Journal: Circ Arrhythm Electrophysiol

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Abstract

Racial Disparities in In-hospital Adverse Events Among Patients with Atrial Fibrillation Implanted with a Watchman Left Atrial Appendage Occlusion Device: A United States National Perspective.

Khan MZ, Munir MB, Darden D, Pasupula DK, ... Reeves R, Hsu JC

Background:
- Left atrial appendage occlusion using a Watchman device has shown promise in reducing stroke risk in selected atrial fibrillation patients. Limited data exist on differences in characteristics and in-hospital outcomes of Watchman recipients in the United States based on race/ethnicity. Methods - Data were extracted from the National Inpatient Sample database for calendar years 2015-2018. The study sample was stratified into four groups (White, Black, Hispanic and Other races). Baseline characteristics, procedural complications and key in-hospital outcomes were then assessed. We also analyzed the independent association of race/ethnicity with key in-hospital outcomes including major complications, prolonged hospital stay and increased hospitalization cost. Results - A total of 34,960 Watchman recipients were included in the final analysis. Black and Hispanic patients had higher prevalence of heart failure, hypertension, obesity and renal failure when compared to White patients. The crude rate of overall procedural complications was also higher in Blacks, Hispanics and patients of Other race when compared to White patients (15.2%, 12.4% and 14.1% vs. 9.9%, p < 0.01). After multivariable adjustment, compared to White patients, Blacks, Hispanics and patients of Other race experienced a higher likelihood of a major complication from the procedure (adjusted odds ratio [aOR] 1.223; 95% confidence interval (CI) 0.986-1.517, aOR 1.296; 95% CI 1.075-1.561 and aOR 1.924; 95% CI 1.569-2.360, respectively) and prolonged length of stay > 1-day (aOR 1.631; 95% CI 1.431-1.859, aOR 1.239; 95% CI, 1.110-1.383 and aOR 1.619; 95% CI 1.403-1.869, respectively).
Conclusions:
- Non-White patients undergoing Watchman implantation had higher prevalence of key co-morbidities and also experienced increased Watchman related adverse events including procedural complications and prolonged length of stay, even after adjustment for potential confounders. Further research is needed to identify etiologies behind differential outcomes among non-White patients after Watchman implantation.




Circ Arrhythm Electrophysiol: 27 Apr 2021; epub ahead of print
Khan MZ, Munir MB, Darden D, Pasupula DK, ... Reeves R, Hsu JC
Circ Arrhythm Electrophysiol: 27 Apr 2021; epub ahead of print | PMID: 33909473
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Abstract

Treatment-Related Changes in Left Atrial Structure in Atrial Fibrillation: Findings from the CABANA Imaging Substudy.

Rettmann ME, Holmes Iii DR, Monahan KH, Breen JF, ... Robb RA, Packer DL

Background:
- The Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial was a randomized, prospective trial of left atrial catheter ablation versus drug therapy for treatment of atrial fibrillation (AF). As part of CABANA, a prospective imaging sub-study was conducted. The main objectives were to describe the patterns of changes in the dimensions of the left atrium (LA) and pulmonary veins (PVs), and the relationship between these changes with treatment assignment and clinical outcomes. Methods - CT or MRI was acquired at baseline and follow-up in 121 ablation (median follow-up 101 days) and 85 drug patients (median follow-up 97 days). Left atrial volume index (LAVI), mean PV ostial diameter (MPV) , and ostial diameters of each PV separately were computed. We examined the relationship between the change from baseline to follow-up with subsequent clinical outcomes (composite of death, disabling stroke, serious bleeding, or cardiac arrest [CABANA primary endpoint], total mortality or cardiovascular hospitalization, first AF recurrence after the 90 day blanking period, first AF/atrial flutter/ atrial tachycardia after the 90 day blanking period) using Cox proportional-hazards models. Results - The median (25th, 75th) change from baseline for LAVI was -7.8 mL/m2 (-16.4, 0.2), ablation arm and -3.5 mL/m2 (-11.4, 2.6), drug therapy arm. The LAVI decreased in 52.9% of ablation patients versus 40.0% of drug therapy patients. Change for MPV was -2.7 mm (-4.2, -1.3) in the ablation arm versus -0.1 mm (-1.5, 0.8) in the drug therapy arm. Changes in LA and PV dimensions had no consistent relationship with the risk of developing the study primary endpoint. Reductions in LAVI, and in MPV diameter were associated with decreased risk of AF recurrence.
Conclusions:
- Ablation patients demonstrated more frequent and larger atrial structural changes compared with drug patients. These changes suggest a critical relationship between structural features and AF generation.




Circ Arrhythm Electrophysiol: 12 Apr 2021; epub ahead of print
Rettmann ME, Holmes Iii DR, Monahan KH, Breen JF, ... Robb RA, Packer DL
Circ Arrhythm Electrophysiol: 12 Apr 2021; epub ahead of print | PMID: 33848199
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Abstract

Sex and Racial Differences in Autopsy-Defined Causes of Presumed Sudden Cardiac Death.

Tseng ZH, Ramakrishna S, Salazar JW, Vittinghoff E, Olgin JE, Moffatt E

Background:
- Sudden cardiac death (SCD) studies report higher incidence in men and Blacks but presume cardiac cause. We sought to identify sex and race differences in rates and causes of presumed SCDs in a prospective postmortem study in San Francisco County. Methods - All incident presumed SCDs meeting World Health Organization definition ages 18-90 were autopsied via active surveillance of consecutive out-of-hospital deaths in the POstmortem Systematic InvesTigation of Sudden Cardiac Death (POST SCD) Study (2/1/2011 - 3/1/2014). Autopsy-defined sudden arrhythmic deaths (SADs) had no extra-cardiac cause or acute heart failure. Results - Among 541 presumed SCDs, 525 (97%) were autopsied; 362 (69%) were male, 110 Asian (21%), 81 Black (15%), 40 Hispanic (8%), 279 White (53%), and 15 Other Race (3%). Adjusted for age and race, women had more non-cardiac causes of presumed SCD, including pulmonary emboli (8% vs. 2%) and neurologic causes (10% vs. 3%, both p<0.01). Of autopsy-defined SAD, men had 3-fold higher rates while women had more primary electrical disease (4% vs. 2%, p=0.02) and non-ischemic causes (53% vs. 39%, p<0.01). Age-adjusted incidence rate ratios were higher for Black women (2.55, p<0.01), and lower for Asian and Hispanic men (0.51 for both, p<0.05) than their White counterparts. Myocardial infarction without obstructive coronary arteries was more common among SADs in Asians than Whites (7% vs. 1%; adjusted p<0.05). Sudden neurologic deaths were more common in Asians, endocrine causes more common in Blacks, and gastrointestinal causes more common in Hispanics than Whites (adjusted p all <0.05).
Conclusions:
- In this countywide postmortem study of presumed SCDs, women had more non-ischemic and non-cardiac causes. Black women had higher rates of autopsy-defined SAD than White women while Asian and Hispanic men had lower rates than White men. These findings have implications for risk stratification and prevention of sudden mortality in women and minority populations.




Circ Arrhythm Electrophysiol: 08 Apr 2021; epub ahead of print
Tseng ZH, Ramakrishna S, Salazar JW, Vittinghoff E, Olgin JE, Moffatt E
Circ Arrhythm Electrophysiol: 08 Apr 2021; epub ahead of print | PMID: 33835824
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Abstract

Radiofrequency vs. Cryoballoon Catheter Ablation for Paroxysmal Atrial Fibrillation: Durability of Pulmonary Vein Isolation and Effect on AF Burden: The RACE-AF Randomized Controlled Trial.

Sørensen SK, Johannessen A, Worck R, Hansen ML, Hansen J

Background:
- Recurrent paroxysmal atrial fibrillation (PAF) after catheter ablation is presumably caused by failure to achieve durable pulmonary vein isolation (PVI). The primary methods of PVI are radiofrequency (RF) and cryoballoon (CRYO) catheter ablation, but these methods have not been directly compared with respect to PVI durability and the effect thereof on AF burden (% of time in AF). Methods - Accordingly, we performed a randomized trial including 98 patients (68% male, 61 [55-67] years) with PAF assigned 1:1 to PVI by contact-force sensing, irrigated RF catheter or second-generation CRYO catheter. Implantable cardiac monitors were inserted ≥1 month before PVI for assessment of AF burden and recurrence, and all patients, irrespective of AF recurrence, underwent a second procedure 4-6 months after PVI to determine PVI durability. Results - In the second procedure, 152/199 (76%) pulmonary veins (PVs) were found durably isolated after RF and 161/200 (81%) after CRYO (NS), corresponding to durable isolation of all veins in 47% of patients in both groups (NS). Median AF burden before PVI was 5.4% (interquartile range: 0.5-13.0%) vs. 4.0% (0.6-18.1%), RF vs. CRYO, and reduced to 0.0% (0.0-0.1%) and 0.0% (0.0-0.5%), respectively - a reduction of 99.9% (92.9-100.0%) and 99.3% (85.9-100.0%) (all NS). AF burden after PVI significantly correlated to the number of durably isolated PVs (p < 0.01), but 9/45 (20%) patients with durable isolation of all veins had recurrence of AF within 4-6 months after PVI (excluding a 3-month blanking period).
Conclusions:
- PVI by RF and CRYO catheter ablation produce similar moderate to high PVI durability. Both treatments lead to marked reductions in AF burden, which is related to the number of durably isolated PVs. However, for one fifth of PAF patients, complete and durable PVI was not sufficient to prevent even short-term AF recurrence.




Circ Arrhythm Electrophysiol: 08 Apr 2021; epub ahead of print
Sørensen SK, Johannessen A, Worck R, Hansen ML, Hansen J
Circ Arrhythm Electrophysiol: 08 Apr 2021; epub ahead of print | PMID: 33835823
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Abstract

The Association of Structural Inequities and Race with out-of-Hospital Sudden Death during the COVID-19 Pandemic.

Mountantonakis SE, Epstein LM, Coleman K, Martinez J, ... Davidson KW, Roswell RO

Background:
- Social influencers of health (SIOH) namely race, ethnicity and structural inequities are known to affect the incidence of out of hospital sudden death (OHSD). We sought to examine the association between SIOH and the incidence of OHSD in the diverse neighborhoods of New York City (NYC) during the first wave of COVID-19 epidemic. Methods - NYC ZIP stratified data on OHSD were obtained from the Fire Department of New York during the first wave of COVID-19 epidemic (March 1 - April 10, 2019) and the same period in 2020. To assess associates of OHSD, ZIP code-specific sociodemographic characteristics for 8,491,238 NYC residents were obtained via the US Census Bureau\'s 2018 American Community Survey and the New York Police Department\'s crime statistics. Results - Between March 1 and April 10, 2020, the number of OHSD rose to 4,334 from 1,112 compared to the year prior. Of the univariate ZIP code level variables evaluated, proportions of: Black race, Hispanic/Latino ethnicity, single parent household, unemployed inhabitants, people completing less than high school education, inhabitants with no health insurance, people financially struggling or living in poverty, percent of non-citizens and population density were associated with increased rates of OHSD within ZIP codes. In multivariable analysis, ZIP codes with higher proportions of inhabitants with less than high school education (p < 0.001) and higher proportions of Black race (p = 0.04) were independent predictors for increases in ZIP code rates of OHSD.
Conclusions:
- Educational attainment and the proportion of Black race in NYC ZIP codes remained independent predictors of increased rates of ZIP code level OHSD during the COVID-19 outbreak even after controlling for 2019 rates. To facilitate health equity, future research should focus on characterizing the impacts of structural inequities while exploring strategies to mitigate their effects.




Circ Arrhythm Electrophysiol: 08 Apr 2021; epub ahead of print
Mountantonakis SE, Epstein LM, Coleman K, Martinez J, ... Davidson KW, Roswell RO
Circ Arrhythm Electrophysiol: 08 Apr 2021; epub ahead of print | PMID: 33835821
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Abstract

Evolving Cardiac Electrical Therapies for Advanced Heart Failure Patients.

Sharif ZI, Galand V, Hucker WJ, Singh JP
Symptomatic heart failure (HF) patients despite optimal medical therapy and advances such as invasive hemodynamic monitoring remain challenging to manage. While cardiac resynchronization therapy remains a highly effective therapy for a subset of HF patients with wide QRS, a majority of symptomatic HF patients are poor candidates for such. Recently, cardiac contractility modulation, neuromodulation based on carotid baroreceptor stimulation, and phrenic nerve stimulation have been approved by the US Food and Drug Administration and are emerging as therapeutic options for symptomatic HF patients. This state-of-the-art review examines the role of these evolving electrical therapies in advanced HF.



Circ Arrhythm Electrophysiol: 30 Mar 2021; 14:e009668
Sharif ZI, Galand V, Hucker WJ, Singh JP
Circ Arrhythm Electrophysiol: 30 Mar 2021; 14:e009668 | PMID: 33858178
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Abstract

Long QT Syndrome 2 PAS Domain Variant Induces hERG1a/1b Subunit Imbalance in Patient-specific iPSC-cardiomyocytes.

Feng L, Zhang J, Lee C, Kim G, ... January CT, Kamp TJ

Background:
- Inherited long QT syndrome type 2 (LQT2) results from variants in the KCNH2 gene encoding the hERG1 potassium channel. Two main isoforms, hERG1a and hERG1b, assemble to form tetrameric channel. The N-terminal Per-Arnt-Sim (PAS) domain, present only on hERG1a subunits, is a hotspot for pathogenic variants, but it is unknown whether PAS domain variants impact hERG1b expression to contribute to the LQT2 phenotype. We aimed to use patient-specific induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) to investigate the pathogenesis of the hERG1a PAS domain variant hERG1-H70R. Methods - Human iPSCs were derived from a LQT2 patient carrying the PAS domain variant hERG1-H70R. CRISPR/Cas9 gene editing produced isogenic control iPSC lines. Differentiated iPSC-CMs were evaluated for their electrophysiology, hERG1a/1b mRNA expression, and hERG1a/1b protein expression. Results - Action potentials from single hERG1-H70R iPSC-CMs were prolonged relative to controls, and voltage clamp studies showed an underlying decrease in IKr with accelerated deactivation. In hERG1-H70R iPSC-CMs, transcription of hERG1a and hERG1b mRNA was unchanged compared to controls based on nascent nuclear transcript analysis, but hERG1b mRNA was significantly increased as was the ratio of hERG1b/hERG1a in mRNA complexes, suggesting post-transcriptional changes. Expression of complex glycosylated hERG1a in hERG1-H70R iPSC-CMs was reduced due to impaired protein trafficking, whereas the expression of the complex glycosylated form of hERG1b was unchanged.
Conclusions:
- Patient-specific hERG1-H70R iPSC-CMs reveal a newly appreciated mechanism of pathogenesis of the LQT2 phenotype due to both impaired trafficking of hERG1a and maintained expression of hERG1b that produces subunit imbalance and reduced IKr with accelerated deactivation.




Circ Arrhythm Electrophysiol: 16 Mar 2021; epub ahead of print
Feng L, Zhang J, Lee C, Kim G, ... January CT, Kamp TJ
Circ Arrhythm Electrophysiol: 16 Mar 2021; epub ahead of print | PMID: 33729832
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Abstract

In Vitro Cell Selectivity of Reversible and Irreversible Electroporation in Cardiac Tissue.

Hunter DW, Kostecki G, Fish JM, Jensen JA, Tandri H

Background:
- Pulmonary vein isolation (PVI) is a common catheter ablation technique used to treat atrial fibrillation originating from the pulmonary veins. However, incomplete lesion formation, pulmonary vein reconnection, and collateral damage to the phrenic nerve and esophagus can occur. Electroporation is a new modality to ablate and has the potential for permanent PVI and selective efficacy on cardiac tissue, however strong evidence of selective myocardial injury using electroporation is lacking. Methods - Monolayers of neonatal rat ventricular cardiomyocytes (NRVM), rat cortical neurons (RCN), and esophageal smooth muscle cells (SMC) were stained with propidium iodide to measure shock-induced cell death. Biphasic shocks (10 ms) were delivered from line electrodes (1 mm separation). NRVMs were optically mapped to evaluate post-electroporation electrical conduction. Results - Conduction block occurred when 50-80% of the cells near the electrode were killed, and required 400 & 50 V/cm with the electrodes in contact vs. 690 & 70 V/cm with the electrodes 1 mm above the cells (p<0.01). For 400 V/cm shocks applied in contact with cells, NRVM cultures yielded the highest degree of cell death (~60%) compared to RCN (~40%) and SMCs (~20%). When the electrode was raised 1 mm SMCs were nearly unaffected by the shock.
Conclusions:
- Cell type alone yielded selective efficacy to electroporation without the confounding influences present in clinical studies, but electrode proximity to the target tissue remains important for efficacy. This exciting result suggests that electroporation may be a more selective modality for PVI.




Circ Arrhythm Electrophysiol: 16 Mar 2021; epub ahead of print
Hunter DW, Kostecki G, Fish JM, Jensen JA, Tandri H
Circ Arrhythm Electrophysiol: 16 Mar 2021; epub ahead of print | PMID: 33729827
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Abstract

Patterns of Care for Atrial Fibrillation Before, During, and at Discharge from Hospitalization: From the Get with The Guidelines - Atrial Fibrillation Registry.

Desai NR, Sciria CT, Zhao X, Piccini JP, ... Fonarow GC, Lewis WR

Background:
- Atrial fibrillation (AF) is the most common arrhythmia encountered in the hospital. However, contemporary treatment of patients hospitalized with AF, including stroke prevention, switching between these therapies, and rhythm control interventions are not well studied. We aimed to examine trends in inpatient interventions for AF, including switching oral anticoagulation [warfarin to direct oral anticoagulants (DOACs)], cardioversion, catheter ablation, and amiodarone use in hospitalized patients with AF. Methods - Using data from the Get With The Guidelines - AFIB (GWTG-AFIB) registry from the American Heart Association (AHA), we analyzed patterns of medication and procedure use among hospitalized patients with AF from January 3, 2013 to March 28, 2017. To identify significant predictors of switching, multivariable hierarchical regression models were developed with patient baseline characteristics and comorbidities. Results - Among 31,280 patients with AF from 97 participating hospitals, 47.1% were on anticoagulation at presentation (6,695 warfarin, 7,393 DOAC) and the majority were continued at discharge (91.1%). Of those who were not receiving anticoagulation prior to hospitalization, 60.6% started anticoagulation at discharge (25.0% warfarin and 75.0% DOAC). The prevalence of switching from warfarin to DOAC was 4.0% and was more likely with younger age and lower CHA2DS2-VASc. Among 28,143 patients (excluding those discharged from the emergency department or observation status), 32.0% underwent cardioversion (56.1% chemically-assisted and 49.4% electrical), 6.4% AF ablation, and 1.0% left atrial appendage occlusion device implantation. Patients of white race, younger age, and lower CHA2DS2-VASc were significantly more likely to undergo cardioversion or AF ablation, while older patients with higher CHA2DS2-VASc were significantly more likely to be initiated on amiodarone.
Conclusions:
- Despite guideline recommendations prioritizing DOAC therapy, there are relatively low rates of switching from warfarin to DOAC in patients hospitalized with AF. Moreover, there is substantial variation in switching and utilization of rhythm control strategies, highlighting opportunities for performance improvement.




Circ Arrhythm Electrophysiol: 15 Mar 2021; epub ahead of print
Desai NR, Sciria CT, Zhao X, Piccini JP, ... Fonarow GC, Lewis WR
Circ Arrhythm Electrophysiol: 15 Mar 2021; epub ahead of print | PMID: 33724875
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Abstract

Immuno-Electrophysiological Mechanisms of Functional Electrical Connections Between Recipient and Donor Heart in Patients with Orthotopic Heart Transplantation Presenting with Atrial Arrhythmias.

Herweg B, Nellaiyappan M, Welter-Frost AM, Tran T, ... Noujaim SF, Weston MW

Background:
- The formation of recipient-to donor atrio-atrial connections (AAC) in patients after orthotopic heart transplantation (OHT) is poorly understood. We sought to investigate the mechanisms of atrial tachyarrhythmias after OHT, the role of AACs, and their relationship to the immunological match. Methods - In a large series of OHT patients we performed a retrospective review of 42 patients who underwent catheter ablation for atrial arrhythmias. A realistic 3D computer model of human atria was used to study AAC conductivity. Results - Patient age was 55±15 years (71% male). 24/42 patients (57%) had bi-atrial anastomosis. An AAC was found in 9/42 patients (21%, right-sided in 5 patients with bi-atrial anastomosis, left-sided in 4 patients). The AAC became apparent at the time of the electrophysiology study 10.1±7.6 years after OHT (range 0.3-22.2 years). Donor-specific antibodies (DSAB) were present in no patient with AAC, but were present in 69% of patients without AAC, p=0.002. In all patients with AAC, a recipient atrial tachycardia propagated via AAC to the donor atrium (4 patients presented with atrial fibrillation). Simulations showed AAC conduction requires an isthmus of ≥2 mm and is cycle length (CL) and location dependent. Patients without AAC (n=13) frequently presented with donor atrial arrhythmias, in 77% cavo-tricuspid isthmus (CTI) flutter was ablated. The procedural success was high, although, 12 patients (29%) required re-ablation.
Conclusions:
- AACs are found in 21% of OHT patients with atrial tachyarrhythmias and can manifest very early after OHT. Immune privilege characterized by the absence of DSAB may facilitate AAC formation. Propagation across an AAC is width, CL and location dependent. Patients with AAC present with focal atrial tachycardias or atrial fibrillation originating from the recipient atria; patients without most frequently present with CTI dependent atrial flutter. While multiple arrhythmias frequently require re-ablation, ablative therapy is highly effective.




Circ Arrhythm Electrophysiol: 15 Mar 2021; epub ahead of print
Herweg B, Nellaiyappan M, Welter-Frost AM, Tran T, ... Noujaim SF, Weston MW
Circ Arrhythm Electrophysiol: 15 Mar 2021; epub ahead of print | PMID: 33724864
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Abstract

Posterior Left Atrial Adipose Tissue Attenuation Assessed by Computed Tomography and Recurrence of Atrial Fibrillation after Catheter Ablation.

El Mahdiui M, Simon J, Smit JM, Kuneman JH, ... Bax JJ, Maurovich-Horvat P

Background:
- Atrial fibrillation (AF) recurrence following catheter ablation remains high. Recent studies have shown a relation between epicardial adipose tissue (EAT) and AF. EAT secretes several pro- and anti-inflammatory adipokines that directly interact with the adjacent myocardium. The aim of the current study was to evaluate whether posterior left atrial (LA) adipose tissue attenuation, as marker of inflammation, is related to AF recurrences after catheter ablation. Methods - Consecutive patients with symptomatic AF referred for first AF catheter ablation who underwent CT were included. The total EAT and posterior LA adipose tissue were manually traced and adipose tissue was automatically recognized as tissue with Hounsfield units (HU) between -195 and -45. The attenuation value of the posterior LA adipose tissue was assessed and the population divided according to the mean HU value (-96.4 HU). Results - In total, 460 patients (66% male, age 61 ± 10 years) were included in the analysis. After a median follow-up of 18 months (IQR 6-32), 168 (37%) patients had AF recurrence. Patients with higher attenuation (≥-96.4 HU) of the posterior LA adipose tissue showed higher AF recurrence rates compared to patients with lower attenuation (<-96.4 HU) (log-rank test p=0.046). Univariate analysis showed an association between AF recurrence and higher posterior LA adipose tissue attenuation (≥-96.4 HU) (p<0.05). On multivariable analysis posterior LA adipose tissue attenuation (HR 1.26; 95% CI 0.90-1.76; p=0.181) remained a promising predictor of AF recurrence following catheter ablation.
Conclusions:
- Posterior LA adipose tissue attenuation is a promising predictor of AF recurrence in patients who undergo catheter ablation. Higher adipose tissue attenuation might signal increased local inflammation and serve as an imaging biomarker of increased risk of AF recurrence.




Circ Arrhythm Electrophysiol: 14 Mar 2021; epub ahead of print
El Mahdiui M, Simon J, Smit JM, Kuneman JH, ... Bax JJ, Maurovich-Horvat P
Circ Arrhythm Electrophysiol: 14 Mar 2021; epub ahead of print | PMID: 33720759
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Abstract

Management of Arrhythmias After Heart Transplant: Current State and Considerations for Future Research.

Joglar JA, Wan EY, Chung MK, Gutierrez A, ... Dhingra R, Gopinathannair R
Orthotropic heart transplantation remains the most effective therapy for patients with end-stage heart failure, with a median survival of ≈13 years. Yet, a number of complications are observed after orthotropic heart transplantation, including atrial and ventricular arrhythmias. Several factors contribute to arrhythmias, such as autonomic denervation, effect of the surgical technique, acute and chronic rejection, and transplant vasculopathy among others. To minimize risk of future arrhythmias, the bicaval technique and minimizing ischemic time are current surgical standards. Sinus node dysfunction is the most common indication for early (within 30 days) pacemaker implantation, whereas atrioventricular block incidence increases as time from transplant increases. Atrial fibrillation can occur in the first few weeks following transplantation but is uncommon in the long term unless secondary to a precipitant such as acute rejection. The most common atrial arrhythmias are atrial flutters, which are mainly typical, but atypical circuits can be observed such as those that involve the remnant donor atrium in regions immediately adjacent to the atrioatrial anastomosis suture line. Choosing the appropriate pharmacological therapy requires careful consideration due to the potential interaction with immunosuppressive agents. Despite historical concerns, adenosine is effective and safe at reduced doses if administered under cardiac monitoring. Catheter ablation has emerged as an effective treatment strategy for symptomatic supraventricular tachycardias, including ablation of atypical flutter circuits. Cardiac allograft vasculopathy is an important risk factor for sudden cardiac death, yet the role of prophylactic implantable cardioverter-defibrillator implant for sudden death prevention is unclear. Current indications for implantable cardioverter-defibrillator implantation are as in the nontransplant population. A number of questions for future research are posed.



Circ Arrhythm Electrophysiol: 27 Feb 2021; 14:e007954
Joglar JA, Wan EY, Chung MK, Gutierrez A, ... Dhingra R, Gopinathannair R
Circ Arrhythm Electrophysiol: 27 Feb 2021; 14:e007954 | PMID: 33685207
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Impact:

This program is still in alpha version.