Swan LAA morphology was independently associated with prior stroke/TIA in the overall study population (OR 3.40, P <0.001), and in patients with (OR 2.88, P = 0.012) and without known AF (OR 3.96, P = 0.011).
Conclusions:
- Swan morphology of the LAA is independently associated with prior stroke and/or TIA in patients with known AF, as well as in patients not previously diagnosed with AF.




Circ Arrhythm Electrophysiol: 18 Jul 2021; epub ahead of print
Smit JM, Simon J, El Mahdiui M, Száraz L, ... Maurovich-Horvat P, Bax JJ
Circ Arrhythm Electrophysiol: 18 Jul 2021; epub ahead of print | PMID: 34279121
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Abstract

Left Atrial Isolation and Appendage Occlusion in Patients with Atrial Fibrillation at End Stage Left Atrial Fibrotic Disease.

Zedda A, Huo Y, Kronborg M, Ulbrich S, ... Piorkowski J, Piorkowski C

Background:
- Atrial fibrillation (AF) ablation in an end-stage left atrial (LA) fibrotic disease is more complex, has more recurrences and may compromise transport function and stroke risk. We explored whether a total left atrial isolation procedure (TLAI) followed by left atrial appendage occlusion (LAAO) is a feasible treatment concept for rhythm and stroke risk control. Methods - Symptomatic AF patients with extended LA fibrosis were enrolled consecutively for TLAI followed by LAAO. At enrollment all patients received a sinus rhythm LA voltage map. For TLAI, LA anterior and paraseptal ablation lines were placed, combined with right atrial and epicardial line completion and right pulmonary vein isolation - as needed. Rhythm follow-up was provided through continuous monitoring using implantable cardiac devices. Results - 92 patients (71±9y, 41% male, 84% persistent AF, CHA2DS2-VASc 4) underwent 104 ablation procedures. Follow-up duration measured 48±22 months. At 12-month follow-up 70 out of 92 (76%) patients were free from any atrial arrhythmia recurrence, off antiarrhythmic drugs. All intended LAAO procedures were successfully performed 6-8 weeks after TLAI. Combination of TLAI and LAAO attenuated the native 4% annual stroke risk to <1% over the entire course of the study. Patients\' clinical AF and heart failure symptoms (EHRA and NYHA classification) significantly improved and remained stable during further follow-up. Invasive hemodynamic assessment as well as echocardiographic transport function analysis did not show evidence of detrimental hemodynamic effects of the treatment concept.
Conclusions:
- This is the first report on a structured concept of interventional electrical LA isolation and LA appendage occlusion for rhythm and stroke risk control in AF patients at an end-stage left atrial fibrotic disease. We report feasibility, safety, and efficacy of such a treatment approach.




Circ Arrhythm Electrophysiol: 15 Jul 2021; epub ahead of print
Zedda A, Huo Y, Kronborg M, Ulbrich S, ... Piorkowski J, Piorkowski C
Circ Arrhythm Electrophysiol: 15 Jul 2021; epub ahead of print | PMID: 34270906
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Abstract

Bucindolol Decreases Atrial Fibrillation Burden in Patients with Heart Failure and the Arg389Arg Genotype.

Piccini JP, Dufton C, Carroll IA, Healey JS, ... Bristow MR, Connolly SJ

Background:
- Bucindolol is a genetically targeted β-blocker/mild vasodilator with the unique pharmacologic properties of sympatholysis and ADRB1 Arg389 receptor inverse agonism. In the GENETIC-AF trial conducted in a genetically defined heart failure (HF) population at high risk for recurrent atrial fibrillation (AF), similar results were observed for bucindolol and metoprolol succinate for the primary endpoint of time to first atrial fibrillation (AF) event; however, AF burden and other rhythm control measures were not analyzed. Methods - The prevalence of ECGs in normal sinus rhythm, AF interventions for rhythm control (cardioversion, ablation and antiarrhythmic drugs), and biomarkers were evaluated in the overall population entering efficacy follow-up (N=257). AF burden was evaluated for 24 weeks in the device substudy (N=67). Results - In 257 patients with HF the mean age was 65.6 ± 10.0 years, 18% were female, mean left ventricular ejection fraction (LVEF) was 36%, and 51% had persistent AF. Cumulative 24-week AF burden was 24.4% (95% CI: 18.5, 30.2) for bucindolol and 36.7% (95% CI: 30.0, 43.5) for metoprolol (33% reduction, p < 0.001). Daily AF burden at the end of follow-up was 15.1% (95% CI: 3.2, 27.0) for bucindolol and 34.7% (95% CI: 17.9, 51.2) for metoprolol (55% reduction, p < 0.001). For the metoprolol and bucindolol respective groups the prevalence of ECGs in normal sinus rhythm was 4.20 and 3.03 events per patient (39% increase in the bucindolol group, p < 0.001), while the rate of AF interventions was 0.56 and 0.82 events per patient (32% reduction for bucindolol, p = 0.011). Reductions in plasma norepinephrine (p = 0.038) and NT-proBNP (p = 0.009) were also observed with bucindolol compared to metoprolol.
Conclusions:
- Compared with metoprolol, bucindolol reduced AF burden, improved maintenance of sinus rhythm, and lowered the need for additional rhythm control interventions in patients with HF and the ADRB1 Arg389Arg genotype.




Circ Arrhythm Electrophysiol: 15 Jul 2021; epub ahead of print
Piccini JP, Dufton C, Carroll IA, Healey JS, ... Bristow MR, Connolly SJ
Circ Arrhythm Electrophysiol: 15 Jul 2021; epub ahead of print | PMID: 34270905
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Abstract

Transcriptomic Profiling of Canine Atrial Fibrillation Models after One Week of Sustained Arrhythmia.

Leblanc FJA, Vahdati Hassani F, Liesinger L, Qi X, ... Lettre G, Nattel S

Background:
- Atrial fibrillation (AF), the most common sustained arrhythmia, is associated with increased morbidity, mortality, and health-care costs. AF develops over many years and is often related to substantial atrial structural and electrophysiological remodeling. AF may lack symptoms at onset and atrial biopsy samples are generally obtained in subjects with advanced disease, so it is difficult to study earlier-stage pathophysiology in humans. Methods - Here, we characterized comprehensively the transcriptomic (miRNAseq and mRNAseq) changes in the left atria of two robust canine AF-models after one week of electrically-maintained AF, without or with ventricular rate-control via atrioventricular node-ablation/ventricular pacing. Results - Our RNA-sequencing experiments identified thousands of genes that are differentially expressed, including a majority that have never before been implicated in AF. Gene-set enrichment analyses highlighted known (e.g. extracellular matrix structure organization) but also many novel pathways (e.g. muscle structure development, striated muscle cell differentiation) that may play a role in tissue remodeling and/or cellular trans-differentiation. Of interest, we found dysregulation of a cluster of non-coding RNAs, including many microRNAs but also the MEG3 long non-coding RNA orthologue, located in the syntenic region of the imprinted human DLK1-DIO3 locus. Interestingly (in the light of other recent observations), our analysis identified gene-targets of differentially expressed microRNAs at the DLK1-DIO3 locus implicating glutamate signaling in AF pathophysiology.
Conclusions:
- Our results capture molecular events that occur at an early stage of disease development using well-characterized animal models, and may therefore inform future studies that aim to further dissect the causes of AF in humans.




Circ Arrhythm Electrophysiol: 15 Jul 2021; epub ahead of print
Leblanc FJA, Vahdati Hassani F, Liesinger L, Qi X, ... Lettre G, Nattel S
Circ Arrhythm Electrophysiol: 15 Jul 2021; epub ahead of print | PMID: 34270327
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Abstract

Management of Congenital Long-QT Syndrome: Commentary From the Experts.

Kaufman ES, Eckhardt LL, Ackerman MJ, Aziz PF, ... A M Wilde A, Zareba W
While published guidelines are useful in the care of patients with long-QT syndrome, it can be difficult to decide how to apply the guidelines to individual patients, particularly those with intermediate risk. We explored the diversity of opinion among 24 clinicians with expertise in long-QT syndrome. Experts from various regions and institutions were presented with 4 challenging clinical scenarios and asked to provide commentary emphasizing why they would make their treatment recommendations. All 24 authors were asked to vote on case-specific questions so as to demonstrate the degree of consensus or divergence of opinion. Of 24 authors, 23 voted and 1 abstained. Details of voting results with commentary are presented. There was consensus on several key points, particularly on the importance of the diagnostic evaluation and of β-blocker use. There was diversity of opinion about the appropriate use of other therapeutic measures in intermediate-risk individuals. Significant gaps in knowledge were identified.



Circ Arrhythm Electrophysiol: 29 Jun 2021; 14:e009726
Kaufman ES, Eckhardt LL, Ackerman MJ, Aziz PF, ... A M Wilde A, Zareba W
Circ Arrhythm Electrophysiol: 29 Jun 2021; 14:e009726 | PMID: 34238011
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Abstract

Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association.

Gopinathannair R, Chen LY, Chung MK, Cornwell WK, ... American Heart Association Electrocardiography and Arrhythmias Committee and Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Hypertension; Council on Lifestyle and Cardiometabolic Health; and the Stroke Council
Atrial fibrillation and heart failure with reduced ejection fraction are increasing in prevalence worldwide. Atrial fibrillation can precipitate and can be a consequence of heart failure with reduced ejection fraction and cardiomyopathy. Atrial fibrillation and heart failure, when present together, are associated with worse outcomes. Together, these 2 conditions increase the risk of stroke, requiring oral anticoagulation in many or left atrial appendage closure in some. Medical management for rate and rhythm control of atrial fibrillation in heart failure remain hampered by variable success, intolerance, and adverse effects. In multiple randomized clinical trials in recent years, catheter ablation for atrial fibrillation in patients with heart failure and reduced ejection fraction has shown superiority in improving survival, quality of life, and ventricular function and reducing heart failure hospitalizations compared with antiarrhythmic drugs and rate control therapies. This has resulted in a paradigm shift in management toward nonpharmacological rhythm control of atrial fibrillation in heart failure with reduced ejection fraction. The primary objective of this American Heart Association scientific statement is to review the available evidence on the epidemiology and pathophysiology of atrial fibrillation in relation to heart failure and to provide guidance on the latest advances in pharmacological and nonpharmacological management of atrial fibrillation in patients with heart failure and reduced ejection fraction. The writing committee\'s consensus on the implications for clinical practice, gaps in knowledge, and directions for future research are highlighted.



Circ Arrhythm Electrophysiol: 30 May 2021; 14:HAE0000000000000078
Gopinathannair R, Chen LY, Chung MK, Cornwell WK, ... American Heart Association Electrocardiography and Arrhythmias Committee and Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Hypertension; Council on Lifestyle and Cardiometabolic Health; and the Stroke Council
Circ Arrhythm Electrophysiol: 30 May 2021; 14:HAE0000000000000078 | PMID: 34129347
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