Topic: Electrophysiology

Abstract

Rivaroxaban in Patients with Atrial Fibrillation and a Bioprosthetic Mitral Valve.

Guimarães HP, Lopes RD, de Barros E Silva PGM, Liporace IL, ... Berwanger O,
Background
The effects of rivaroxaban in patients with atrial fibrillation and a bioprosthetic mitral valve remain uncertain.
Methods
In this randomized trial, we compared rivaroxaban (20 mg once daily) with dose-adjusted warfarin (target international normalized ratio, 2.0 to 3.0) in patients with atrial fibrillation and a bioprosthetic mitral valve. The primary outcome was a composite of death, major cardiovascular events (stroke, transient ischemic attack, systemic embolism, valve thrombosis, or hospitalization for heart failure), or major bleeding at 12 months.
Results
A total of 1005 patients were enrolled at 49 sites in Brazil. A primary-outcome event occurred at a mean of 347.5 days in the rivaroxaban group and 340.1 days in the warfarin group (difference calculated as restricted mean survival time, 7.4 days; 95% confidence interval [CI], -1.4 to 16.3; P<0.001 for noninferiority). Death from cardiovascular causes or thromboembolic events occurred in 17 patients (3.4%) in the rivaroxaban group and in 26 (5.1%) in the warfarin group (hazard ratio, 0.65; 95% CI, 0.35 to 1.20). The incidence of stroke was 0.6% in the rivaroxaban group and 2.4% in the warfarin group (hazard ratio, 0.25; 95% CI, 0.07 to 0.88). Major bleeding occurred in 7 patients (1.4%) in the rivaroxaban group and in 13 (2.6%) in the warfarin group (hazard ratio, 0.54; 95% CI, 0.21 to 1.35). The frequency of other serious adverse events was similar in the two groups.
Conclusions
In patients with atrial fibrillation and a bioprosthetic mitral valve, rivaroxaban was noninferior to warfarin with respect to the mean time until the primary outcome of death, major cardiovascular events, or major bleeding at 12 months. (Funded by PROADI-SUS and Bayer; RIVER ClinicalTrials.gov number, NCT02303795.).

Copyright © 2020 Massachusetts Medical Society.

N Engl J Med: 13 Nov 2020; epub ahead of print
Guimarães HP, Lopes RD, de Barros E Silva PGM, Liporace IL, ... Berwanger O,
N Engl J Med: 13 Nov 2020; epub ahead of print | PMID: 33196155
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Abstract

Chronic obstructive pulmonary disease and atrial fibrillation: an interdisciplinary perspective.

Simons SO, Elliott A, Sastry M, Hendriks JM, ... Crijns HJGM, Linz D

Chronic obstructive pulmonary disease (COPD) is highly prevalent among patients with atrial fibrillation (AF), shares common risk factors, and adds to the overall morbidity and mortality in this population. Additionally, it may promote AF and impair treatment efficacy. The prevalence of COPD in AF patients is high and is estimated to be ∼25%. Diagnosis and treatment of COPD in AF patients requires a close interdisciplinary collaboration between the electrophysiologist/cardiologist and pulmonologist. Differential diagnosis may be challenging, especially in elderly and smoking patients complaining of unspecific symptoms such as dyspnoea and fatigue. Routine evaluation of lung function and determination of natriuretic peptides and echocardiography may be reasonable to detect COPD and heart failure as contributing causes of dyspnoea. Acute exacerbation of COPD transiently increases AF risk due to hypoxia-mediated mechanisms, inflammation, increased use of beta-2 agonists, and autonomic changes. Observational data suggest that COPD promotes AF progression, increases AF recurrence after cardioversion, and reduces the efficacy of catheter-based antiarrhythmic therapy. However, it remains unclear whether treatment of COPD improves AF outcomes and which metric should be used to determine COPD severity and guide treatment in AF patients. Data from non-randomized studies suggest that COPD is associated with increased AF recurrence after electrical cardioversion and catheter ablation. Future prospective cohort studies in AF patients are needed to confirm the relationship between COPD and AF, the benefits of treatment of either COPD or AF in this population, and to clarify the need and cost-effectiveness of routine COPD screening.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J: 17 Nov 2020; epub ahead of print
Simons SO, Elliott A, Sastry M, Hendriks JM, ... Crijns HJGM, Linz D
Eur Heart J: 17 Nov 2020; epub ahead of print | PMID: 33206945
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Abstract

Cryoablation or Drug Therapy for Initial Treatment of Atrial Fibrillation.

Andrade JG, Wells GA, Deyell MW, Bennett M, ... Verma A,
Background
Guidelines recommend a trial of one or more antiarrhythmic drugs before catheter ablation is considered in patients with atrial fibrillation. However, first-line ablation may be more effective in maintaining sinus rhythm.
Methods
We randomly assigned 303 patients with symptomatic, paroxysmal, untreated atrial fibrillation to undergo catheter ablation with a cryothermy balloon or to receive antiarrhythmic drug therapy for initial rhythm control. All the patients received an implantable cardiac monitoring device to detect atrial tachyarrhythmia. The follow-up period was 12 months. The primary end point was the first documented recurrence of any atrial tachyarrhythmia (atrial fibrillation, atrial flutter, or atrial tachycardia) between 91 and 365 days after catheter ablation or the initiation of an antiarrhythmic drug. The secondary end points included freedom from symptomatic arrhythmia, the atrial fibrillation burden, and quality of life.
Results
At 1 year, a recurrence of atrial tachyarrhythmia had occurred in 66 of 154 patients (42.9%) assigned to undergo ablation and in 101 of 149 patients (67.8%) assigned to receive antiarrhythmic drugs (hazard ratio, 0.48; 95% confidence interval [CI], 0.35 to 0.66; P<0.001). Symptomatic atrial tachyarrhythmia had recurred in 11.0% of the patients who underwent ablation and in 26.2% of those who received antiarrhythmic drugs (hazard ratio, 0.39; 95% CI, 0.22 to 0.68). The median percentage of time in atrial fibrillation was 0% (interquartile range, 0 to 0.08) with ablation and 0.13% (interquartile range, 0 to 1.60) with antiarrhythmic drugs. Serious adverse events occurred in 5 patients (3.2%) who underwent ablation and in 6 patients (4.0%) who received antiarrhythmic drugs.
Conclusions
Among patients receiving initial treatment for symptomatic, paroxysmal atrial fibrillation, there was a significantly lower rate of atrial fibrillation recurrence with catheter cryoballoon ablation than with antiarrhythmic drug therapy, as assessed by continuous cardiac rhythm monitoring. (Funded by the Cardiac Arrhythmia Network of Canada and others; EARLY-AF ClinicalTrials.gov number, NCT02825979.).

Copyright © 2020 Massachusetts Medical Society.

N Engl J Med: 15 Nov 2020; epub ahead of print
Andrade JG, Wells GA, Deyell MW, Bennett M, ... Verma A,
N Engl J Med: 15 Nov 2020; epub ahead of print | PMID: 33197159
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Abstract

Cryoballoon Ablation as Initial Therapy for Atrial Fibrillation.

Wazni OM, Dandamudi G, Sood N, Hoyt R, ... Nissen SE,
Background
In patients with symptomatic paroxysmal atrial fibrillation that has not responded to medication, catheter ablation is more effective than antiarrhythmic drug therapy for maintaining sinus rhythm. However, the safety and efficacy of cryoballoon ablation as initial first-line therapy have not been established.
Methods
We performed a multicenter trial in which patients 18 to 80 years of age who had paroxysmal atrial fibrillation for which they had not previously received rhythm-control therapy were randomly assigned (1:1) to receive treatment with antiarrhythmic drugs (class I or III agents) or pulmonary vein isolation with a cryoballoon. Arrhythmia monitoring included 12-lead electrocardiography conducted at baseline and at 1, 3, 6, and 12 months; patient-activated telephone monitoring conducted weekly and when symptoms were present during months 3 through 12; and 24-hour ambulatory monitoring conducted at 6 and 12 months. The primary efficacy end point was treatment success (defined as freedom from initial failure of the procedure or atrial arrhythmia recurrence after a 90-day blanking period to allow recovery from the procedure or drug dose adjustment, evaluated in a Kaplan-Meier analysis). The primary safety end point was assessed in the ablation group only and was a composite of several procedure-related and cryoballoon system-related serious adverse events.
Results
Of the 203 participants who underwent randomization and received treatment, 104 underwent ablation, and 99 initially received drug therapy. In the ablation group, initial success of the procedure was achieved in 97% of patients. The Kaplan-Meier estimate of the percentage of patients with treatment success at 12 months was 74.6% (95% confidence interval [CI], 65.0 to 82.0) in the ablation group and 45.0% (95% CI, 34.6 to 54.7) in the drug-therapy group (P<0.001 by log-rank test). Two primary safety end-point events occurred in the ablation group (Kaplan-Meier estimate of the percentage of patients with an event within 12 months, 1.9%; 95% CI, 0.5 to 7.5).
Conclusions
Cryoballoon ablation as initial therapy was superior to drug therapy for the prevention of atrial arrhythmia recurrence in patients with paroxysmal atrial fibrillation. Serious procedure-related adverse events were uncommon. (Supported by Medtronic; STOP AF First ClinicalTrials.gov number, NCT03118518.).

Copyright © 2020 Massachusetts Medical Society.

N Engl J Med: 15 Nov 2020; epub ahead of print
Wazni OM, Dandamudi G, Sood N, Hoyt R, ... Nissen SE,
N Engl J Med: 15 Nov 2020; epub ahead of print | PMID: 33197158
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Abstract

Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.

Yannopoulos D, Bartos J, Raveendran G, Walser E, ... Tolar J, Aufderheide TP
Background
Among patients with out-of-hospital cardiac arrest (OHCA) and ventricular fibrillation, more than half present with refractory ventricular fibrillation unresponsive to initial standard advanced cardiac life support (ACLS) treatment. We did the first randomised clinical trial in the USA of extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation versus standard ACLS treatment in patients with OHCA and refractory ventricular fibrillation.
Methods
For this phase 2, single centre, open-label, adaptive, safety and efficacy randomised clinical trial, we included adults aged 18-75 years presenting to the University of Minnesota Medical Center (MN, USA) with OHCA and refractory ventricular fibrillation, no return of spontaneous circulation after three shocks, automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System, and estimated transfer time shorter than 30 min. Patients were randomly assigned to early ECMO-facilitated resuscitation or standard ACLS treatment on hospital arrival by use of a secure schedule generated with permuted blocks of randomly varying block sizes. Allocation concealment was achieved by use of a randomisation schedule that required scratching off an opaque layer to reveal assignment. The primary outcome was survival to hospital discharge. Secondary outcomes were safety, survival, and functional assessment at hospital discharge and at 3 months and 6 months after discharge. All analyses were done on an intention-to-treat basis. The study qualified for exception from informed consent (21 Code of Federal Regulations 50.24). The ARREST trial is registered with ClinicalTrials.gov, NCT03880565.
Findings
Between Aug 8, 2019, and June 14, 2020, 36 patients were assessed for inclusion. After exclusion of six patients, 30 were randomly assigned to standard ACLS treatment (n=15) or to early ECMO-facilitated resuscitation (n=15). One patient in the ECMO-facilitated resuscitation group withdrew from the study before discharge. The mean age was 59 years (range 36-73), and 25 (83%) of 30 patients were men. Survival to hospital discharge was observed in one (7%) of 15 patients (95% credible interval 1·6-30·2) in the standard ACLS treatment group versus six (43%) of 14 patients (21·3-67·7) in the early ECMO-facilitated resuscitation group (risk difference 36·2%, 3·7-59·2; posterior probability of ECMO superiority 0·9861). The study was terminated at the first preplanned interim analysis by the National Heart, Lung, and Blood Institute after unanimous recommendation from the Data Safety Monitoring Board after enrolling 30 patients because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Cumulative 6-month survival was significantly better in the early ECMO group than in the standard ACLS group. No unanticipated serious adverse events were observed.
Interpretation
Early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation significantly improved survival to hospital discharge compared with standard ACLS treatment.
Funding
National Heart, Lung, and Blood Institute.

Copyright © 2020 Elsevier Ltd. All rights reserved.

Lancet: 11 Nov 2020; epub ahead of print
Yannopoulos D, Bartos J, Raveendran G, Walser E, ... Tolar J, Aufderheide TP
Lancet: 11 Nov 2020; epub ahead of print | PMID: 33197396
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Abstract

Platelets Promote Ang II (Angiotensin II)-Induced Atrial Fibrillation by Releasing TGF-β1 (Transforming Growth Factor-β1) and Interacting With Fibroblasts.

Liu Y, Lv H, Tan R, An X, ... Yin X, Xia YL

Hypertension is a risk factor of atrial fibrillation (AF), and a certain number of patients with hypertension were found with an enlarged left atrium. Platelet activation is found in patients with hypertension or pressure overload/Ang II (angiotensin II)-induced hypertensive animal models and contribute to ventricular fibrosis. Whether hypertension-induced atrial fibrosis is mediated by platelets remains unknown. Our previous experimental data showed that platelet-derived TGF-β1 (transforming growth factor-β1) was reduced in patients with hypertensive AF. The present study is to investigate whether platelet-derived TGF-β1 promotes Ang II-induced atrial fibrosis and AF. Platelet activation and atrial platelet accumulation were measured in sinus rhythm controls, normotensive AF, and patients with hypertensive AF. Ang II (1500 ng/kg per minute, 3 weeks) infused mice with pharmacological (clopidogrel) and genetic platelet inhibition (TGF-β1 deletion in platelets) were used. Platelet activation, atrial structural remodeling, atrial electrical transmission, AF inducibility, inflammation, and fibrosis were measured in mice. We found that circulating platelets were activated in patients with hypertensive AF. A large amount of platelet was accumulated in the atriums of patients with hypertensive AF. Both clopidogrel treatment and platelet-specific deletion of TGF-β1 attenuated Ang II-induced structural remodeling, atrial electrical transmission, AF inducibility, as well as atrial inflammation and fibrosis than mice without interventions. Furthermore, clopidogrel blocked atrial platelet accumulation and platelet-fibroblast conjugation. Platelets promoted atrial fibroblast differentiation in cell culture. Profibrotic actions of platelets are largely via activation of atrial fibroblasts by releasing TGF-β1 and inducing platelet-fibroblast conjugation, and platelet inhibition is sufficient to inhibit atrial fibrosis and AF inducibility.



Hypertension: 29 Nov 2020; 76:1856-1867
Liu Y, Lv H, Tan R, An X, ... Yin X, Xia YL
Hypertension: 29 Nov 2020; 76:1856-1867 | PMID: 33175633
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Abstract

Associations of symptoms and quality of life with outcomes in patients with atrial fibrillation.

Krisai P, Blum S, Aeschbacher S, Beer JH, ... Conen D,
Objective
We aimed to investigate changes in atrial fibrillation (AF)-related symptoms and quality of life (QoL) over time, and their impact on prognosis.
Methods
We prospectively followed 3836 patients with known AF for a mean of 3.7 years. Information on AF-related symptoms and QoL was obtained yearly. The primary end point was a composite of stroke or systemic embolism. Main secondary end points included stroke subtypes, all-cause mortality, cardiovascular death, hospitalisation for congestive heart failure (CHF), myocardial infarction and major bleeding. We assessed associations using multivariable, time-updated Cox proportional hazards models.
Results
Mean age was 72 years, 72% were male. Patients with AF-related symptoms (66%) were younger (70 vs 74 years, p<0.0001), more often had paroxysmal AF (56% vs 37%, p<0.0001) and had lower QoL (71 vs 72 points, p=0.009). The incidence of the primary end point was 1.05 and 1.02 per 100 person-years in patients with and without symptoms, respectively. The multivariable adjusted HR (aHR) (95% CIs) for the primary end point was 1.11 (0.77 to 1.59; p=0.56) for AF-related symptoms. AF-related symptoms were not associated with any of the secondary end points. QoL was not significantly related to the primary end point (aHR per 5-point increase 0.98 (0.94 to 1.03; p=0.37)), but was significantly related to CHF hospitalisations (0.92 (0.90 to 0.94; p<0.0001)), cardiovascular death (0.90 (0.86 to 0.95; p<0.0001)) and all-cause mortality (0.88 (0.86 to 0.90; p<0.0001)).
Conclusions
AF-related symptoms were not associated with adverse outcomes and should therefore not be the basis for prognostic treatment decisions. QoL was strongly associated with CHF, cardiovascular death and all-cause mortality.

© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 29 Nov 2020; 106:1847-1852
Krisai P, Blum S, Aeschbacher S, Beer JH, ... Conen D,
Heart: 29 Nov 2020; 106:1847-1852 | PMID: 32234819
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Abstract

Prognostic significance of natriuretic peptide levels in atrial fibrillation without heart failure.

Hamatani Y, Iguchi M, Ueno K, Aono Y, ... Morita S, Akao M
Objectives
Natriuretic peptides are an important prognostic marker in patients with heart failure (HF). However, little is known regarding their prognostic significance in patients with atrial fibrillation (AF) without HF and natriuretic peptides levels are underused in these patients in daily practice.
Methods
The Fushimi AF Registry is a community-based prospective survey of patients with AF in Fushimi-ku, Kyoto, Japan. We investigated patients with AF without HF (defined as prior HF hospitalisation, New York Heart Association functional class≥2 or left ventricular ejection fraction<40%) using the data of B-type natriuretic peptide (BNP, n=388) or N-terminal pro-B-type natriuretic peptide (NT-proBNP, n=771) at enrolment. BNPs were converted to NT-proBNP using a conversion formula. We divided the patients according to quartiles of NT-proBNP levels and compared the backgrounds and outcomes.
Results
Of 1159 patients (mean age: 72.1±10.2 years, median CHADS-VASc score: 3 and oral anticoagulant (OAC) prescription: 671 (56%)), the median NT-proBNP level was 488 (IQR 169-1015) ng/L. Patients with high NT-proBNP levels were older, had higher CHADS-VASc scores and had more OAC prescription (all p<0.001). Kaplan-Meier curves demonstrated that NT-proBNP levels were significantly associated with higher incidences of stroke/systemic embolism, all-cause death and HF hospitalisation during a median follow-up period of 5.0 years (log rank, all p<0.001). Multivariable Cox regression analyses revealed that NT-proBNP levels were an independent predictor of adverse outcomes even after adjustment by various confounders.
Conclusion
NT-proBNP levels are a significant prognostic marker for adverse outcomes in patients with AF without HF and may have clinical value.
Trial registration number
UMIN000005834.

© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 19 Nov 2020; epub ahead of print
Hamatani Y, Iguchi M, Ueno K, Aono Y, ... Morita S, Akao M
Heart: 19 Nov 2020; epub ahead of print | PMID: 33219109
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Abstract

Left Atrial Appendage Thrombus Detected During Hyperacute Stroke Imaging Is Associated With Atrial Fibrillation.

Senadeera SC, Palmer DG, Keenan R, Beharry J, ... Lim A, Wu TY
Background and purpose
Left atrial appendage (LAA) is the likely embolic source in atrial fibrillation (AF)-related cardioembolic strokes. We sought to determine the prevalence of LAA thrombus on hyperacute stroke imaging and its association with AF.
Methods
We retrospectively examined the clinical and radiological features of patients assessed through the hyperacute stroke imaging pathway over a 12-month period at Christchurch Hospital. The LAA was included in the computed tomography angiogram scan-range as part of the multimodal imaging protocol. Two radiological readers blinded to clinical information independently assessed for the presence of LAA thrombus. The association between AF and LAA thrombus was determined by multivariable logistic regression analysis.
Results
Of 303 patients included in the analysis, the overall prevalence of LAA thrombus was 6.6% and 14.9% in patients with known AF. Patients with LAA thrombus were older (85 versus 75 years, <0.01), more commonly had known or newly diagnosed AF (75% versus 30%, <0.01) and heart failure (30% versus 8%, =0.01), and was associated with intracranial large vessel occlusion (65% versus 39%, =0.02). In the multivariable model, AF (odds ratio, 3.71 [95% CI, 1.25-11.01] =0.02) was independently associated with LAA thrombus after adjusting for age and congestive heart failure. Inter-rater reliability was moderate (kappa=0.56).
Conclusions
LAA thrombus is a potential radiological marker of AF and can be assessed as a part of hyperacute stroke imaging.



Stroke: 08 Nov 2020:STROKEAHA120030258; epub ahead of print
Senadeera SC, Palmer DG, Keenan R, Beharry J, ... Lim A, Wu TY
Stroke: 08 Nov 2020:STROKEAHA120030258; epub ahead of print | PMID: 33161849
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Abstract

Bleeding risk with rivaroxaban compared with vitamin K antagonists in patients aged 80 years or older with atrial fibrillation.

Hanon O, Vidal JS, Pisica-Donose G, Orvoën G, ... Boureau AS,
Objective
Direct oral anticoagulants have been evaluated in the general population, but proper evidence for their safe use in the geriatric population is still missing. We compared the bleeding risk of a direct oral anticoagulant (rivaroxaban) and vitamin K antagonists (VKAs) among French geriatric patients with non-valvular atrial fibrillation (AF) aged ≥80 years.
Methods
We performed a sequential observational prospective cohort study, using data from 33 geriatric centres. The sample comprised 908 patients newly initiated on VKAs between September 2011 and September 2014 and 995 patients newly initiated on rivaroxaban between September 2014 and September 2017. Patients were followed up for up to 12 months. One-year risks of major, intracerebral, gastrointestinal bleedings, ischaemic stroke and all-cause mortality were compared between rivaroxaban-treated and VKA-treated patients with propensity score matching and Cox models.
Results
Major bleeding risk was significantly lower in rivaroxaban-treated patients (7.4/100 patient-years) compared with VKA-treated patients (14.6/100 patient-years) after multivariate adjustment (HR 0.66; 95% CI 0.43 to 0.99) and in the propensity score-matched sample (HR 0.53; 95% CI 0.33 to 0.85). Intracerebral bleeding occurred less frequently in rivaroxaban-treated patients (1.3/100 patient-years) than in VKA-treated patients (4.0/100 patient-years), adjusted HR 0.59 (95% CI 0.24 to 1.44) and in the propensity score-matched sample HR 0.26 (95% CI 0.09 to 0.80). Major lower bleeding risk was largely driven by lower risk of intracerebral bleeding.
Conclusions
Our study findings indicate that bleeding risk, largely driven by lower risk of intracerebral bleeding, is lower with rivaroxaban than with VKA in stroke prevention in patients ≥80 years old with non-valvular AF.

© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Nov 2020; epub ahead of print
Hanon O, Vidal JS, Pisica-Donose G, Orvoën G, ... Boureau AS,
Heart: 30 Nov 2020; epub ahead of print | PMID: 33262185
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Abstract

Risk of Ischemic Stroke in Patients With Atrial Fibrillation After Extracranial Hemorrhage.

Zhou E, Lord A, Boehme A, Henninger N, ... Elkind MSV, Yaghi S
Background and purpose
Anticoagulation therapy not only reduces the risk of ischemic stroke in atrial fibrillation (AF) but also predisposes patients to hemorrhagic complications. There is limited knowledge on the risk of first-ever ischemic stroke in patients with AF after extracranial hemorrhage (ECH).
Methods
We conducted a retrospective study using the California State Inpatient Database including all nonfederal hospital admissions in California from 2005 to 2011. The exposure variable was hospitalization with a diagnosis of ECH with a previous diagnosis of AF. The outcome variable was a subsequent hospitalization with acute ischemic stroke. We excluded patients with stroke before or at the time of ECH diagnosis. We calculated adjusted hazard ratios for ischemic stroke during follow-up and at 6-month intervals using Cox regression models adjusted for pertinent demographics and comorbidities. In subgroup analyses, subjects were stratified by primary ECH diagnosis, severity/type of ECH, age, CHADS-VASc score, or the presence/absence of a gastrointestinal or genitourinary cancer.
Results
We identified 764 257 patients with AF (mean age 75 years, 49% women) without a documented history of stroke. Of these, 98 647 (13%) had an ECH-associated hospitalization, and 22 748 patients (3%) developed an ischemic stroke during the study period. Compared to patients without ECH, subjects with ECH had ≈15% higher rate of ischemic stroke (overall adjusted hazard ratio, 1.15 [95% CI, 1.11-1.19]). The risk appeared to remain elevated for at least 18 months after the index ECH. In subgroup analyses, the risk was highest in subjects with a primary admission diagnosis of ECH, severe ECH, gastrointestinal-type ECH, with gastrointestinal or genitourinary cancer, and age ≥60 years.
Conclusions
Patients with AF hospitalized with ECH may have a slightly elevated risk for future ischemic stroke. Particular consideration should be given to the optimal balance between the benefits and risks of anticoagulation therapy and the use of nonanticoagulant alternatives, such as left atrial appendage closure in this vulnerable population.



Stroke: 29 Nov 2020; 51:3592-3599
Zhou E, Lord A, Boehme A, Henninger N, ... Elkind MSV, Yaghi S
Stroke: 29 Nov 2020; 51:3592-3599 | PMID: 33028172
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Abstract

Hybrid Convergent Procedure for the Treatment of Persistent and Long Standing Persistent Atrial Fibrillation: Results of CONVERGE Clinical Trial.

DeLurgio DB, Crossen KJ, Gill J, Blauth C, ... Gilligan DM, Calkins H

- The limited effectiveness of endocardial catheter ablation (CA) for persistent and long-standing persistent atrial fibrillation (Ps/LSP-AF) treatment led to the development of a minimally-invasive epicardial/endocardial ablation approach (Hybrid Convergent) to achieve a more comprehensive lesion set with durable transmural lesions. The multi-center randomized controlled CONVERGE trial (NCT01984346) evaluated the safety of Hybrid Convergent and compared its effectiveness to CA for Ps/LSP-AF treatment.- One-hundred fifty-three patients were randomized 2:1 to Hybrid Convergent vs. CA. Primary effectiveness was freedom from AF/AFL/AT absent new/increased dosage of previously failed/intolerant class I/III anti-arrhythmic drugs (AADs) through 12-months. Primary safety was major adverse events through 30 days. CONVERGE permitted left atrium size up to 6cm and imposed no limits on AF duration, making it the only ablation trial to substantially include LSP-AF i.e. 42% patients with LSP-AF.- Of 149 evaluable patients at 12 months, primary effectiveness was achieved in 67.7% (67/99) patients with Hybrid Convergent and 50.0% (25/50) with CA (p=0.036) on/off previously failed AADs and in 53.5% (53/99) versus 32.0% (16/50) (p=0.0128) respectively off AADs. At 18-months using 7-day Holter, 74.0% (53/72) Hybrid Convergent and 55% (23/42) CA patients experienced ≥90% AF burden reduction. A total of 2.9% (3/102) patients had primary safety events within 7 days, and 4.9% (5/102) between 8-30 days post-procedure. No deaths, cardiac perforations or atrioesophageal fistulas occurred. All but one primary safety event resolved.- The Hybrid Convergent procedure has superior effectiveness compared to the CA for the treatment of Ps/LSP-AF.



Circ Arrhythm Electrophysiol: 12 Nov 2020; epub ahead of print
DeLurgio DB, Crossen KJ, Gill J, Blauth C, ... Gilligan DM, Calkins H
Circ Arrhythm Electrophysiol: 12 Nov 2020; epub ahead of print | PMID: 33185144
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Abstract

Artificial Intelligence-Electrocardiography to Predict Incident Atrial Fibrillation: A Population-Based Study.

Christopoulos G, Graff-Radford J, Lopez CL, Yao X, ... Friedman PA, Noseworthy PA

- An artificial intelligence (AI) algorithm applied to electrocardiography (ECG) during sinus rhythm (SR) has recently been shown to detect concurrent episodic atrial fibrillation (AF). We sought to characterize the value of AI-ECG as a predictor of future AF and assess its performance compared to the CHARGE-AF score in a population-based sample.- We calculated the probability of AF using AI-ECG, among participants in the population-based Mayo Clinic Study of Aging who had no history of AF at the time of the baseline study visit. Cox proportional hazards models were fit to assess the independent prognostic value and interaction between AI-ECG AF model output and CHARGE-AF score. Concordance (C) statistics were calculated for AI-ECG AF model output, CHARGE-AF score and combined AI-ECG and CHARGE-AF score.- A total of 1,936 participants with median age 75.8 (interquartile range [IQR] 70.4, 81.8) years and median CHARGE-AF score 14.0 (IQR 13.2, 14.7) were included in the analysis. Participants with AI-ECG AF model output of >0.5 at the baseline visit had cumulative incidence of AF 21.5% at 2 years and 52.2% at 10 years. When included in the same model, both AI-ECG AF model output (hazard ratio [HR] 1.76 per standard deviation (SD) after logit transformation, 95% confidence interval [CI] 1.51, 2.04) and CHARGE-AF score (HR 1.90 per SD, 95% CI 1.58, 2.28) independently predicted future AF without significant interaction (p=0.54). C statistics were 0.69 (95% CI 0.66, 0.72) for AI-ECG AF model output, 0.69 (95% CI 0.66, 0.71) for CHARGE-AF and 0.72 (95% CI 0.69, 0.75) for combined AI-ECG and CHARGE-AF score.- In the present study, both the AI-ECG AF model output and CHARGE-AF score independently predicted incident AF. The AI-ECG may offer a means to assess risk with a single test and without requiring manual or automated clinical data abstraction.



Circ Arrhythm Electrophysiol: 12 Nov 2020; epub ahead of print
Christopoulos G, Graff-Radford J, Lopez CL, Yao X, ... Friedman PA, Noseworthy PA
Circ Arrhythm Electrophysiol: 12 Nov 2020; epub ahead of print | PMID: 33185118
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Abstract

Characterization of Lesions Created by a Heated, Saline Irrigated Needle-Tip Catheter in the Normal and Infarcted Canine Heart.

Dickow J, Suzuki A, Henz BD, Madhavan M, ... Curley MG, Packer DL

- Inability to eliminate intramural arrhythmogenic substrate may lead to recurrent ventricular tachycardia after catheter ablation. The aim of the present study was to evaluate intramural and full thickness lesion formation using a heated saline-enhanced radiofrequency (SERF) needle-tip catheter, compared to a conventional ablation catheter in normal and infarcted myocardium.- Twenty-two adult mongrel dogs (30-40 kg, 15 normal and 7 myocardial infarct group) were studied. Lesions were created using the SERF catheter (40W/50°C) or a standard contact force (CF) catheter in both groups.- Comparing SERF to CF ablation, the SERF catheter produced larger lesion volumes than the standard CF catheter - even with >20 g of CF - in both normal (983.1 ± 905.8 mm3 vs. 461.9 ± 178.3 mm3; p=0.023) and infarcted left ventricular myocardium (1052.3 ± 543.0 mm3 vs. 340.3 ± 160.5 mm3; p=0.001). SERF catheter lesions were more often transmural than standard CF lesions with >20 g of CF in both groups (59.1% vs. 7.7%; p<0.001 and 60.0% vs. 12.5%; p=0.017, respectively). Using the SERF catheter, mean depth of ablated lesions reached 90% of the left ventricular wall in both normal and infarcted myocardium.- The SERF catheter created more transmural and larger ablative lesions in both normal and infarcted canine myocardium. SERF ablation is a promising new approach for endocardial intramural and full thickness ablation of ventricular tachycardia substrate that is not accessible with current techniques.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Dickow J, Suzuki A, Henz BD, Madhavan M, ... Curley MG, Packer DL
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198498
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Abstract

The Pros and Cons of Left Bundle Branch Pacing: A Single Center Experience.

Ravi V, Hanifin JL, Larsen T, Huang HD, Trohman RG, Sharma PS

- Left Bundle Branch Pacing (LBBP) has recently emerged as a promising alternative modality for conduction system pacing. However, limited real-world data exists on the advantages and complications associated with LBBP. We analyzed the Rush conduction system pacing registry on LBBP to assess the success rates and complications associated with LBBP.- All patients with an indication for pacing (PPM) or cardiac resynchronization therapy (CRT) that underwent LBBP for various reasons from 06/2018 to 04/2020 were included in the analysis.- A total of 57 of 59 patients underwent successful LBBP (success rate 97%). The average follow-up duration was 6.2 ± 5 months. The implanted devices included 38 dual-chamber pacemakers, 17 CRT defibrillators, and 2 CRT pacing systems. The most common reason for performing LBBP was a high His Bundle Pacing threshold (n = 23) at implant. The mean LBBP capture threshold at implant was 0.62 ± 0.21 V @ 0.4 ms which remained stable during follow up at 0.65 ± 0.68 V @ 0.4ms. In 21 patients with cardiomyopathy, there was a significant improvement in LVEF from 30 ± 11% to 42 ± 15%. A total of 7 lead-related complications (12.3%) were noted in the follow-up period. Three patients (5.3%) required lead revision during the follow-up period. Interventricular septal (IVS) perforation occurred (as late sequela) after 2 weeks in one patient.- LBBP can be achieved with a high success rate and low capture thresholds. Left ventricular dysfunction improved significantly during follow-up. Lead-related complications were relatively common occurring in 12.3% of initially successful implants. Lead revision was required in 3 (5%) of patients.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Ravi V, Hanifin JL, Larsen T, Huang HD, Trohman RG, Sharma PS
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198496
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Abstract

Left Cardiac Sympathetic Denervation Monotherapy in Patients with Congenital Long QT Syndrome.

Niaz T, Bos JM, Sorensen KB, Moir C, Ackerman MJ

- Videoscopic left cardiac sympathetic denervation (LCSD) is an effective anti-fibrillatory, minimally invasive therapy for patients with potentially life-threatening arrhythmia syndromes like long QT syndrome (LQTS). Although initially used primarily for treatment intensification following documented LQTS-associated breakthrough cardiac events (BCEs) while on beta-blockers, LCSD as one-time monotherapy for certain patients with LQTS requires further evaluation. We are presenting our early experience with LCSD-monotherapy for carefully selected patients with LQTS.- Among the 1400 patients evaluated and treated for LQTS, a retrospective review was performed on the 204 patients with LQTS who underwent LCSD at our institution since 2005 to identify the patients where the LCSD served as stand-alone, monotherapy. Clinical data on symptomatic status prior to diagnosis, clinical and genetic diagnosis, and BCEs after diagnosis were analyzed to determine efficacy of LCSD-monotherapy.- Overall, 64 of 204 patients (31%) were treated with LCSD alone [37 (58%) female, mean QTc 466 ± 30 ms, 16 (25%) patients were symptomatic prior to diagnosis with a mean age at diagnosis 17.3 ± 11.8 years, 5 had (8%) ≥ 1 BCE after diagnosis, and mean age at LCSD was 21.1 ± 11.4 years]. The primary motivation for LCSD-monotherapy was an unacceptable quality of life stemming from beta-blocker related side effects (i.e. beta-blocker intolerance) in 56/64 patients (88%). The underlying LQTS genotype was LQT1 in 36 (56%) and LQT2 in 20 (31%). There were no significant LCSD-related surgical complications. With a mean follow-up of 2.7 ± 2.4 years so far, only 3 patients have experienced a non-lethal, post-LCSD BCE in 180 patient-years.- LCSD may be a safe and effective stand-alone therapy for select patients who do not tolerate beta-blockers. However, LCSD is not curative and patient selection will be critical when potentially considering LCSD as monotherapy.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Niaz T, Bos JM, Sorensen KB, Moir C, Ackerman MJ
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198487
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Abstract

Long-Term Evaluation of the Vagal Denervation by Cardioneuroablation using Holter and Heart Rate Variability.

Pachon-M JC, Pachon-M EI, Pachon CTC, Santillana-P TG, ... Silva RF, Osorio TG

- Several disorders present reflex or persistent increase in vagal tone that may cause refractory symptoms even in a normal heart patient. Cardioneuroablation (CNA), the vagal denervation by RF ablation of the neuromyocardial interface, was developed to treat these conditions without pacemaker implantation. A theoretical limitation could be the reinnervation, that naturally grows in the first year, that could recover the vagal hyperactivity. This study aims to verify the vagal denervation degree in the chronic phase after CNA. Additionally, it intends to investigate the arrhythmias behavior after CNA.- prospective longitudinal study with intra-patient comparison of 83 very symptomatic cases without significant cardiopathy, submitted to CNA, 49(59%) male, 47.3±17 years-old, having vagal paroxysmal atrial fibrillation 58(70%) or neurocardiogenic syncope 25(30%), NYHA Class < II and absence of significant comorbidities. CNA was performed in both atria by interatrial septum puncture, with irrigated conventional catheter and electroanatomic reconstruction. Ablation targeted the neuromiocardial interface by fragmentation mapping (AF-Nests) using the Velocity Fractionation software, conventional recording and anatomical localization of the ganglionated plexi. There were compared the time and frequency domain of the heart rate variability (HRV) and arrhythmias in 24h Holter pre-, 1-year-post- and 2-year-post-CNA. Clinical outpatient follow-up and serial Holter showed 80% asymptomatic cases at 40 months.- Time and frequency domain HRV demonstrated significant decrease in all autonomic parameters, showing an important parasympathetic and sympathetic activity reduction at 2 years-post-CNA (p<0.001). There was no difference in HRV between the 1-year- and 2-post-CNA (p>0.05) suggesting that the reinnervation has halted. There was also an important reduction in all brady- and tachyarrhythmias pre- vs. post-CNA, (p <0.01).- There is an important and significant vagal and sympathetic denervation after 2 years of CNA with a significant reduction in brady and tachyarrhythmia in the whole group. There were no complications.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Pachon-M JC, Pachon-M EI, Pachon CTC, Santillana-P TG, ... Silva RF, Osorio TG
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198486
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Abstract

Personalized Digital-heart Technology for Ventricular Tachycardia Ablation Targeting in Hearts with Infiltrating Adiposity.

Sung E, Prakosa A, Aronis KN, Zhou S, ... Chrispin J, Trayanova NA

- Infiltrating adipose tissue (inFAT) is a newly recognized pro-arrhythmic substrate for post-infarct ventricular tachycardias (VT) identifiable on contrast-enhanced computed tomography (CE-CT). This study presents novel digital-heart technology that incorporates inFAT from CE-CT to non-invasively predict VT ablation targets and assesses the capability of the technology by comparing its predictions with VT ablation procedure data from patients with ischemic cardiomyopathy (ICM).- Digital-heart models reflecting patient-specific inFAT distributions were reconstructed from CE-CTs. The Digital-heart Identification of Fat-based Ablation Targeting (DIFAT) technology evaluated the rapid-pacing-induced VTs in each personalized inFAT-based substrate. DIFAT targets that render the inFAT substrate non-inducible to VT, including VTs that arise post-ablation, were determined. DIFAT predictions were compared to corresponding clinical ablations to assess the capabilities of the technology.- DIFAT was developed and applied retrospectively to 29 ICM patients with CE-CTs. DIFAT ablation volumes were significantly less than the estimated clinical ablation volumes (1.87±0.35 cm vs. 7.05±0.88 cm, p<0.0005). DIFAT targets overlapped with clinical ablations in 79% of patients, mostly in the apex (72%) and inferior/inferolateral (74%). In 3 patients, DIFAT targets co-localized with redo ablations delivered years after the index procedure.- DIFAT is a novel digital-heart technology for individualized VT ablation guidance designed to eliminate VT inducibility following initial ablation. DIFAT predictions co-localized well with clinical ablation locations but provided significantly smaller lesions. DIFAT also predicted VTs targeted in redo procedures years later. As DIFAT uses widely accessible CT, its integration into clinical workflows may augment therapeutic precision and reduce redo procedures.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Sung E, Prakosa A, Aronis KN, Zhou S, ... Chrispin J, Trayanova NA
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198484
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Abstract

The Diagnostic Value of Cardiac Deceleration Capacity in Vasovagal Syncope.

Zheng L, Sun W, Liu S, Liang E, ... Asirvatham SJ, Yao Y

- Increased parasympathetic activity is thought to play important roles in syncope events of vasovagal syncope (VVS) patients. However, direct measurements of the vagal control are difficult. The novel deceleration capacity (DC) of heart rate measure has been used to characterize the vagal modulation. This study aimed to assess vagal control in VVS patients and evaluate the diagnostic value of the DC in VVS.- Altogether 161 consecutive VVS patients (43 ± 15 years; 62 males) were enrolled. Tilt table test (TTT) was positive in 101 and negative in 60 patients. Sixty-five healthy subjects were enrolled as controls. DC and heart rate variability (HRV) in 24-hour electrocardiogram, echocardiogram, and biochemical examinations were compared between the syncope and control groups.- DC was significantly higher in the syncope group than in the control group (9.6 ± 3.3 ms vs. 6.5 ± 2.0 ms, 0.001). DC was similarly increased in VVS patients with a positive and negative TTT (9.7±3.5 ms and 9.4±2.9 ms, =0.614). In multivariable logistic regression analyses, DC was independently associated with syncope (=1.518, 95%1.301-1.770,=0.0001). For the prediction of syncope, the area under curve (AUC) analysis showed similar values when comparing single DC and combined DC with other risk factors (=0.1147). From the receiver operator characteristic (ROC) curves for syncope discrimination, the optimal cut-off value for the DC was 7.12 ms.- DC > 7.5 ms may serve as a good tool to monitor cardiac vagal activity and discriminate VVS, particularly in those with negative TTT.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Zheng L, Sun W, Liu S, Liang E, ... Asirvatham SJ, Yao Y
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33197331
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Abstract

Characteristics of Patients with Arrhythmogenic Left Ventricular Cardiomyopathy: Combining Genetic and Histopathologic Findings.

Casella M, Gasperetti A, Sicuso R, Conte E, ... Dello Russo A, Tondo C

- Arrhythmogenic left ventricular cardiomyopathy (ALVC) is an under-characterized phenotype of arrhythmogenic cardiomyopathy involving the LV ab initio. ALVC was not included in the 2010 International Task Force Criteria (ITFC) for arrhythmogenic right ventricular cardiomyopathy diagnosis and data regarding this phenotype are scarce.- clinical characteristics were reported from all consecutive patients diagnosed with ALVC, defined as a LV isolated late gadolinium enhancement (LGE) and fibro-fatty replacement (FFR) at cardiac magnetic resonance (CMR) plus genetic variants associated with ARVC and/or of an endomyocardial biopsy (EMB) showing FFR complying with the 2010 ITFC in the LV.- twenty-five ALVC patients (53 [48-59] years, 60% male) were enrolled. T-wave inversion in infero-lateral and left precordial leads were the most common ECG abnormalities. Overall arrhythmic burden at study inclusion was 56%. CMR showed LV LGE in the LV lateral and/or posterior basal segments in all patients. In 72% of the patients an invasive evaluation was performed, in which electroanatomical voltage mapping (EVM) and EVM-guided EMB showed low endocardial voltages and FFR in areas of LGE presence. Genetic variants in desmosomal genes (desmoplakin and desmoglein-2) were identified in 12/25 of the cohort presenting pathogenic/likely-pathogenic variants. A definite/borderline 2010 ITFC ARVC diagnosis was reached only in 11/25 patients.- ALVC presents with a preferential involvement of the lateral and/or postero-lateral basal LV and is associated mostly with variants in desmoplakin and desmoglein-2 genes. An amendment to the current ITFC is reasonable to better diagnose ALVC patients.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Casella M, Gasperetti A, Sicuso R, Conte E, ... Dello Russo A, Tondo C
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33197325
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Abstract

Impact of Vein of Marshall Ethanol Infusion on Mitral Isthmus Block: Efficacy and Durability.

Nakashima T, Pambrun T, Vlachos K, Goujeau C, ... Jaïs P, Derval N

- Achieving bidirectional mitral isthmus (MI) block using radiofrequency catheter ablation (RFCA) alone is challenging, and MI reconnection is common. Adjunctive vein of Marshall (VOM) ethanol infusion (VOM-Et) can facilitate acute MI block. However, little is known regarding its long-term success. This study sought to evaluate the impact of adjunctive VOM-Et on MI block achievement and durability compared to RFCA alone.- Patients undergoing a first attempt of posterior MI ablation were grouped according to their MI block index strategy: adjunctive VOM-Et and RFCA alone. Rates of acute MI block and MI reconnection observed during repeat procedures were compared between the two groups.- The VOM-Et group consisted of 152 patients (63.8 ± 9.4 years) undergoing adjunctive VOM-Et for MI block. The RFCA group consisted of 110 patients (60.9 ± 9.2 years) undergoing MI ablation using RFCA alone. Acute MI block was more frequently achieved in the VOM-Et group (98.7% [150/152] vs. 63.6% [70/110]; p < 0.001) with shorter RFCA duration (5.00 [3.00-7.00] vs. 19.0 [13.6-22.0] mins; p < 0.001). Of the 220 patients with MI block achieved during the index procedure, 81 underwent a repeat procedure during follow-up (VOM-Et group: 23.3% [35/150] vs. RFCA group: 65.7% [46/70], respectively; p < 0.001). A significantly greater number of patients exhibited durable MI block in the VOM-Et group (62.9% [22/35] vs. 32.6% [15/46], respectively; p = 0.008).- Beyond facilitating acute MI block, VOM-Et is associated with greater lesion durability as evidenced by higher rates of MI block during repeat procedures.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Nakashima T, Pambrun T, Vlachos K, Goujeau C, ... Jaïs P, Derval N
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33197321
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Abstract

Office, central and ambulatory blood pressure for predicting incident atrial fibrillation in older adults.

Matsumoto K, Jin Z, Homma S, Elkind MSV, ... Sacco RL, Di Tullio MR
Objectives
Recently, more sophisticated blood pressure (BP) measurements, such as central and ambulatory BP (ABP), have proven to be stronger predictors of future cardiovascular disease than conventional office BP. Their predictive value for atrial fibrillation development is not established. We investigated the prognostic impact for incident atrial fibrillation of office, central and ambulatory BP measurements in a predominantly older population-based cohort.
Methods
Of 1004 participants in the Cardiovascular Abnormalities and Brain Lesions (CABL) study, 769 in sinus rhythm with no history of atrial fibrillation or stroke (mean age 70.5 years) underwent ABP and arterial wave reflection analysis for central BP determination. Fine and Gray\'s proportional subdistribution hazards models were used to assess the association of BP parameters with incident atrial fibrillation.
Results
During 9.5 years, atrial fibrillation occurred in 83 participants. No office BP variable showed a significant association with incident atrial fibrillation. Central SBP and central pulse pressure were marginally associated with incident atrial fibrillation in multivariate analysis. Among ABP variables, 24-h SBP [adjusted hazard ratio per 10 mmHg, 1.24; 95% confidence interval (CI) 1.07--1.44; P = 0.004], daytime SBP (adjusted hazard ratio per 10 mmHg, 1.21; 95% CI 1.04--1.40; P = 0.011) and night-time SBP (adjusted hazard ratio per 10 mmHg, 1.22; 95% CI 1.07--1.39; P = 0.002) were significantly associated with incident atrial fibillation.
Conclusion
In a predominantly older, stroke-free community-based cohort, ABP was a better independent predictor of incident atrial fibrillation than central BP, whereas office BP was inadequate for this purpose.



J Hypertens: 30 Dec 2020; 39:46-52
Matsumoto K, Jin Z, Homma S, Elkind MSV, ... Sacco RL, Di Tullio MR
J Hypertens: 30 Dec 2020; 39:46-52 | PMID: 33031165
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Abstract

Prognostic Implications of Significant Isolated Tricuspid Regurgitation in Patients With Atrial Fibrillation Without Left-Sided Heart Disease or Pulmonary Hypertension.

Dietz MF, Goedemans L, Vo NM, Prihadi EA, ... Delgado V, Bax JJ

The prognostic impact of isolated tricuspid regurgitation (TR) in patients with atrial fibrillation (AF) has not been investigated. The purpose of this study was to investigate the prognostic implications of significant isolated TR in AF patients without left-sided heart disease, pulmonary hypertension, or primary structural abnormalities of the tricuspid valve. A total of 63 AF patients with moderate and severe TR were matched for age and gender to 116 AF patients without significant TR. Patients were followed for the occurrence of all-cause mortality, hospitalization for heart failure and stroke. Patients with significant isolated TR (mean age 71 ± 8 years, 57% men) more often had paroxysmal AF as compared with patients without TR (mean age 71 ± 7 years, 60% men) (60% vs 43%, p = 0.028). In addition, right atrial size and tricuspid annular diameter were significantly larger in patients with significant isolated TR compared with their counterparts. During follow-up (median 62 [34 to 95] months), 53 events for the combined endpoint occurred. One- and 5-year event-free survival rates for patients with significant isolated TR were 76% and 56%, compared with 92% and 85% for patients without significant TR, respectively (Log rank Chi-Square p <0.001). The presence of significant isolated TR was independently associated with the combined endpoint (hazard ratio, 2.853; 95% confidence interval, 1.458 to 5.584; p = 0.002). In conclusion, in the absence of left-sided heart disease and pulmonary hypertension, significant isolated TR is independently associated with worse event-free survival in patients with AF.

Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:84-90
Dietz MF, Goedemans L, Vo NM, Prihadi EA, ... Delgado V, Bax JJ
Am J Cardiol: 14 Nov 2020; 135:84-90 | PMID: 32866441
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Abstract

Comparison of Frequency of Atrial Fibrillation in Blacks Versus Whites and the Utilization of Race in a Novel Risk Score.

Kowlgi GN, Gunda S, Padala SK, Koneru JN, Deshmukh AJ, Ellenbogen KA

Blacks have a lower prevalence of atrial fibrillation (AF) compared with Whites. We sought to confirm previously reported ethnic trends in AF in Blacks and Whites in a large database, and develop a prediction score for AF. Over 330 million hospital discharges between the years 2003 to 2013 from the National Inpatient Sample database were analyzed. All hospitalizations with a diagnosis of AF formed the study cohort. Traditional risk factors for the development of AF were compared between Blacks and Whites. Univariate and multiple logistic regression analyses were used to formulate a risk score to predict AF-CHADSAVES (Congestive heart failure, Hypertension, Age>65 years, Diabetes Mellitus, prior Stroke, Age>75 years, Vascular disease, White Ethnicity, and previous cardiothoracic Surgery). AF prevalence in Whites was 11.3% vs 4.6% in Blacks (p < 0.001). Blacks were younger (33.8% vs 14.4% patients <65 years, p < 0.01) and had less males (46.3% vs 49.4%, p < 0.01). Blacks had more hypertension (71.3% vs 64.1%, p < 0.01), congestive heart failure (24.8% vs 22.6%, p < 0.01), diabetes mellitus with (7.5% vs 4.7%, p < 0.01) or without complications (30.3% vs 23.1%, p < 0.01), renal failure (29.7% vs 17.1%, p < 0.01), and obesity (13.1% vs 8.7%, p < 0.01). CHADSAVES predicted AF in the study population (NIS 2003 to 2013) with an AUC of 0.82 and verified in a validation cohort (NIS 2014) with an AUC of 0.85. In conclusion, our data confirm a significant AF ethnicity paradox. Despite a higher prevalence of traditional risk factors for AF, Blacks had >2-fold lower prevalence of AF compared with Whites. CHADSAVES can be used effectively to predict AF in inpatients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:68-76
Kowlgi GN, Gunda S, Padala SK, Koneru JN, Deshmukh AJ, Ellenbogen KA
Am J Cardiol: 14 Nov 2020; 135:68-76 | PMID: 32866451
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Abstract

Ventricular Fibrillation Storm in Coronavirus 2019.

Elsaid O, McCullough PA, Tecson KM, Williams RS, Yoon A

Cardiac arrhythmia is a known manifestation of novel coronavirus 2019 (COVID-19) infection. Herein, we describe the clinical course of an otherwise healthy patient who experienced persistent ventricular tachycardia and fibrillation which is believed to be directly related to inflammation, as opposed to acute myocardial injury or medications that can prolong the QT interval.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:177-180
Elsaid O, McCullough PA, Tecson KM, Williams RS, Yoon A
Am J Cardiol: 14 Nov 2020; 135:177-180 | PMID: 32871109
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Abstract

Comparison of Outcomes After Ablation of Atrial Fibrillation in Patients With Heart Failure With Preserved Versus Reduced Ejection Fraction.

Aldaas OM, Malladi CL, Mylavarapu PS, Lupercio F, ... Feld GK, Hsu JC

Catheter ablation improves outcomes in atrial fibrillation (AF) patients with heart failure (HF) with reduced ejection fraction (HFrEF). We sought to evaluate the efficacy and safety of catheter ablation of AF in HF patients with a preserved ejection fraction (HFpEF). We performed a retrospective study of all patients who underwent de novo radiofrequency catheter ablation enrolled in the UC San Diego AF Ablation Registry. The primary outcome was recurrence of all atrial arrhythmias on or off antiarrhythmic drugs (AAD). Of 547 total patients, 51 (9.3%) had HFpEF, 40 (7.3%) had HFrEF, and 456 (83.4%) were without HF. There was no difference in recurrence of atrial arrhythmias on or off AAD (Adjusted Hazard Ratio [AHR] 1.92 [95% CI 0.97 to 3.83] for HFpEF vs HFrEF and AHR 0.90 [95% CI 0.59 to 1.39] for HFpEF vs no HF) or off AAD (AHR 1.96 [95% CI 0.99 to 3.90] for HFpEF vs HFrEF and AHR 1.14 [95% CI 0.74 to 1.77] for HFpEF vs no HF). There was also no difference in rates of all-cause hospitalizations (AHR 1.80 [95% CI 0.97 to 3.33] for HFpEF vs HFrEF and AHR 2.05 [95% CI 1.30 to 3.23] for HFpEF vs no HF) or rates of all-cause mortality (AHR 0.53 [95% CI 0.05 to 6.11] for HFpEF vs HFrEF and AHR 2.46 [95% CI 0.34 to 17.92] for HFpEF vs no HF). There were no significant differences in AAD use (p = 0.176) or procedural complications between groups (p = 0.980). In conclusion, there were no significant differences in arrhythmia-free survival between patients with HFpEF and HFrEF that underwent catheter ablation of AF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:62-70
Aldaas OM, Malladi CL, Mylavarapu PS, Lupercio F, ... Feld GK, Hsu JC
Am J Cardiol: 30 Nov 2020; 136:62-70 | PMID: 32941815
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Abstract

Relation of Atrial Fibrillation to Angiographic Characteristics and Coronary Artery Disease Severity in Patients Undergoing Percutaneous Coronary Intervention.

Pastori D, Biccirè FG, Lip GYH, Menichelli D, ... Gaudio C, Tanzilli G

Patients with atrial fibrillation (AF) have an increased risk of coronary artery disease (CAD) compared to patients without. Angiographic characteristics, clinical presentation and severity of CAD according to the presence of AF have been poorly described. We performed a retrospective study of 303 consecutive patients (mean age 69.6±10.8 years; 23.1% women) with and without AF undergoing percutaneous coronary intervention. Data on 1) type of CAD presentation, 2) coronary involvement and 3) number of diseased coronary vessels (≥70%/luminal narrowing) were collected. CHADS-VASc and 2MACE scores were calculated. Presentation of CAD was STEMI in 37.6% of patients, NSTEMI-UA in 55.1%, and other in 7.3%. NSTEMI-UA was more common in AF (69.6% vs. 46.6%, p<0.001), while STEMI was more in the non-AF (22.3% vs. 46.6%, p<0.001) group. Left anterior descending artery (LAD) was the most common diseased vessel (70.6%) followed by right coronary artery (RCA, 56.4%) and obtuse marginal artery (36.6%). Patients with AF had a significantly lower RCA involvement (47.3% vs. 61.8%, p=0.016), with a trend for LAD (64.3% vs. 74.3%, p=0.069). At multivariable logistic regression analysis, AF remained inversely associated with RCA involvement (Odds Ratio [OR] 0.541, 95% Confidence Interval [CI] 0.335-0.874, p=0.012) and with ≥3 vessel CAD (OR 0.470, 95%CI 0.272-0.810, p=0.007). The 2 MACE score was associated with diseased LAD (OR 1.301, 95%CI 1.103-1.535, p=0.002) and with ≥3 vessel CAD (OR 1.330, 95%CI 1.330-1.140, p<0.001). In conclusion, patients with AF show lower RCA involvement and generally less severe CAD compared to non-AF ones. 2MACE score was higher in LAD obstruction and identified patients with severe CAD.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 17 Nov 2020; epub ahead of print
Pastori D, Biccirè FG, Lip GYH, Menichelli D, ... Gaudio C, Tanzilli G
Am J Cardiol: 17 Nov 2020; epub ahead of print | PMID: 33220321
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Abstract

Outcomes Associated with Dronedarone Use in Patients with Atrial Fibrillation.

Goehring EL, Bohn RL, Pezzullo J, Tave AK, ... Sicignano N, Naccarelli GV

The antiarrhythmic drug dronedarone was designed to reduce the extra-cardiac adverse effects associated with amiodarone use in treatment of patients with atrial fibrillation / atrial flutter (AF/AFL). This epidemiological study used a retrospective cohort design to compare risk of cardiovascular-related hospitalizations and death in AF/AFL patients treated with dronedarone versus other antiarrhythmic drugs (AADs). AF/AFL patients with incident dronedarone fills were matched by propensity score (PS) to incident users of other AADs. The primary study outcome was hospitalization for cardiovascular (CV) causes within 24 months after the first study drug fill. A secondary composite outcome comprised hospitalization for CV causes or all-cause mortality during follow-up. In the AF/AFL patient cohort meeting eligibility criteria, 6,964 incident users of dronedarone and 25 607 incident users of other AADs were identified. The PS-matched cohort comprised 6,349 Dronedarone users (91.2% of all eligible) and 12,698 other AAD users. Dronedarone patients had a significantly lower risk of hospitalization for a CV event compared to Other AAD users (hazard ratio = 0.87; 95% confidence interval = 0.79 to 0.96). This was consistent with results for the composite outcome (hazard ratio=0.86; 95% confidence interval = 0.78 to 0.95). In conclusion, AF/AFL patients initiated on dronedarone versus other AADs had significantly lower risk of CV hospitalizations as well as the composite CV hospitalization / death from any cause.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:77-83
Goehring EL, Bohn RL, Pezzullo J, Tave AK, ... Sicignano N, Naccarelli GV
Am J Cardiol: 14 Nov 2020; 135:77-83 | PMID: 32861738
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Abstract

Safety and Efficacy of Oral Anticoagulants for Atrial Fibrillation in Patients After Bariatric Surgery.

Hendricks AK, Zieminski JJ, Yao X, Dunlay SM, ... Herrin TR, Nei SD

Anticoagulation management is challenging in bariatric surgery patients, due to altered gastrointestinal anatomy and potentially reduced absorption. Few studies have evaluated clinical outcomes in this population. The objective of this study was to compare the efficacy and safety of oral anticoagulants in patients with and without a history of bariatric surgery. A retrospective, matched cohort study was conducted, utilizing data from the OptumLabs Data Warehouse. Patients ≥18 years old, with nonvalvular atrial fibrillation (NVAF), and treated with an oral anticoagulant between January 1, 2010 and December 31, 2018 were included. Outcomes were compared between bariatric and nonbariatric surgery patients. Secondary analysis compared warfarin to the direct oral anticoagulants (DOAC) in the bariatric cohort. The primary efficacy outcome was the rate of ischemic stroke and systemic embolism and the primary safety outcome was major bleeding. A total of 1,673 bariatric surgery and 155,619 nonbariatric surgery patients were identified. There was no significant difference in the rate of ischemic stroke or systemic embolism (0.83 vs 1.32 per 100 person years; Hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.31 to 1.22; p = 0.17) or major bleeding (5.30 vs 4.87 per 100 person years; HR 1.05, 95% CI 0.80 to 1.37; p = 0.73) between bariatric and nonbariatric surgery patients. In bariatric surgery patients alone, efficacy and safety were similar with warfarin compared with the DOACs. Results of this study suggest that bariatric surgery patients are not at an increased thrombotic or bleeding risk when using oral anticoagulants for NVAF. DOACs may be a reasonable alternative to warfarin.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:76-80
Hendricks AK, Zieminski JJ, Yao X, Dunlay SM, ... Herrin TR, Nei SD
Am J Cardiol: 30 Nov 2020; 136:76-80 | PMID: 32941819
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Abstract

Comparison in Patients < 75 Years of Age - Versus - Those > 75 Years on One-year-Events With Atrial Fibrillation and Left Atrial Appendage Occluder (From the Prospective Multicenter German LAARGE Registry).

Nasasra AE, Brachmann J, Lewalter T, Akin I, ... Senges J, Zeymer U

Left atrial appendage closure (LAAC) is an alternative to oral anticoagulation therapy in patients with non-valvular atrial fibrillation for the prevention of embolic stroke and systemic embolism. Although elderly patients (>75 years) have both higher ischemic and bleeding risk as compared with younger patients, they benefit from optimal anticoagulation. The subanalysis aimed to assess the indications, the safety, efficacy, and 1-year outcomes of interventional LAAC in elderly patients (≥ 75 years) compared with younger (< 75 years) patients in clinical practice. We analyzed data from the prospective Left-Atrium-Appendage Occluder Registry Germany. A total of 638 patients were included in the registry, 402 (63%) were aged ≥ 75 years. Compared with younger subjects, patients aged ≥75 were more likely to have higher CHA2DS2-VASC and HAS-BLED scores. Procedural success rate was high und similar in both groups (97.6%). Periprocedural adverse events were not statistically significant in groups (11.9% in <75 years vs 12.9% in ≥75 years; p = 0.80). At 1 year follow-up, all-cause mortality was higher in patients aged ≥75 compared withwith younger group (13.0% vs 7.8 %,p = 0.04), mainly due to non-cardiovascular causes (10.6% vs 6.0%). No significant differences in major bleeding, stroke, systemic embolism were observed. In conclusion, LAAC is feasible and safe in patients with AF at high stroke risk and with contraindications for OAC and should be considered as candidates for LAA closure. Elderly patients often present these characteristics and could benefit from this novel therapy.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 30 Nov 2020; 136:81-86
Nasasra AE, Brachmann J, Lewalter T, Akin I, ... Senges J, Zeymer U
Am J Cardiol: 30 Nov 2020; 136:81-86 | PMID: 32946860
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Abstract

Comparisons of Edoxaban Versus Warfarin on Levels of Plasma Prothrombin Fragment in Patients With Nonvalvular Atrial Fibrillation.

Tamura A, Yamamoto E, Kawano Y

The effect of edoxaban on plasma prothrombin fragment 1+2 (PTF1+2), a sensitive maker of in vivo thrombin generation, has not been fully investigated in nonvalvular atrial fibrillation (NVAF). We compared plasma PTF1+2 levels between 25 NVAF patients receiving warfarin and 100 NVAF patients receiving edoxaban and additionally analyzed the association between plasma PTF1+2 levels and the dose of edoxaban. Plasma PTF1+2 levels were significantly higher in patients receiving edoxaban than in those receiving warfarin (141.5 ± 50.0 pmol/l vs 93.1 ± 55.7 pmol/l, p < 0.001). The prevalence of plasma PF1+2 levels above the upper limit (229 pmol/l) of the normal range did not differ between the 2 groups (4% vs 4%), whereas the prevalence of plasma PTF1+2 levels below the lower limit (69 pmol/l) of the normal range was significantly lower in patients receiving edoxaban than in those receiving warfarin (1% vs 48%, p < 0.001). Multiple linear regression analysis identified age and warfarin treatment as independent variables associated with the plasma PTF1+2 level. In a subgroup analysis, plasma PTF1+2 levels were significantly higher in 58 receiving edoxaban of 30 mg/day than in 42 receiving edoxaban of 60 mg/day (157.6 ± 50.8 pmol/l vs 121.6 ± 39.8 pmol/l, p = 0.01); however, after adjusting for confounding factors, the dose of edoxaban was not independently associated with the plasma PTF1+2 level. In conclusion, edoxaban sufficiently inhibits thrombin generation unrelated to its dose in NVAF, although its inhibitory effect is weaker compared with warfarin.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:71-75
Tamura A, Yamamoto E, Kawano Y
Am J Cardiol: 30 Nov 2020; 136:71-75 | PMID: 32946856
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Abstract

Predictors and Mechanisms of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy.

Raphael CE, Liew AC, Mitchell F, Kanaganayagam GS, ... Pennell DJ, Prasad SK

Atrial fibrillation (AF) in hypertrophic cardiomyopathy (HC) is associated with significant symptomatic deterioration, heart failure, and thromboembolic disease. There is a need for better mechanistic insight and improved identification of at risk patients. We used cardiovascular magnetic resonance (CMR) to assess predictors of AF in HC, in particular the role of myocardial fibrosis. Consecutive patients with HC referred for CMR 2003 to 2013 were prospectively enrolled. CMR parameters including left ventricular volumes, presence and percentage of late gadolinium enhancement in the left ventricle (%LGE) and left atrial volume index (LAVi) were measured. Overall, 377 patients were recruited (age 62 ± 14 years, 73% men). Sixty-two patients (16%) developed new-onset AF during a median follow up of 4.5 (interquartile range 2.9 to 6.0) years. Multivariable analysis revealed %LGE (hazard ratio [HR] 1.3 per 10% (confidence interval: 1.0 to 1.5; p = 0.02), LAVi (HR 1.4 per 10 mL/m[1.2 to 1.5; p < 0.001]), age at HC diagnosis, nonsustained ventricular tachycardia and diabetes to be independent predictors of AF. We constructed a simple risk prediction score for future AF based on the multivariable model with a Harrell\'s C-statistic of 0.73. In conclusion, the extent of ventricular fibrosis and LA volume independently predicted AF in patients with HC. This finding suggests a mechanistic relation between fibrosis and future AF in HC. CMR with quantification of fibrosis has incremental value over LV and LA measurements in risk stratification for AF. A risk prediction score may be used to identify patients at high risk of future AF who may benefit from more intensive rhythm monitoring and a lower threshold for oral anticoagulation.

Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Nov 2020; 136:140-148
Raphael CE, Liew AC, Mitchell F, Kanaganayagam GS, ... Pennell DJ, Prasad SK
Am J Cardiol: 30 Nov 2020; 136:140-148 | PMID: 32950468
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Abstract

Active compression versus standard anterior-posterior defibrillation for external cardioversion of atrial fibrillation. A prospective randomized study.

Squara F, Elbaum C, Garret G, Liprandi L, ... Moceri P, Ferrari E
Background
Electrical cardioversion is the first line rhythm control therapy for symptomatic persistent atrial fibrillation (AF). Contemporary use of biphasic shock waveforms and anterior-posterior positioning of defibrillation electrodes have improved cardioversion efficacy; however, it remains unsuccessful in >10% of the patients.
Objective
To assess the efficacy of applying active compression on defibrillation electrodes during AF cardioversion.
Methods
We performed a bicentre randomized study including patients referred for persistent AF cardioversion. Elective external cardioversion was performed by a standardized step-up protocol with increasing biphasic shock energy (50-100-150-200J). Patients were randomly assigned to standard anterior-posterior defibrillation, or to defibrillation with active compression applied over the anterior electrode. If sinus rhythm was not achieved at 200J, a single cross-over shock (200J) was applied. Defibrillation threshold, total delivered energy, number of shocks and success rate were compared between groups.
Results
We included 100 patients, 50 in each group. In active compression group, defibrillation threshold was lower (103.1±49.9 vs. 130.4±47.7 J; p=0.008), as well as total delivered energy (203±173.3 vs. 309±213.5 J; p=0.0076) and number of shocks (2.2±1.1 vs. 2.9±1.2; p=0.0033), and cardioversion was more often successful (48/50 patients [96%] vs. 42/50 patients [84%]; p=0.0455) than in standard anterior-posterior group. Cross-over from compression to standard group was not successful (0/2 patients) whereas cross-over from standard to compression group was successful in 50% of the patients (4/8).
Conclusion
Active compression applied to the anterior defibrillation electrode is more effective for persistent AF cardioversion than standard anterior-posterior cardioversion, with lower defibrillation threshold and higher success rate.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 08 Nov 2020; epub ahead of print
Squara F, Elbaum C, Garret G, Liprandi L, ... Moceri P, Ferrari E
Heart Rhythm: 08 Nov 2020; epub ahead of print | PMID: 33181323
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Abstract

Meta-Analysis of Safety and Efficacy of Direct Oral Anticoagulants Versus Warfarin According to Time in Therapeutic Range in Atrial Fibrillation.

Lee JJ, Ha ACT, Dorian P, Verma M, Goodman SG, Friedrich JO

Among atrial fibrillation (AF) patients, it is unclear whether the efficacy and safety of direct oral anticoagulants (DOAC) relative to warfarin is consistent across various levels of international normalized ratio (INR) control. To determine the efficacy and safety of DOAC agents compared to warfarin for patients with various levels of anticoagulation control as reflected by their time in therapeutic range (TTR), we conducted a systematic review and meta-analysis of published randomized controlled trials of DOAC versus (vs.) warfarin which reported outcomes stratified by TTR. Based on reported center-based TTR (cTTR) ranges, degrees of INR control were categorized into 3 cTTR strata: low (<60%), intermediate (60-66%), and high (>66%). Pooled hazard ratios (HR) and 95% confidence intervals (CI) were determined for stroke or systemic embolism (SSE), major bleeding, and intracranial hemorrhage (ICH). Across all cTTR strata, DOAC-treated patients had lower risk of SSE vs. warfarin, with a HR of 0.73 (95% CI 0.61-0.88) for the low, 0.76 (95% CI 0.59-0.98) intermediate; and 0.78 (95% CI 0.63-0.96) high cTTR subgroups. Compared to warfarin, DOAC-treated patients had lower risk of major bleeding in the low and intermediate cTTR strata, and similar risk in the highest cTTR stratum (HR 1.00, 95% CI 0.80-1.26). Patients treated with DOAC had lower risk of ICH compared to warfarin (HR 0.55, 95% CI; 0.40-0.74) which was observed across all cTTR strata. In conclusion, regardless of the degree of INR control, DOAC agents are preferable over warfarin as stroke prevention therapy for patients with AF.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 11 Nov 2020; epub ahead of print
Lee JJ, Ha ACT, Dorian P, Verma M, Goodman SG, Friedrich JO
Am J Cardiol: 11 Nov 2020; epub ahead of print | PMID: 33189659
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Abstract

Novel Score to Predict Very Late Recurrences after Catheter Ablation of Atrial Fibrillation.

Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J

Various predictors of atrial fibrillation (AF) recurrence have been shown based on the baseline characteristics before catheter ablation (CA). This study aimed to develop a novel scoring system for predicting very late recurrences of AF (VLRAFs) after an initial CA, taking the post-procedural clinical data into account and reassessing VLRAFs in 12-month patients\' condition using previously known pre-procedural predictors of AF recurrences. We retrospectively studied 327 patients who underwent an initial CA with freedom from AF for over 12 months. We elucidated the predictors of VLRAFs and created a new score to predict VLRAFs in the discovery AF cohort (n=181). Thereafter, we investigated whether the new scoring system could accurately predict VLRAFs in the validation AF cohort (n=146). In the discovery AF cohort, VLRAFs were observed in fifty-three patients (29%) during the follow-up period (mean follow-up duration: 55 months). The univariate and multivariate Cox proportional-hazards model demonstrated that non-pulmonary vein (PV) foci, early recurrences of AF (ERAFs), atrial premature contraction (APC) burden ≥ 142/24hours, and minimum prematurity index of the APCs ≤ 48% were associated with VLRAFs after CA. We created a new scoring system to predict VLRAFs, the n-PReDCt score (non-PV: 1 point, ERAFs (Recurrences of AF in early phase after CA): 1 point, APC burDen ≥ 142/24hours: 1 point, and minimum prematurity index (=Coupling interval) of the APCs of ≤ 48%: 1 point). The n-PReDCt score was significantly associated with VLRAFs by a Kaplan-Meier analysis in the discovery AF and validation AF cohorts (p<0.0001 and p<0.0001, respectively).

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 16 Nov 2020; epub ahead of print
Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J
Am J Cardiol: 16 Nov 2020; epub ahead of print | PMID: 33217347
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Abstract

Epicardial Course of the Septopulmonary Bundle: Anatomical Considerations and Clinical Implications for Roof Line Completion.

Pambrun T, Duchateau J, Delgove A, Denis A, ... Walton RD, Derval N
Background
Gaps in the roof line have been ascribed to epicardial conduction using the septopulmonary bundle.
Objective
We sought to evaluate the frequency of septopulmonary bundle bypass during roof line ablation, to describe anatomical conditions favoring this epicardial gap, and to propose an alternative strategy when present.
Methods
One hundred consecutive patients underwent atrial fibrillation ablation. A de novo roof line was created between the superior pulmonary veins. In cases of residual gaps, a floor line was created between the inferior pulmonary veins. Microtomography imaging and histological analyses of five human donor hearts were performed: a specific focus was made on the dome and the PW.
Results
Residual gaps were more frequent in roof lines than floor lines (33% vs 15%; p = 0.049). Electrogram morphologies, activation sequences, and pacing maneuvers indicated an epicardial bypass of the roof line in all cases. Conduction block was obtained in 67 roof and 28 floor lines, resulting in a 95% success rate of linear block, without \"box\" isolation. Between the superior pulmonary veins, the atrial myocardium was thicker and consistently displayed adipose tissue separating the septopulmonary bundle from the septoatrial bundle.
Conclusion
Epicardial conduction across the roof line is common and requires careful electrogram analysis to detect. In such cases, a floor line can be an effective alternative strategy, with clear validation criteria. Myocardial thickness and fat interposition may explain difficulties in achieving lesion transmurality during roof line ablation.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 10 Nov 2020; epub ahead of print
Pambrun T, Duchateau J, Delgove A, Denis A, ... Walton RD, Derval N
Heart Rhythm: 10 Nov 2020; epub ahead of print | PMID: 33188900
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Abstract

Percutaneous Management of Superior Vena Cava Syndrome in Patients with Cardiovascular Implantable Electronic Devices.

Gabriels J, Chang D, Maytin M, Tadros T, ... Eisenhauer A, Epstein LM
Background
There is no consensus regarding the optimal management of cardiovascular implantable electronic device (CIED)-related superior vena cava (SVC) syndrome.
Objective
We report our experience with transvenous lead extractions (TLEs) in the setting of symptomatic CIED-related SVC syndrome.
Methods
We reviewed all TLEs performed at a high-volume center over a fourteen-year period and identified cases in which a TLE was performed for symptomatic SVC syndrome. Patient characteristics, extraction details, percutaneous management of the SVC occlusions and clinical follow data were analyzed.
Results
Over a fourteen-year period, more than 1600 TLEs were performed. Of these, 16 patients underwent a TLE for symptomatic SVC syndrome. The average age was 53.1±12.8 years and 56.3% were men. Thirty-seven leads, with an average dwell time of 5.8 years (range 2-12 years), were extracted. Following the extraction, six patients (37.5%) received an SVC stent. A balloon angioplasty was performed prior to stenting in five cases (31.3%). There was one major complication (6.3%) due to an SVC tear that was managed surgically with a favorable outcome. Eleven patients underwent re-implantation of a CIED. Over a median follow-up of 5.5 years (IQR 2 to 8.5), 12 patients (75%) remained free of symptoms.
Conclusion
Combining a TLE with the percutaneous treatment of symptomatic SVC syndrome is a safe and viable treatment strategy.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 15 Nov 2020; epub ahead of print
Gabriels J, Chang D, Maytin M, Tadros T, ... Eisenhauer A, Epstein LM
Heart Rhythm: 15 Nov 2020; epub ahead of print | PMID: 33212249
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Abstract

Reassessing the role of Antitachycardia Pacing in Fast Ventricular Arrhythmias in Primary Prevention Implantable Cardioverter Defibrillator Recipients: Results from MADIT-RIT.

Schuger C, Daubert JP, Zareba W, Rosero S, ... McNitt S, Kutyifa V
Background
In MADIT-RIT high rate cut-off (Arm B) and delayed therapy (Arm C) reduced the risk of inappropriate ICD interventions, when compared to conventional programming (Arm A), however appropriate but unnecessary therapies were not evaluated.
Objective
To assess the value of ATP for fast ventricular arrhythmias (VA)≥200 bpm in primary prevention (PP) ICD patients.
Methods
We compared ATP only, ATP and shock, and shock only rates in MADIT-RIT patients treated for VA≥200 bpm. The only difference between these randomized groups was the time delay between VT detection and therapy (3.4 sec vs. 4.9 sec vs. 14.4 sec).
Results
Arm A, 11.5% had events, initial therapy in 10.5% was ATP, in 1% was shock. Final therapy was ATP in 8% and shock in 3.5%. Arm B, 6.6% had events, 4.2% were initially treated with ATP, 2.4% with shock. Final therapy was ATP in 2.8% and shock in 3.8%. Arm C, 4.7% patients had events, 2.5% were initially treated with ATP, 2.3% with shock. Final therapy was ATP in 1.4%, and shock in 3.3%. The final shock rate was similar, Arms A vs. B (3.5% vs. 3.8%, p=0.800) and in Arms A vs. C (3.5% vs. 3.3%, p=0.855) despite the marked discrepancy in initial ATP therapy utilization.
Conclusion
In MADIT-RIT, there was a significant reduction in ATP interventions with therapy delays due to spontaneous termination, with no difference in shock therapies, suggesting that earlier interventions for VA≥200 bpm are likely unnecessary leading to an overestimation of the value of ATP in PP ICD recipients.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 20 Nov 2020; epub ahead of print
Schuger C, Daubert JP, Zareba W, Rosero S, ... McNitt S, Kutyifa V
Heart Rhythm: 20 Nov 2020; epub ahead of print | PMID: 33232811
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Abstract

The electrophysiological effects of ranolazine in a goat model of lone atrial fibrillation.

Opačić D, van Hunnik A, Zeemering S, Dhalla A, ... Schotten U, Verheule S
Background
There is still an unmet need for pharmacological treatment of atrial fibrillation (AF) with few effects on ventricular electrophysiology. Ranolazine is an antiarrhythmic drug reported to have a strong atrial selectivity.
Objective
To investigate the electrophysiological effects of ranolazine in atria with AF-induced electrical remodeling in a model of lone AF in awake goats.
Methods
Electrode patches were implanted on the atrial epicardium of 8 Dutch milk goats. Experiments were performed at baseline and after 2 and 14 days of electrically maintained AF. Several electrophysiological parameters and AF episode duration were measured during the infusion of vehicle and different doses of ranolazine (target plasma levels 4μM, 8μM and 16μM, respectively).
Results
The highest dose of ranolazine significantly prolonged AERP and decreased atrial CV both at baseline and after 2 days of AF. After 2 weeks of AF, ranolazine prolonged the p5 and p50 of the AFCL distribution in a dose-dependent manner but was not effective in restoring sinus rhythm. No adverse ventricular arrhythmic events, i.e. premature ventricular beats or signs of hemodynamic instability were observed during the infusion of ranolazine at any point in this study.
Conclusion
The lowest investigated dose of ranolazine, which is expected to block both late I and atrial peak I had no effect on the investigated electrophysiological parameters. The highest dose affected both atrial and ventricular electrophysiological parameters at different stages of AF-induced remodeling but was not efficacious in cardioverting AF to sinus rhythm in a goat model of lone AF.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 20 Nov 2020; epub ahead of print
Opačić D, van Hunnik A, Zeemering S, Dhalla A, ... Schotten U, Verheule S
Heart Rhythm: 20 Nov 2020; epub ahead of print | PMID: 33232809
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Abstract

The frequency spectrum of sympathetic nerve activity and arrhythmogenicity in ambulatory dogs.

Liu X, Yuan Y, Wong J, Meng G, ... Everett TH, Chen PS
Background
Sympathetic nerve activity (SNA), heart rate (HR) and blood pressure (BP) all have very low frequency (VLF), low frequency (LF) and high frequency (HF) oscillations.
Objective
To test the hypotheses that the frequency spectra of the subcutaneous nerve activity (ScNA), stellate ganglion nerve activity (SGNA), HR and BP are important to cardiac arrhythmogenesis.
Methods
We used radiotransmitters to record SGNA, ScNA, HR and BP in 6 ambulatory dogs and determined the dominant frequency and PAT episodes in 3-min windows over a 24-hr period.
Results
The frequency spectra determined in the ScNA reflected that in the SGNA. HF oscillations were present in both ScNA and SGNA at all time but could be overshadowed by the much larger LF and VLF burst activities. The dominant frequency could occur in any of the 3 frequency bands. There were circadian variations with more frequent occurrences of the HF oscillations at night. The HF oscillations in HR and BP matched the HF oscillations in SGNA and ScNA. PATs occurred only when dominant frequencies of SGNA and ScNA were in the LF and VLF bands.
Conclusions
The HF oscillations in BP and HR correlate with the HF oscillations in SNA and are present at all time. HF oscillations can be overshadowed by the much larger LF and VLF burst activities. The PATs only occur when LF or VLF but not when HF is the dominant frequency. The frequency spectra determined in the ScNA reflect that in the SGNA.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 23 Nov 2020; epub ahead of print
Liu X, Yuan Y, Wong J, Meng G, ... Everett TH, Chen PS
Heart Rhythm: 23 Nov 2020; epub ahead of print | PMID: 33246037
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Abstract

Current Strategies to Minimize Post -Operative Hematoma Formation in Patients Undergoing Cardiac Implantable Electronic Device Implantation: A Review.

Mehta N, Doerr K, Skipper A, Rojas-Pena E, Dixon S, Haines D

There are an increasing number of cardiac electronic device implants and generator changes with a longer patient life expectancy along with concomitant increase in antiplatelet and anticoagulant regimens, which can increase the incidence of pocket hematomas (PH). We have conducted an in-depth analysis on the relevant literature, which is rife with varying definition of hematomas, on ways to reduce PH. We have analyzed studies on peri-procedural medication management, intra-procedural use of pro-hemostatic agents and post procedure role of compression devices. Introduction.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 22 Nov 2020; epub ahead of print
Mehta N, Doerr K, Skipper A, Rojas-Pena E, Dixon S, Haines D
Heart Rhythm: 22 Nov 2020; epub ahead of print | PMID: 33242669
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Abstract

Predictive value of atrial fibrillation during the post radiofrequency ablation blanking period.

Calkins H, Gache L, Frame D, Boo LM, ... Duytschaever M, Packer DL
Background
Recurrent arrhythmia following catheter ablation of atrial fibrillation (AF) may present early, during a standard 3-month blanking period. Early recurrence has been correlated to late recurrence but the degree to which its absence predicts longer-term success has not been quantified.
Objective
To explore and quantify the relationship between early and late arrhythmia recurrence, specifically the negative predictive value, that is, the degree to which absence of blanking period recurrence predicts absence of late recurrence.
Methods
A systematic literature review and meta-analysis were conducted, using statistical methods of a diagnostic test accuracy review. Studies of AF ablation using point-by-point radiofrequency, with repeated monitoring of arrhythmia recurrence including asymptomatic recurrence, and with separate data by AF type, were eligible.
Results
Nine studies met the pre-specified eligibility criteria. In paroxysmal AF, 89% (confidence interval [CI] 82-94%) of patients free from early recurrence remained free from late recurrence. The estimate for persistent AF was similar (91%,CI 75-97%). This finding was robust in sensitivity analyses. Patients with early recurrence had a wider range of likely outcomes with longer-term follow-up.
Conclusion
Freedom from AF recurrence during the blanking period is highly predictive of longer-term success in catheter ablation. Clinical trials in this area may be able to leverage these findings to more quickly assess the potential utility of new ablation technologies and methods, for example by using early surrogate measures of success.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 22 Nov 2020; epub ahead of print
Calkins H, Gache L, Frame D, Boo LM, ... Duytschaever M, Packer DL
Heart Rhythm: 22 Nov 2020; epub ahead of print | PMID: 33242668
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Impact:
Abstract

Sex-Differences in Arrhythmic Burden with the Wearable Cardioverter Defibrillator.

Goldenberg I, Erath JW, Russo AM, Burch AE, ... McNitt S, Kutyifa V
Background
Data on the arrhythmic burden of women at-risk for sudden cardiac death are very limited, especially in patients using the wearable cardioverter defibrillator (WCD).
Objective
We aimed to characterize WCD compliance, atrial and ventricular arrhythmic burden, and WCD outcomes by sex, in patients enrolled in the WEARIT-II U.S. Registry.
Methods
In WEARIT-II, we stratified 2,000 patients by sex into women (n=598), and men (n=1402). WCD wear time, ventricular and atrial arrhythmia events during WCD use, and ICD implantation rates at the end of WCD use were evaluated.
Results
WCD mean wear time was similar in women and men (94 vs. 90 days, p=0.145), with longer daily use in women (21.4 vs. 20.7 hour/day, p=001). Burden of ventricular tachycardia (VT) or ventricular fibrillation (VF) was higher in females with 30 events per 100 patient-years compared to 18 events per 100 patient-years in men (p=0.017), with similar findings for treated, and non-treated VT/VF. Recurrent atrial arrhythmias/SVT were also more frequent in women than in men (167 vs. 73 events per 100 patient-years, p=0.042). However, ICD implantation rate at the end of WCD use was similar in both women and men (41% vs. 39%, p=0.448).
Conclusions
In WEARIT-II, we have shown a higher burden of ventricular and atrial arrhythmia events in women as compared to men. ICD implantation rates at the end of WCD use were similar. Our findings warrant monitoring women at risk for sudden cardiac death who have a high burden of atrial and ventricular arrhythmias while using the WCD.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 24 Nov 2020; epub ahead of print
Goldenberg I, Erath JW, Russo AM, Burch AE, ... McNitt S, Kutyifa V
Heart Rhythm: 24 Nov 2020; epub ahead of print | PMID: 33248269
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Impact:
Abstract

Mortality after cardioverter-defibrillator replacement: results of the DECODE SUrvival SCore Index (DECODE-SUSCI).

Berisso MZ, Martignani C, Ammendola E, Narducci ML, ... Malacrida M, Biffi M
Background
Device replacement is the ideal time to reassess health care goals regarding continuing ICD therapy. Only few data are available on the decision making at this time.
Objective
To identify factors associated with poor prognosis at the time of ICD replacement and to develop a prognostic index able to stratify those patients at risk of dying early.
Methods
Detect long-term complications after ICD replacement (DECODE) was a prospective, single-arm, multicenter cohort study aimed at estimating long-term complications in a large population of patients who underwent ICD/CRT-D replacement. Potential predictors of death were investigated, and all these factors were gathered into a survival score index (SUSCI).
Results
We included 983 consecutive patients (median age 71 years, 76% male, 55% ischemic, 47% CRT-D). During a median follow-up time of 761[628-904] days, 114 (12%) patients died. At multivariate Cox regression analysis NYHA class III/IV, Ischemic cardiomyopathy, BMI<26, insulin administration, age≥75 years, history of AF and a hospitalization within 30 days before ICD replacement remained associated with death. The SUSCI score showed a good discriminatory power with an HR=2.6 (95%CI:2.2-3.1, p<0.0001). The risk of death increased according to the severity of the risk profile ranging from 0% - low-risk - to 47% - high-risk -.
Conclusions
A simple score that includes a limited set of variables appears to be predictive for total mortality in an unselected, real-world population undergoing ICD replacement. Evaluation of the patient\'s profile may assist in predicting vulnerability and should prompt individualized options, especially for high-risk patients.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 25 Nov 2020; epub ahead of print
Berisso MZ, Martignani C, Ammendola E, Narducci ML, ... Malacrida M, Biffi M
Heart Rhythm: 25 Nov 2020; epub ahead of print | PMID: 33249200
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Abstract

Catheter-free ablation of infarct scar through proton beam therapy: Tissue effects in a porcine model.

Hohmann S, Deisher AJ, Konishi H, Rettmann ME, ... Herman MG, Packer DL
Background
Scar-related ventricular arrhythmias are common after myocardial infarction. Catheter ablation can improve prognosis, but the procedure is invasive and results are not always satisfactory. Noninvasive, catheter-free ablation using ionizing radiation has recently gained interest among electrophysiologists, but the tissue effects and physiological outcome have not been fully characterized.
Objective
The purpose of this study was to investigate the structural effects of cardiac scanned pencil beam proton therapy on infarct scar, the time course of imaging biomarkers, arrhythmias, and cardiac function in a porcine model.
Methods
Fourteen infarcted swine underwent proton beam treatment of the scar (40 or 30 Gy) and were followed for up to 30 weeks. Magnetic resonance imaging was performed every 4 weeks.
Results
Treated scar areas showed a significantly lower fraction of surviving myocytes at 30 weeks compared to untreated scar (30.1% ± 18.5% and 59.9% ± 10.1% in treated and untreated infarct, respectively), indicating scar homogenization. Four animals died suddenly during follow-up, all from documented monomorphic ventricular tachycardia. Cardiac function remained stable over the course of the study. Distinct imaging morphologies corresponded to certain tissue dose ranges and time points.
Conclusion
Radioablation of cardiac infarct scar leads to significant homogenization of the scar, replicating the histologic effects of radiofrequency ablation. These changes correspond to distinct imaging morphologies on delayed contrast-enhanced cardiac magnetic resonance imaging, enabling noninvasive confirmation of tissue ablation effects The present study is the first to thoroughly investigate the structural effects of cardiac proton beam therapy in infarcted myocardium.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2190-2199
Hohmann S, Deisher AJ, Konishi H, Rettmann ME, ... Herman MG, Packer DL
Heart Rhythm: 29 Nov 2020; 17:2190-2199 | PMID: 32673796
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Impact:
Abstract

Off-label dosing of non-vitamin K antagonist oral anticoagulants and clinical outcomes in Asian patients with atrial fibrillation.

Chan YH, Chao TF, Chen SW, Lee HF, ... Lip GYH, Chen SA
Background
Off-label dosing non-vitamin K antagonist oral anticoagulants (NOACs) are commonly prescribed for Asian patients with atrial fibrillation (AF).
Objective
The purpose of this study was to investigate the associations between inappropriate dosing of NOACs and clinical outcomes.
Methods
We used medical data from a multicenter health care system in Taiwan, which included 2068, 5135, 2589, 1483, and 2342 AF patients taking dabigatran, rivaroxaban, apixaban, edoxaban, and warfarin, respectively. The risks of ischemic stroke/systemic embolism (IS/SE) and major bleeding in patients treated with underdosing or overdosing NOACs were compared to those of on-label dosing NOACs and warfarin.
Results
About 27% and 5% of AF patients were treated with underdosing and overdosing NOACs, respectively. Compared to on-label dosing, underdosing NOACs were associated with a significantly higher risk of IS/SE (adjusted hazard ratio [aHR] 1.59; 95% confidence interval [CI] 1.25-2.02; P <.001), whereas overdosing NOACs were associated with a significantly higher risk of major bleeding (aHR 2.01; 95% CI 1.13-3.56; P = .017). Compared to warfarin, the 4 on-label dosing NOACs were associated with a comparable risk of IS/SE and a significantly lower risk of major bleeding, whereas underdosing NOACs were associated with a higher risk of IS/SE (aHR 1.46; P = .012).
Conclusion
About 3 in 10 Asian AF patients were treated with off-label dosing NOACs in daily practice. Compared to on-label dosing, underdosing was associated with a higher risk of IS/SE, whereas overdosing was associated with a higher risk of major bleeding. Thus, even for Asian AF patients at higher risk for bleeding, NOACs still should be prescribed at the dosing based on clinical trial criteria and guideline recommendations.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2102-2110
Chan YH, Chao TF, Chen SW, Lee HF, ... Lip GYH, Chen SA
Heart Rhythm: 29 Nov 2020; 17:2102-2110 | PMID: 32702416
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Abstract

Alcohol consumption and risk of atrial fibrillation in asymptomatic healthy adults.

Cha MJ, Oh GC, Lee H, Park HE, Choi SY, Oh S
Background
Excessive alcohol consumption is related to atrial fibrillation (AF) development in the general population.
Objective
The purpose of this study was to investigate the effect of alcohol consumption on new-onset AF development in asymptomatic healthy individuals.
Methods
Asymptomatic healthy adults (age <75 years; body mass index <30 kg/m) undergoing routine health examinations from 2007 to 2015 were screened. Those with sinus rhythm and without any previously diagnosed medical or surgical illness were recruited for analysis. The primary outcome was new-onset AF. Secondary outcomes were a composite of non-AF cardiac events, including clinically significant tachy- or bradyarrhythmias, acute myocardial infarction, heart failure, or cardiac death.
Results
Among 19,634 individuals (50% male; age 19-74 years), 199 cardiac events were recorded, including new-onset AF (n = 160), acute myocardial infarction (n = 30), and clinically significant tachy- or bradyarrhythmia (n =19), during mean follow-up of 7.0 ± 2.8 years. The incidence of new-onset AF was higher in drinkers (hazard ratio [HR] 2.21; 95% confidence interval [CI] 1.55-3.14; P <.001), whereas composite non-AF cardiac events were not correlated to alcohol. There was a dose-dependent increase in the risk of AF according to the amount of alcohol consumed, and the risk increased more abruptly in men than in women. The risk of AF was highest in frequent binge drinkers (HR 3.15; 95% CI 1.98-4.99; P <.001), compared to infrequent light drinkers.
Conclusion
In the asymptomatic healthy population, drinking increases the risk of new-onset AF in a dose-dependent manner, regardless of sex. Frequent binge drinking should be avoided.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2086-2092
Cha MJ, Oh GC, Lee H, Park HE, Choi SY, Oh S
Heart Rhythm: 29 Nov 2020; 17:2086-2092 | PMID: 32673797
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Abstract

Determining the optimal duration for premature ventricular contraction monitoring.

Hsia BC, Greige N, Patel SK, Clark RM, ... Di Biase L, Krumerman A
Background
Premature ventricular contractions (VPC) have hour-to-hour and day-to-day variation. High VPC burden correlates with cardiomyopathy.
Objective
To determine the optimal duration for ambulatory electrocardiogram monitoring for accurate assessment of VPC burden.
Methods
Our group performed a retrospective analysis on patch monitors used for any indication with overall VPC burden ≥5.0% between February 1, 2016, and February 1, 2020. We generated cumulative daily VPC averages for each day of wear and performed linear regression analysis between each cumulative daily average and overall burden. Patients were divided into groups based on low or high VPC frequency, and the analysis was repeated. Split-sample validation was used to internally validate the overall prediction model.
Results
A total of 116 patches representing 107 patients (mean age: 64.5; female: 48%) were analyzed. Mean overall VPC burden was 13.4% ± 7.5% (range: 5.0%-42.0%). Day 1 R was 60%, P < .001, and continued to increase to R 88%, P < .001 at day 14. Median percent and absolute error decreased from 22.70% (interquartile range [IQR]: 9.73-34.39) and 2.58% (IQR: 1.24-4.59) at day 1 to 5.62% (IQR: 2.82-8.39) and 0.55% (IQR: 0.28-1.05) at day 14. Patients with higher overall VPC frequencies achieved a more rapid rise in R relative to those with lower frequencies. Split-sample validation supported the internal validity of our linear regression prediction model.
Conclusion
Mobile telemetry for a period of ∼7 days accurately reflects overall VPC burden. Measurement of VPC burden for only 24-48 hours may not accurately reflect total burden. Monitoring for 2 weeks or longer adds little additional VPC information.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2119-2125
Hsia BC, Greige N, Patel SK, Clark RM, ... Di Biase L, Krumerman A
Heart Rhythm: 29 Nov 2020; 17:2119-2125 | PMID: 32679267
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Abstract

Transvenous phrenic nerve stimulation for central sleep apnea is safe and effective in patients with concomitant cardiac devices.

Nayak HM, Patel R, McKane S, James KJ, ... Costanzo MR, Augostini R
Background
Central sleep apnea is common in heart failure patients. Transvenous phrenic nerve stimulation (TPNS) requires placing a lead to stimulate the phrenic nerve and activate the diaphragm. Data are lacking concerning the safety and efficacy of TPNS in patients with concomitant cardiovascular implantable electronic devices (CIEDs).
Objective
To report the safety and efficacy of TPNS in patients with concomitant CIEDs.
Methods
In the remedē System Pivotal Trial, 151 patients underwent TPNS device implant. This analysis compared patients with concomitant CIEDs to those without with respect to safety, implant metrics, and efficacy of TPNS. Safety was assessed using incidence of adverse events and device-device interactions. A detailed interaction protocol was followed. Implant metrics included overall TPNS implantation success. Efficacy endpoints included changes in the apnea-hypopnea index (AHI) and quality of life.
Results
Of 151 patients, 64 (42%) had a concomitant CIED. There were no significant differences between the groups with respect to safety. There were 4 CIED oversensing events in 3 patients leading to 1 inappropriate defibrillator shock and delivery of antitachycardia pacing. There was no difference in efficacy between the CIED and non-CIED subgroups receiving TPNS, with both having similar percentages of patients who achieved ≥50% reduction in AHI and quality-of-life improvement.
Conclusion
Concomitant CIED and TPNS therapy is safe. The presence of a concomitant CIED did not seem to impact implant metrics, implantation success, and TPNS efficacy. A detailed interaction protocol should be followed to minimize the incidence of device-device interaction.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2029-2036
Nayak HM, Patel R, McKane S, James KJ, ... Costanzo MR, Augostini R
Heart Rhythm: 29 Nov 2020; 17:2029-2036 | PMID: 32619739
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Abstract

Common and rare susceptibility genetic variants predisposing to Brugada syndrome in Thailand.

Makarawate P, Glinge C, Khongphatthanayothin A, Walsh R, ... Veerakul G, Nademanee K
Background
Mutations in SCN5A are rarely found in Thai patients with Brugada syndrome (BrS). Recent evidence suggested that common genetic variations may underlie BrS in a complex inheritance model.
Objective
The purpose of this study was to find common and rare/low-frequency genetic variants predisposing to BrS in persons in Thailand.
Methods
We conducted a genome-wide association study (GWAS) to explore the association of common variants in 154 Thai BrS cases and 432 controls. We sequenced SCN5A in 131 cases and 205 controls. Variants were classified according to current guidelines, and case-control association testing was performed for rare and low-frequency variants.
Results
Two loci were significantly associated with BrS. The first was near SCN5A/SCN10A (lead marker rs10428132; odds ratio [OR] 2.4; P = 3 × 10). Conditional analysis identified a novel independent signal in the same locus (rs6767797; OR 2.3; P = 2.7 × 10). The second locus was near HEY2 (lead marker rs3734634; OR 2.5; P = 7 × 10). Rare (minor allele frequency [MAF] <0.0001) coding variants in SCN5A were found in 8 of the 131 cases (6.1% in cases vs 2.0% in controls; P = .046; OR 3.3; 95% confident interval [CI] 1.0-11.1), but an enrichment of low-frequency (MAF<0.001 and >0.0001) variants also was observed in cases, with 1 variant (SCN5A: p.Arg965Cys) detected in 4.6% of Thai BrS patients vs 0.5% in controls (P = 0.015; OR 9.8; 95% CI 1.2-82.3).
Conclusion
The genetic basis of BrS in Thailand includes a wide spectrum of variant frequencies and effect sizes. As previously shown in European and Japanese populations, common variants near SCN5A and HEY2 are associated with BrS in the Thai population, confirming the transethnic transferability of these 2 major BrS loci.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2145-2153
Makarawate P, Glinge C, Khongphatthanayothin A, Walsh R, ... Veerakul G, Nademanee K
Heart Rhythm: 29 Nov 2020; 17:2145-2153 | PMID: 32619740
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Impact:
Abstract

Catheter Ablation for Atrial Fibrillation in Patients With Concurrent Heart Failure.

Arora S, Jaswaney R, Jani C, Zuzek Z, ... Viles-Gonzalez J, Deshmukh A

Due to limited real-world data, the aim of this study was to explore the impact of catheter ablation (CA) for atrial fibrillation (AF) in heart failure (HF). This retrospective cohort study identified 119,694 patients with AF and HF from the Nationwide Readmissions Database (NRD) from 2016 to 2017. Propensity-matching was generated using demographics, comorbidities, hospital and other characteristics through multivariate logistic regression. Greedy\'s propensity score match (1:15) algorithm was used to create matched data. The primary end point was a composite of HF readmission and mortality at 1 year. Secondary outcomes include HF readmission, mortality, AF readmission, and any-cause readmission at 1 year. Of the 119,694 patients, 63,299 had HF with reduced ejection fraction (HFrEF), and 56,395 had HF with preserved ejection fraction (HFpEF). In the overall HFrEF cohort, the primary outcome was similar (HR, 95% confidence interval, p-value) (1.01, 0.91 to 1.13, 0.811). AF readmission (0.41, 0.33 to 0.49, <0.001) and any readmission (0.87, 0.82 to 0.93, <0.001) were reduced with CA. In the propensity-matched HFrEF cohort, results were unchanged (primary outcome: 1.10, 0.95 to 1.27, 0.189; AF readmission: 0.46, 0.36 to 0.59, <0.001; any readmission: 0.89, 0.82 to 0.98, 0.015). In the overall HFpEF cohort, the primary outcome was similar (0.90, 0.78 to 1.04, 0.154). AF readmission was reduced with CA (0.54, 0.44 to 0.65, <0.001). In the propensity-matched HFpEF cohort, results were unchanged (primary outcome 1.10, 0.92 to 1.31, 0.289; AF readmission 0.44, 0.33 to 0.57, <0.001). CA did not reduce mortality and HF readmission at one year irrespective of the type of HF, but significantly reduce readmission due to AF.

Published by Elsevier Inc.

Am J Cardiol: 14 Dec 2020; 137:45-54
Arora S, Jaswaney R, Jani C, Zuzek Z, ... Viles-Gonzalez J, Deshmukh A
Am J Cardiol: 14 Dec 2020; 137:45-54 | PMID: 33002464
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Abstract

Thromboembolic Risk of Cessation of Oral Anticoagulation Post Catheter Ablation in Patients With and Without Atrial Fibrillation Recurrence.

Rong B, Han W, Lin M, Hao L, ... Wang R, Zhong J

Cessation of oral anticoagulation (OAC) is common after the first 3 months of catheter ablation of atrial fibrillation (AF); however, thromboembolic risk has not been defined in patients with and without AF recurrence (RAF vs NRAF) post ablation. We identified 796 patients who discontinued OAC at 3 months post AF ablation from January 2015 to May 2018 in our center. Regular follow-up was performed to detect RAF, collect medication management and thromboembolic and major bleeding events. CHADS-VASc score was 1.79 ± 1.50; 547 (68.7%) patients were at intermediate and high risk (i.e., CHADS-VASc score ≥1 in male patients, or ≥2 in female patients); 169 (21.2%) were RAF. During 29.2±12.2 months follow-up, the incidence rate of thromboembolism was 1.62 per 100 patient-year (7 in 431 years) in RAF, 0.33 per 100 patient-year (5 in 1,503 years) in NRAF. After adjusting for potential confounding factors, RAF was associated with more 3.5-fold higher rate of thromboembolism compared with NRAF (adjusting HR, 4.488; 95% CI, 1.381 to 14.586). Rate of thromboembolism was even higher in patients with intermediate and high risk (2.16 per 100 patient-year [7 in 323 years] vs 0.38 per 100 patient-year [4 in 1,043 years], aHR, 5.807; 95% CI, 1.631 to 20.671). In multivariate logistic regression analysis, RAF was the only independent predictor of thromboembolism (4.837 [1.498 to 15.621], p = 0.008). In conclusion, cessation of OAC in NRAF may be reasonable, especially for patients with the contraindications for continuing OAC; however, cessation of OAC appeared unsafe in RAF with a high-risk stroke profile because of high incidence rate of thromboembolism.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Dec 2020; 137:55-62
Rong B, Han W, Lin M, Hao L, ... Wang R, Zhong J
Am J Cardiol: 14 Dec 2020; 137:55-62 | PMID: 33002462
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Impact:
Abstract

Morbidity and mortality in patients precluded for transvenous pacemaker implantation: Experience with a leadless pacemaker.

Garg A, Koneru JN, Fagan DH, Stromberg K, ... Cheng A, Ellenbogen KA
Background
The Micra transcatheter pacemaker is a safe and effective alternative to transvenous permanent pacemakers (TV-PPMs). However, the safety profile and mortality outcomes of Micra implantation in patients deemed poor candidates for TV-PPM are incompletely understood.
Objective
The purpose of this study was to evaluate safety and all-cause mortality in patients undergoing Micra implantation stratified by whether they were precluded for therapy with a TV-PPM.
Methods
Patients from the Micra clinical trials were divided into groups on the basis of whether the implanter considered the patient to be precluded from receiving a TV-PPM. Micra groups were compared with one another as well as with a historical cohort of patients who received a single-chamber TV-PPM.
Results
A total of 2817 patients underwent a Micra implantation attempt, of whom 546 (19%) patients deemed ineligible for TV-PPM implantation for reasons such as venous access issues or prior device infections. Both acute mortality (2.75% vs 1.32%; P=.022) and total mortality at 36 months (38.1% vs 20.6%; P<.001) were significantly higher in the precluded group than in the nonprecluded group. Mortality was similar among nonprecluded patients and patients implanted with a TV-PPM. The major complication rate through 36 months was similar between the 2 Micra groups (3.81% vs 4.30%; P=.40).
Conclusion
All-cause mortality is higher in Micra patients deemed ineligible for TV-PPM implantation than in nonprecluded Micra patients and those who received a TV-PPM, in part related to a higher incidence of chronic comorbidities in these patients. The overall major complication rate was low and did not differ by preclusion status.
Clinical trial registration
Micra Post-Approval Registry ClinicalTrials.gov identifier: NCT02536118; Micra Continued Access Study ClinicalTrials.gov identifier: NCT02488681; Micra Transcatheter Pacing Study ClinicalTrials.gov identifier: NCT02004873; Medtronic Product Surveillance Registry ClinicalTrials.gov identifier: NCT01524276.

Copyright © 2020 Heart Rhythm Society. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2056-2063
Garg A, Koneru JN, Fagan DH, Stromberg K, ... Cheng A, Ellenbogen KA
Heart Rhythm: 29 Nov 2020; 17:2056-2063 | PMID: 32763431
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Abstract

Progressive implantable cardioverter-defibrillator therapies for ventricular tachycardia: The efficacy and safety of multiple bursts, ramps, and low-energy shocks.

Strik M, Ramirez FD, Welte N, Bonnin T, ... Ploux S, Bordachar P
Background
The Heart Rhythm Society, the European Heart Rhythm Association, the Asia Pacific Heart Rhythm Society, the Latin American Heart Rhythm Society expert consensus statement on optimal implantable cardioverter-defibrillator programming recommends burst antitachycardia pacing (ATP) for the treatment of ventricular tachycardia (VT) up to high rates. The number of bursts is not specified, and treatment by ramps or low-energy shocks is not recommended.
Objectives
We investigated the efficacy and safety of progressive therapies for VTs between 150 and 200 beats/min. After 3 failed bursts, we compared 3 ramps vs 3 bursts followed by a low-energy shock vs high-energy shock.
Methods
Using remote monitoring, we included monomorphic VT episodes treated with ≥1 burst.
Results
A total of 1126 VT episodes were included. A single burst was as likely to terminate VT between 150 and 200 beats/min as VT between 200 and 230 beats/min (63% vs 64%; P=.41), but was more likely to accelerate the latter (3.2% vs 0.25%; P<.01). For VT <200 beats/min, the likelihood of ATP success increased progressively (73% with 2 bursts, 78% with 3 bursts). Three additional bursts further increased VT termination to 89%, similar to the success rate with 3 additional ramps (88%; P=.17). Programming 6 bursts is associated with the probability of acceleration requiring shock of 6.6%. A low-energy first shock was less successful than a high-energy shock (66% vs 86%; P<.01) and more likely to accelerate VT (17% vs 0%; P<.01).
Conclusion
Programming up to 6 burst ATP therapies for VTs 150-200 beats/min can avoid implantable cardioverter-defibrillator shocks in most patients. Ramp ATP after failed bursts were similarly effective. Low-energy shocks are less effective and more arrhythmogenic than high-energy shocks.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2072-2077
Strik M, Ramirez FD, Welte N, Bonnin T, ... Ploux S, Bordachar P
Heart Rhythm: 29 Nov 2020; 17:2072-2077 | PMID: 32739474
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Impact:
Abstract

Mind the gap: Knowledge deficits in evaluating young sudden cardiac death.

Paratz E, Semsarian C, La Gerche A

Sudden cardiac arrest affects around half a million people aged under 50 years old annually, with a 90% mortality rate. Despite high patient numbers and clear clinical need to improve outcomes, many gaps exist in the evidence underpinning patients\' management. Domains identifying the greatest barriers to conducting trials are the prehospital and forensic settings, which also provide care to the majority of patients. Addressing gaps in evidence along each point of the cardiac arrest trajectory is a key clinical priority.

Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2208-2214
Paratz E, Semsarian C, La Gerche A
Heart Rhythm: 29 Nov 2020; 17:2208-2214 | PMID: 32721478
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Impact:
Abstract

High-rate pacing guided by short-term variability of repolarization prevents imminent ventricular arrhythmias automatically by an implantable cardioverter-defibrillator in the chronic atrioventricular block dog model.

Smoczyńska A, Loen V, Aranda A, Beekman HDM, Meine M, Vos MA
Background
The anesthetized, complete chronic atrioventricular block (CAVB) dog model allows reproducible inducibility of torsades de pointes (TdP) arrhythmias due to ventricular remodeling and after a challenge with an I blocker. High-rate pacing (HRP) prevents ventricular arrhythmias but has long-term detrimental effects on cardiac function when applied continuously. Temporal dispersion of repolarization, quantified as short-term variability (STV), increases before ventricular arrhythmias and has been proposed as a marker to guide HRP.
Objective
The purpose of this proof-of-principle study was to show that automatically determined STV can guide HRP to prevent imminent ventricular arrhythmias.
Methods
Eight CAVB dogs were implanted with an implantable cardioverter-defibrillator (ICD) with software to automatically determine STV (STV) in real time. During HRP, STV was measured offline from right ventricular (RV) electrograms (EGMs) and left ventricular (LV) monophasic action potential durations (MAPDs) (STV). The CAVB dogs were challenged twice with dofetilide (0.025 mg/kg intravenously over 5 minutes or until the first TdP). In experiment 1, the individual STV threshold before the first arrhythmic event was determined and programmed into the ICD. In experiment 2, HRP with 100 bpm was initiated automatically once the STV threshold was reached.
Results
In experiment 1, 8 of 8 dogs had repetitive TdP, and STV increased from 0.96 ± 0.42 ms to 2.10 ± 1.26 ms (P <.05). In experiment 2, all dogs reached the STV threshold. HRP decreased STV from 2.02 ± 1.12 ms to 0.78 ± 0.28 ms, which was accompanied by prevention of TdP in 7 of 8 dogs.
Conclusion
STV can guide HRP automatically by an ICD to prevent ventricular arrhythmias.

Copyright © 2020 The Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2078-2085
Smoczyńska A, Loen V, Aranda A, Beekman HDM, Meine M, Vos MA
Heart Rhythm: 29 Nov 2020; 17:2078-2085 | PMID: 32710972
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Impact:
Abstract

Effect of QRS area reduction and myocardial scar on the hemodynamic response to cardiac resynchronization therapy.

Okafor O, Umar F, Zegard A, van Dam P, ... Marshall H, Leyva F
Background
Vectorcardiographic QRS area (QRS) predicts clinical outcomes after cardiac resynchronization therapy (CRT). Myocardial scar adversely affects clinical outcomes after CRT.
Objective
The purpose of this study in patients with an ideally deployed quadripolar left ventricular (LV) lead (QUAD) was to determine whether reducing QRS leads to an acute hemodynamic response (AHR) and whether scar affects this interaction.
Methods
Patients (n = 26; age 69.2 ± 9.12 years [mean ± SD]) underwent assessment of the maximum rate of change of LV pressure (ΔLV dP/dt) during CRT using various left ventricular pacing locations (LVPLs). Cardiac magnetic resonance (CMR) scan was used to localize LV myocardial scar.
Results
Interindividually, ΔQRS (area under the receiver operating characteristic curve [AUC] 0.81; P <.001) and change in QRS duration (ΔQRSd) (AUC 0.76; P <.001) predicted ΔLV dP/dt after CRT. Scar burden correlated with ΔQRS (r = 0.35; P = .003), ΔQRS (r = 0.35; P = .003), and ΔQRSd (r = 0.46; P <.001). A reduction in QRS was observed with LVPLs remote from scar (-3.28 ± 38.1 μVs) or in LVPLs in patients with no scar at all (-43.8 ± 36.8 μVs), whereas LVPLs over scar increased QRS (22.2 ± 58.4 μVs) (P <.001 for all comparisons). LVPLs within 1 scarred LV segment were associated with lower ΔLV dP/dt (-2.21% ± 11.5%) than LVPLs remote from scar (5.23% ± 10.3%; P <.001) or LVPLs in patients with no scar at all (10.2% ± 7.75%) (both P <.001).
Conclusion
Reducing QRS improves the AHR to CRT. Myocardial scar adversely affects ΔQRS and the AHR. These findings may support the use of ΔQRS and CMR in optimizing CRT using QUAD.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2046-2055
Okafor O, Umar F, Zegard A, van Dam P, ... Marshall H, Leyva F
Heart Rhythm: 29 Nov 2020; 17:2046-2055 | PMID: 32717314
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Impact:
Abstract

Predictors of atrial mechanical sensing and atrioventricular synchrony with a leadless ventricular pacemaker: Results from the MARVEL 2 Study.

Garweg C, Khelae SK, Steinwender C, Chan JYS, ... Wood N, Chinitz L
Background
The MARVEL (Micra Atrial TRacking Using a Ventricular AccELerometer) 2 study assessed the efficacy of atrioventricular (AV) synchronous pacing with a Micra leadless pacemaker. Average atrioventricular synchrony (AVS) was 89.2%. Previously, low amplitude of the Micra-sensed atrial signal (A4) was observed to be a factor of low AVS.
Objective
The purpose of this study was to identify predictors of A4 amplitude and high AVS.
Methods
We analyzed 64 patients enrolled in MARVEL 2 who had visible P waves on electrocardiogram for assessing A4 amplitude and 40 patients with third-degree AV block for assessing AVS at rest. High AVS was defined as >90% correct atrial-triggered ventricular pacing. The association between clinical factors and echocardiographic parameters with A4 amplitude was investigated using a multivariable model with lasso variable selection. Variables associated with A4 amplitude together with premature ventricular contraction burden, sinus rate, and sinus rate variability (standard deviation of successive differences of P-P intervals [SDSD]) were assessed for association with AVS.
Results
In univariate analysis, low A4 amplitude was inversely related to atrial function assessed by E/A ratio and e\'/a\' ratio, and was directly related to atrial contraction excursion (ACE) and atrial strain (Ɛa) on echocardiography (all P ≤.05). The multivariable lasso regression model found coronary artery bypass graft history, E/A ratio, ACE, and Ɛa were associated with low A4 amplitude. E/A ratio and SDSD were multivariable predictors of high AVS, with >90% probability if E/A <0.94 and SDSD <5 bpm.
Conclusion
Clinical parameters and echocardiographic markers of atrial function are associated with A4 signal amplitude. High AVS can be predicted by E/A ratio <0.94 and low sinus rate variability at rest.

Copyright © 2020 The Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2037-2045
Garweg C, Khelae SK, Steinwender C, Chan JYS, ... Wood N, Chinitz L
Heart Rhythm: 29 Nov 2020; 17:2037-2045 | PMID: 32717315
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Impact:
Abstract

Is transesophageal echocardiography necessary in patients undergoing ablation of atrial fibrillation on an uninterrupted direct oral anticoagulant regimen? Results from a prospective multicenter registry.

Patel K, Natale A, Yang R, Trivedi C, ... Lakkireddy D, Di Biase L
Background
Thromboembolic stroke is a rare but devastating consequence of atrial fibrillation (AF) ablation. Transesophageal echocardiography (TEE) is recommended to rule out left atrial appendage thrombus; however, its use is variable.
Objective
The purpose of this study was to assess whether TEE is mandatory in patients undergoing AF ablation on uninterrupted direct oral anticoagulants (DOACs).
Methods
Data from our prospective multicenter registry of patients with AF undergoing radiofrequency catheter ablation on uninterrupted DOACs were analyzed. All the included patients were on anticoagulation for at least 4 weeks before ablation. All AF ablation procedures were performed under intracardiac echocardiography guidance. Before transseptal puncture, heparin bolus was administered, followed by continuous infusion, with a target activated clotting time of >300 seconds.
Results
A total of 6186 patients (3180 on apixaban [51.4%], 2528 on rivaroxaban [40.9%], 404 on dabigatran [6.5%], and 74 on edoxaban [1.2%]) were analyzed. The mean age of the study population was 69.4 ± 10.3 years; 4194 patients (67.8%) were male, and 5120 patients (82.8%) had persistent and long-standing persistent AF. The mean CHADS-VASc score was 2.86 ± 1.58; the mean CHADS score was 1.65 ± 1.14. Intracardiac echocardiography ruled out left atrial appendage and left atrial thrombi in all patients and revealed \"smoke\" in 1672 patients (27.03%). Transient ischemic attack was noted in 1 patient with long-standing persistent AF in the setting of a missed dose of rivaroxaban before ablation.
Conclusion
Our study showed that performing AF ablation in patients on uninterrupted DOACs without TEE is safe and feasible in high stroke risk patients. Elimination of routine preablation TEE would have significant economic and clinical implications.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2093-2099
Patel K, Natale A, Yang R, Trivedi C, ... Lakkireddy D, Di Biase L
Heart Rhythm: 29 Nov 2020; 17:2093-2099 | PMID: 32681991
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Impact:
Abstract

New algorithm for accessory pathway localization focused on screening septal pathways in pediatric patients with Wolff-Parkinson-White syndrome.

Baek SM, Song MK, Uhm JS, Kim GB, Bae EJ
Background
Published algorithms for accessory pathway localization in Wolff-Parkinson-White (WPW) syndrome are inaccurate in pediatric patients, especially for septal pathways.
Objective
We aimed to develop a new algorithm that is sensitive for septal pathways and more applicable in pediatric patients.
Methods
In 120 patients (mean age: 11.7 ± 3.9 years) who underwent catheter ablation for WPW syndrome, the candidate criteria for new algorithm were searched by comparing electrocardiography parameters and accessory pathway locations. A new algorithm was designed to increase the sensitivity for septal pathways. For validation, 142 patients (mean age: 15.8 ± 3.7 years) were additionally evaluated. New and published algorithms were applied to electrocardiography of 262 patients and the results were compared.
Results
The new algorithm achieved its best discrimination by combining several parameters together in each step: (1) QRS polarity in V and QRS shape in lead I for left/right discrimination, and (2) delta wave polarity in V, QRS transition in precordial leads, and delta wave polarity in lead III for septal pathway screening. The new algorithm showed higher sensitivity for septal pathways (95.7%) than 7 published algorithms (average: 62.1%), with satisfactory positive predictive value (77.9%). Delta wave polarity in V among septal pathways and QRS axis among right anteroseptal pathway showed age-related trend; this could be the reason for the lower accuracy in localizing septal pathways in children.
Conclusion
The inaccuracy of published algorithms in pediatric patients is due to the age-related trend in the electrocardiography of septal pathways. The new algorithm was superior for localizing septal pathways in pediatric patients.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2172-2179
Baek SM, Song MK, Uhm JS, Kim GB, Bae EJ
Heart Rhythm: 29 Nov 2020; 17:2172-2179 | PMID: 32681992
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Impact:
Abstract

Simultaneous epicardial-endocardial mapping of the sinus node in humans with structural heart disease: Impact of overdrive suppression on sinoatrial exits.

Parameswaran R, Lee G, Morris GM, Royse A, ... Kistler PM, Kalman JM
Background
The 3-dimensional (3D) nature of sinoatrial node (SAN) function has not been characterized in the intact human heart.
Objective
The purpose of this study was to characterize the 3D nature of SAN function in patients with structural heart disease (SHD) using simultaneous endocardial-epicardial (endo-epi) phase mapping.
Methods
Simultaneous intraoperative endo-epi SAN mapping was performed during sinus rhythm at baseline (SR) and postoverdrive suppression at 600 ms (SR) and 400 ms (SR) using 2 Abbott Advisor HD Grid Mapping Catheters. Unipolar and bipolar electrograms (EGMs) were exported for phase analysis to determine (1) activation exits; (2) wavefront propagation sequence; (3) endo-epi dissociation; and (4) fractionation. Comparison of these variables was made among the 3 rhythms from an endo-epi perspective.
Results
Sixteen patients with SHD were included. SR activations were unicentric and predominantly exited cranially (87.5%) with endo-epi synchrony. However, with overdrive suppression, a tendency for caudal exit shift and endo-epi asynchrony was observed: SR vs SR: cranial endo 75% vs 87.5% (P = .046); cranial epi 68.8% vs 87.5% (P = 0.002); caudal endo 12.5% vs 6.2% (P = 0.215); caudal epi 25% vs 6.2% (P = .0003); and SR vs SR: cranial endo 81.3% vs 87.5% (P = 0.335); cranial epi 68.7% vs 87.5% (P = 0.0034; caudal endo 12.5% vs 6.2% (P = .148); caudal epi 31.2% vs 6.2% (P = 0.0017), consistent with multicentricity. EGM fractionation was more prevalent with overdrive suppression.
Conclusion
During mapping of the intact human heart, SAN demonstrated redundancy of sinoatrial exits with postoverdrive shift in sites of earliest activation and epi-endo dissociation of sinoatrial exits.

Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 29 Nov 2020; 17:2154-2163
Parameswaran R, Lee G, Morris GM, Royse A, ... Kistler PM, Kalman JM
Heart Rhythm: 29 Nov 2020; 17:2154-2163 | PMID: 32622994
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Impact:
Abstract

Impact of the CHADS-VASc score on late clinical outcomes in patients undergoing left atrial appendage occlusion.

Agudelo V, Millán X, Li CH, Asmarats L, ... Serra A, Arzamendi D
Background
Left atrial appendage occlusion (LAAO) is an accepted strategy for cardioembolic events prevention in patients with non-valvular atrial fibrillation (AF) unsuitable for anticoagulation. However, uncertainties persist regarding the benefit of LAAO in highly-comorbid patients. The aim of this study was to assess the impact of the CHADS-VASc score beyond thromboembolic risk in predicting clinical outcomes in patients undergoing LAAO.
Methods
160 patients who underwent LAAO were included and categorized into two groups according to their stroke risk (89 with CHADS-VASc >4 vs. 71 with lower risk). The coprimary endpoints were death and stroke at follow-up. Thromboembolic and bleeding events were compared to those predicted from CHADS-VASc and HAS-BLED scores.
Results
Over a median follow-up of 679 days, CHADS-VASc >4 was associated with increased all-cause mortality compared with patients with lower thromboembolic risk (HR: 3.23; 95% CI: 1.28-8.19; p < 0.001). However, the rates of stroke after LAAO were not significantly different between risk groups. The observed annual rates of stroke and major bleeding were lower than predicted.
Conclusions
Despite increased long-term mortality in patients with CHADS-VASc >4, LAAO remains beneficial in reducing stroke and bleeding events in high-risk AF patients unsuitable for anticoagulation.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Nov 2020; 319:78-84
Agudelo V, Millán X, Li CH, Asmarats L, ... Serra A, Arzamendi D
Int J Cardiol: 14 Nov 2020; 319:78-84 | PMID: 32634500
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Impact:
Abstract

A review of global health technology assessments of non-VKA oral anticoagulants in non-valvular atrial fibrillation.

Lopes RD, Berger SE, Di Fusco M, Kang A, ... Deshpande S, Mantovani LG
Background
This review assessed global health technology assessment (HTA) reports and recommendations of non-vitamin K oral anticoagulants (NOACs) in non-valvular atrial fibrillation (NVAF).
Methods
NHTA agency websites were searched for HTA reports evaluating NOACs versus NOACs or vitamin K antagonists. HTA methods and information on patient involvement/access were collected and empirically analyzed.
Results
The review identified 38 unique HTA reports published between 2012 and 2017 in 16 countries including 11 in Europe. NOACs that were cost-effective per local willingness-to-pay (WTP) thresholds were positively recommended for the treatment of NVAF. WTP thresholds ranged from €20,000 to 69,000. Apixaban was recommended in 10/12 (83%) countries, dabigatran in 9/13 (69%) countries, and rivaroxaban in 10/13 (76%) over warfarin. Edoxaban was recommended in 5/7 (71%) countries. Economic evaluations and recommendations comparing NOACs were sparse (two or three countries per NOAC) and generally favored apixaban and edoxaban, followed by dabigatran. Eleven HTA reports from four countries considered the patient voice (Canada [n = 3], Scotland [n = 3], England [n = 4], Brazil [n = 1]); however, only 2/11 (18%) developed recommendations based on this. Among the reports with a positive recommendation, 26/30 (87%) featured a decision that aligned with the approved regulatory label.
Conclusions
Most agencies recommended NOACs over warfarin for patients with NVAF. Few countries made statements recommending one NOAC over another. Given different WTP thresholds, a drug that is cost-effective in one market may not be in another. Therefore, the various NOAC recommendations from HTA agencies cannot be generalized across different countries.

Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Nov 2020; 319:85-93
Lopes RD, Berger SE, Di Fusco M, Kang A, ... Deshpande S, Mantovani LG
Int J Cardiol: 14 Nov 2020; 319:85-93 | PMID: 32634487
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Impact:
Abstract

Kidney function and the risk of heart failure in patients with new-onset atrial fibrillation.

Carrero JJ, Trevisan M, Evans M, Svennberg E, Szummer K
Aims
Heart failure (HF) is the most common complication of patients with atrial fibrillation (AF), but possible risk factors or health consequences are not well described. Low kidney function is a risk factor for both AF and HF. We evaluated estimated glomerular filtration rate (eGFR) as a predictor of HF in patients with AF, and then quantified the adverse health outcomes associated to incident HF.
Methods and results
This is an observational analysis of 19,662 adults without a previous history of HF who had new-onset AF in Stockholm healthcare (Sweden) during 2007-2011. During a median of 713 (IQR 281-1253) days of follow up, 3342 (16.4%) patients developed HF, with incidence rate of 7.4 per 100-person-years (95% CI 7.2-7.7). In Cox regression, eGFR was linearly associated with subsequent HF risk. Compared to eGFR≥60 ml/min/1.73 m, patients with eGFR 30-59 and eGFR<30 ml/min/1.73 m had 13% (HR 1.13; 95% CI 1.04-1.23) and 53% (HR 1.53; 1.25-1.88) higher risk of HF. Results were consistent across various pre-specified subgroups and after excluding early events. Compared to non-HF, developing HF (as a time-varying exposure) was associated with a 5-fold (HR 5.05; 4.07-6.28) higher risk of subsequent kidney function decline, a 1.5 times higher risk of stroke (HR 1.54; 1.35-1.76), and a doubling in the risk of myocardial infarction (HR 2.21; 1.87-2.62) and death (HR 2.17; 2.01-2.33).
Conclusion
In patients with AF, low kidney function associates with the risk of HF. Developing HF heightened the subsequent risk of kidney function decline, cardiovascular event and death.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 30 Nov 2020; 320:101-105
Carrero JJ, Trevisan M, Evans M, Svennberg E, Szummer K
Int J Cardiol: 30 Nov 2020; 320:101-105 | PMID: 32768410
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Impact:
Abstract

Factors associated with bleeding events in patients on rivaroxaban for non-valvular atrial fibrillation: A real-world experience.

Akhtar T, Fratti JDC, Mattumpuram J, Fugar S, ... Mann H, Golzar Y
Background
Rivaroxaban is a direct oral anticoagulant (DOAC) approved for the treatment of non-valvular atrial fibrillation (NVAF). Data related to the risk factors associated with rivaroxaban-induced bleeding in patients with NVAF remain scarce in the community setting. We sought to investigate these bleeding risk factors in a racially diverse patient population.
Methods
We conducted a single-center, retrospective study based on a chart review of patients who received rivaroxaban from our outpatient pharmacy from January 2015 to April 2018 for NVAF. Any reported bleeding event (BE) was recorded as either major or minor bleeding event. Demographic and clinical data were collected and analyzed.
Results
Of the 327 patients included in our analysis, 105 (32%) were female, and the mean age was 62 ± 12 years. Among the included patients, 176 (54%) patients were black, 71 (22%) were white, 51 (15.6%) were Hispanic, 13 (4%) were Asian, and 15 (4.6%) belonged to other races. 89 (27.2%) of the patients had co-prescription of aspirin. A total of 24 (7.3%) patients developed BE, out of which 9 (2.7%) patients had a major BE, and 15 (4.5%) patients had minor BE. Non-fatal gastrointestinal bleeding and epistaxis were the most common type of BE. On multivariable analysis, concurrent aspirin use (81 to 325 mg) (P = 0.03; odds ratio (OR) 2.60 [1.08-6.28]) and increasing age (P = 0.00; OR 1.06 [1.01-1.11]) were independent predictors of BE.
Conclusion
In community practice, aspirin co-prescription is common among NVAF patients prescribed rivaroxaban. Increasing age and concurrent aspirin use are independent predictors of BE.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Nov 2020; 320:78-82
Akhtar T, Fratti JDC, Mattumpuram J, Fugar S, ... Mann H, Golzar Y
Int J Cardiol: 30 Nov 2020; 320:78-82 | PMID: 32598991
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Impact:
Abstract

Prognostic value of chemokines in patients with newly diagnosed atrial fibrillation.

Huang J, Wu N, Xiang Y, Wu L, ... Zhong L, Li Y
Background
Chemokines play an important role in inflammation and atherosclerosis. However, little is known about the relationship between chemokines and the prognosis of atrial fibrillation (AF). This \"real-world\" cohort study was designed to observe the prognostic value of plasma CC motif chemokine ligand (CCL) 18, CCL23, CCL28, CXC motif chemokine ligand (CXCL) 14, CXCL16 in newly diagnosed AF patients.
Methods
Baseline plasma levels of chemokines were measured in a cohort with 299 AF patients using Bio-plex Pro™ xMAP arrays. A Cox proportional hazard model was used to evaluate the associations of chemokines with AF outcomes. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were calculated to evaluate the improvement of chemokines to CHADS-VASc score.
Results
High CCL18 (hazard ratio [HR] 2.65, 95% confidence interval [CI] 1.18-5.98, P = 0.019) and CCL23 levels (HR 2.78, 95%CI 1.07-7.22, P = 0.036) were associated with stroke in AF patient. Patients with low CXCL14 (HR 0.39, 95%CI 0.15-0.97, P = 0.042) and high CXCL16 levels (HR 3.02, 95%CI 1.39-6.58, P = 0.005) have increased risk of all-cause mortality. High CCL16 levels (HR 5.41, 95%CI 2.32-12.63, P < 0.001) were associated with cardiovascular death. However, CCL28 had no significant association with outcomes. Adding chemokines to CHADS-VASc score increased the reclassification and clinical net benefit.
Conclusions
Plasma levels of CCL18, CCL23, CXCL14, and CXCL16 were independently associated with AF outcomes. Chemokines added to CHADS-VASc score significantly enhanced risk assessment for the outcomes. Incorporation of chemokines into clinical decisions may help the management of AF treatment.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Nov 2020; 320:83-89
Huang J, Wu N, Xiang Y, Wu L, ... Zhong L, Li Y
Int J Cardiol: 30 Nov 2020; 320:83-89 | PMID: 32603741
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Impact:
Abstract

Serum N-terminal pro-B-type natriuretic peptide as a predictor for future development of atrial fibrillation in a general population: the Hisayama Study.

Nagata T, Hata J, Sakata S, Oishi E, ... Tsutsui H, Ninomiya T
Background
Biomarkers for predicting future development of atrial fibrillation (AF) have not been fully established in general populations. The aim of this study was to assess the predictive ability of serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) for the development of AF.
Methods and results
A total of 3126 community-dwelling Japanese subjects aged ≥ 40 years without a history of AF in 2002 were followed up for a median of 10.2 years. Serum NT-proBNP levels at baseline were divided into four categories (≤ 54, 55-124, 125-299, and ≥ 300 pg/mL) according to the current guidelines and prior reports. The hazard ratios for the development of AF were estimated using a Cox proportional hazards model. During the follow-up period, 153 subjects developed new-onset AF. The age- and sex-adjusted cumulative incidence of AF increased significantly with higher serum NT-proBNP levels (p < 0.001 for trend). The association remained significant after adjustment for known risk factors for AF and cardiovascular disease (hazard ratio [95% confidence interval]: ≤ 54 pg/mL: 1.00 [reference]; 55-124 pg/mL: 1.72 [1.00-2.97]; 125-299 pg/mL: 3.95 [2.23-6.98]; ≥ 300 pg/mL: 8.51 [4.48-16.17]; p < 0.001 for trend). Furthermore, incorporation of serum NT-proBNP levels into the model consisting of known risk factors for AF and cardiovascular disease significantly improved the predictive ability for developing AF (Harrell\'s c-statistics: 0.828 to 0.844, p = 0.01; continuous net reclassification improvement: 0.41, p < 0.001; integrated discrimination improvement: 0.031, p < 0.001).
Conclusions
Serum NT-proBNP levels can be a risk biomarker for predicting future development of AF in a general Japanese population.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Nov 2020; 320:90-96
Nagata T, Hata J, Sakata S, Oishi E, ... Tsutsui H, Ninomiya T
Int J Cardiol: 30 Nov 2020; 320:90-96 | PMID: 32592745
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Impact:
Abstract

Closing gigantic left atrial appendage using a LAmbre Closure System: first implant experience in North America.

Inohara T, Tsang MY, Lee C, Saw J

Despite maturing experience and growing procedural familiarity, there remain challenges in percutaneous left atrial appendage (LAA) closure due to anatomical complexities. We report a complex and extremely large LAA that was successfully closed percutaneously using a LAmbre Closure System (Lifetech Scientific Corp., Shenzhen, China). Cardiac computed tomography angiography demonstrated a gigantic multi-lobed LAA measuring 48 by 45.3mm at the level of the ostium, that can not be occluded by the currently approved LAA closure devices in Canada. A LAmbre Closure System 30/50mm (lobe/disc) was then successfully deployed under fluoroscopy and transesophageal echocardiogram guidance without procedure-related complications. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
Inohara T, Tsang MY, Lee C, Saw J
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179356
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Abstract

Accuracy of left atrial fibrosis detection with cardiac magnetic resonance: correlation of late gadolinium enhancement with endocardial voltage and conduction velocity.

Caixal G, Alarcón F, Althoff TF, Nuñez-Garcia M, ... Guasch E, Mont L
Aims
Myocardial fibrosis is a hallmark of atrial fibrillation (AF) and its characterization could be used to guide ablation procedures. Late gadolinium enhanced-magnetic resonance imaging (LGE-MRI) detects areas of atrial fibrosis. However, its accuracy remains controversial. We aimed to analyse the accuracy of LGE-MRI to identify left atrial (LA) arrhythmogenic substrate by analysing voltage and conduction velocity at the areas of LGE.
Methods and results
Late gadolinium enhanced-magnetic resonance imaging was performed before ablation in 16 patients. Atrial wall intensity was normalized to blood pool and classified as healthy, interstitial fibrosis, and dense scar tissue depending of the resulting image intensity ratio. Bipolar voltage and local conduction velocity were measured in LA with high-density electroanatomic maps recorded in sinus rhythm and subsequently projected into the LGE-MRI. A semi-automatic, point-by-point correlation was made between LGE-MRI and electroanatomical mapping. Mean bipolar voltage and local velocity progressively decreased from healthy to interstitial fibrosis to scar. There was a significant negative correlation between LGE with voltage (r = -0.39, P < 0.001) and conduction velocity (r = -0.25, P < 0.001). In patients showing dilated atria (LA diameter ≥45 mm) the conduction velocity predictive capacity of LGE-MRI was weaker (r = -0.40 ± 0.09 vs. -0.20 ± 0.13, P = 0.02).
Conclusions
Areas with higher LGE show lower voltage and slower conduction in sinus rhythm. The enhancement intensity correlates with bipolar voltage and conduction velocity in a point-by-point analysis. The performance of LGE-MRI in assessing local velocity might be reduced in patients with dilated atria (LA diameter ≥45).

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 22 Nov 2020; epub ahead of print
Caixal G, Alarcón F, Althoff TF, Nuñez-Garcia M, ... Guasch E, Mont L
Europace: 22 Nov 2020; epub ahead of print | PMID: 33227129
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Impact:
Abstract

Long-term incidence and predictive factors of thromboembolic events after a cryoballoon ablation for atrial fibrillation.

Hermida A, Zaitouni M, Diouf M, Lallemand PM, ... Kubala M, Hermida JS
Background
Long-term outcomes in terms of thromboembolic events (TEs) are poorly described after cryoballoon pulmonary vein isolation (cryo-PVI) for atrial fibrillation (AF). We evaluated the long-term incidence and predictive factors of TE after cryo-PVI.
Methods
All consecutive patients who underwent cryo-PVI for paroxysmal or persistent AF between November 2012 and October 2017 were included. They were prospectively followed for at least 12 months in the ablation center and then by their cardiologist. Data on all ischemic events (stroke, transient ischemic attack (TIA), systemic embolism) were collected.
Results
In total, 450 patients (78% men, median age 61 years) were included. The mean CHADS-VASc score was 1.6 ± 1.3 and 26 patients (6%) had a history of stroke/TIA before the procedure. OAT was discontinued for 75 patients (17%) after the procedure, among whom 50 (67%) had no indication for long-term anticoagulation. Six patients experienced an ischemic event, all considered as a TE: three strokes, two TIAs, and one acute lower-limb ischemia. The mean follow up was 30 months. Thus, the incidence of TE was 0.53%/year. Three of the six patients who experienced a TE had no recurrence of atrial arrhythmia documented before, at the time, or after the event. All patients who experienced a TE had a class I or class IIa indication for long-term anticoagulation. After multivariate analysis, the CHADS-VASc Score (p = .0005) was a predictor of TEs.
Conclusion
The long-term incidence of TEs after cryo-PVI was 0.53%/year. The CHADS-VASc Score was the only independent predictor of TEs.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Dec 2020; 321:99-103
Hermida A, Zaitouni M, Diouf M, Lallemand PM, ... Kubala M, Hermida JS
Int J Cardiol: 14 Dec 2020; 321:99-103 | PMID: 32810541
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Impact:
Abstract

Antiplatelet patterns and outcomes in patients with atrial fibrillation not prescribed an anticoagulant after stroke.

Chang KW, Xian Y, Zhao X, Mi X, ... Fonarow GC, Hsu JC
Background
To determine association of discharge antiplatelet therapy prescription with 1-year outcomes among patients with AF admitted with acute ischemic stroke and discharged without oral anticoagulation.
Methods
In a retrospective cohort study from the Get With The Guidelines-Stroke registry, we identified all Medicare fee-for-service beneficiaries 65 years or older with AF or atrial flutter admitted with acute ischemic stroke and discharged without oral anticoagulation from April 2003 through December 2014, and we determined association of discharge antiplatelet therapy prescription with 1-year outcomes using Medicare claims data. Primary outcomes were 1-year mortality and composite endpoint of major adverse cardiovascular/neurologic/bleeding events (MACNBE).
Results
Of 64,228 subjects (median [interquartile range] age, 84 [78-89] years; 62.5% female), 54,621 (85.0%) were discharged with antiplatelet therapy, and 9607 (15.0%) were discharged with no antithrombotic therapy. The unadjusted rates of 1-year mortality were lower among patients receiving antiplatelet therapy (37.3%) than among those receiving no antithrombotic therapy (48.1%); unadjusted rates of MACNBE were lower for those receiving antiplatelet therapy (45.5%) compared with those receiving no antithrombotic therapy (55.2%). After adjusting for potential confounders, antiplatelet therapy prescription was associated with reduced 1-year mortality (adjusted hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.62-0.66, P < .001) and MACNBE (adjusted HR 0.69, 95% CI 0.67-0.71, P < .001).
Conclusions
Among Medicare beneficiaries with AF admitted for acute ischemic stroke but not discharged on oral anticoagulant therapy, antiplatelet therapy, compared with no antithrombotic therapy, was associated with reduced 1-year mortality and MACNBE.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Dec 2020; 321:88-94
Chang KW, Xian Y, Zhao X, Mi X, ... Fonarow GC, Hsu JC
Int J Cardiol: 14 Dec 2020; 321:88-94 | PMID: 32805327
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Impact:
Abstract

The coronary artery calcium score correlates with left atrial low-voltage area: Sex differences.

Hojo R, Fukamizu S, Tokioka S, Inagaki D, ... Sakurada H, Hiraoka M
Introduction
In patients with coronary artery disease, a high coronary artery calcium score (CACS) correlates with atrial fibrillation (AF); however, the association between left atrial (LA) remodeling progression and coronary arteriosclerosis is unclear. This study aimed to evaluate the relationship between LA remodeling progression and the CACS.
Methods
This retrospective study enrolled 148 patients with AF (paroxysmal AF, n=94) who underwent catheter ablation. Voltage mapping for the left atrium and coronary computed tomography for CACS calculations were performed. The ratio of the LA low-voltage area (LA-LVA), defined by values <0.5 mV divided by the total LA surface without pulmonary veins, was calculated. Patients with LA-LVA (<0.5 mV) >5% and ≤5% were classified as the LVA (n=30) and non-LVA (n=118) groups, respectively. Patient characteristics and CACS values were compared between the two groups.
Results
LA volume, age, CHA DS VASc score, and percentage of female patients were significantly higher, and the estimated glomerular filtration rate was lower in the LVA group than in the non-LVA group. The CACS was significantly higher in the LVA group (248.4 vs 13.2, p=0.001). Multivariate analysis identified the LA volume index and CACS as independent predictors of LA-LVA (<0.5 mV) >5%. The areas under the receiver operating characteristic curves for predicting LA-LVA (<0.5 mV) >5% with CACS were 0.695 in the entire population, 0.782 in men, and 0.587 in women.
Conclusion
Progression of LA remodeling and coronary artery calcification may occur in parallel. A high CACS may indicate advanced LA remodeling, especially in men. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Nov 2020; epub ahead of print
Hojo R, Fukamizu S, Tokioka S, Inagaki D, ... Sakurada H, Hiraoka M
J Cardiovasc Electrophysiol: 17 Nov 2020; epub ahead of print | PMID: 33206418
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Impact:
Abstract

Prognostic impact of multiple fragmented QRS on cardiac events in idiopathic dilated cardiomyopathy.

Marume K, Noguchi T, Kamakura T, Tateishi E, ... Ogawa H, Yasuda S
Aims 
To evaluate the prognostic impact of fragmented QRS (fQRS) on idiopathic dilated cardiomyopathy (DCM).
Methods and results 
We conducted a prospective observational study of 290 consecutive patients with DCM (left ventricular ejection fraction ≤ 40%) and narrow QRS who underwent cardiac magnetic resonance. We defined fQRS as the presence of various RSR\' patterns in ≥2 contiguous leads representing the anterior (V1-V5), inferior (II, III, and aVF), or lateral (I, aVL, and V6) myocardial segments. Multiple fQRS was defined as the presence of fQRS in ≥2 myocardial segments. Patients were divided into three groups: no fQRS, single fQRS, or multiple fQRS. The primary endpoint was a composite of hard cardiac events consisting of heart failure death, sudden cardiac death (SCD), or aborted SCD. The secondary endpoints were all-cause death and arrhythmic event. During a median follow-up of 3.8 years (interquartile range, 1.8-6.2), 31 (11%) patients experienced hard cardiac events. Kaplan-Meier analysis showed that the rates of hard cardiac events and all-cause death were similar in the single-fQRS and no-fQRS groups and higher in the multiple-fQRS group (P = 0.004 and P = 0.017, respectively). Multivariable Cox regression identified that multiple fQRS is a significant predictor of hard cardiac events (hazard ratio, 2.23; 95% confidence interval, 1.07-4.62; P = 0.032). The multiple-fQRS group had the highest prevalence of a diffuse late gadolinium enhancement pattern (no fQRS, 21%; single fQRS, 22%; multiple fQRS, 39%; P < 0.001).
Conclusion 
Multiple fQRS, but not single fQRS, is associated with future hard cardiac events in patients with DCM.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 18 Nov 2020; epub ahead of print
Marume K, Noguchi T, Kamakura T, Tateishi E, ... Ogawa H, Yasuda S
Europace: 18 Nov 2020; epub ahead of print | PMID: 33212485
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Impact:
Abstract

Electrophysiological Identification of Superior Vena Cava: Novel Insight into Slow Conduction or Conduction Block.

Matsunaga-Lee Y, Egami Y, Ukita K, Kawamura A, ... Nishino M, Tanouchi J
Introduction
It has not been clarified how to identify the electrophysiological junction between right atrium (RA) and superior vena cava (SVC). The aim of this study was to identify the electrophysiological RA-SVC junction according to slow conduction or conduction bock and to examine the electrophysiological SVC isolation procedure.
Methods
Seventy-three consecutive atrial fibrillation patients who underwent SVC mapping using a CARTO 3 system were enrolled in this study. Slow conduction or conduction block between the RA and SVC was identified by adjusting the lower threshold criteria of the early meets late function and was described as a white line. The SVC isolation was performed along the white line and with pacing maneuvers to confirm direct SVC capture.
Results
Activation mapping (1296±631 points) was obtained in 66 patients (90%) in 4.6±1.8 min. Slow conduction or conduction block was observed in all patients. The threshold for detecting slow conduction or conduction block was 24±8 ms. The location of the electrophysiological RA-SVC junction was higher in the anterior portion (anterior-septal, anterior, and anterior-lateral) than in the posterior portion (posterior-septal, posterior, and posterior-lateral) (-2.3±6.2 mm vs. 7.1±6.3 mm, p<0.001). The SVC isolation at the electrophysiological RA-SVC junction was successful in all patients without any injury to the sinus node function. Asymptomatic phrenic nerve injury was observed in 3 patients (4.5%).
Conclusion
In all patients, the electrophysiological RA-SVC junction determined by slow conduction or conduction block was identified and the electrophysiological SVC isolation was performed successfully and safely. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 18 Nov 2020; epub ahead of print
Matsunaga-Lee Y, Egami Y, Ukita K, Kawamura A, ... Nishino M, Tanouchi J
J Cardiovasc Electrophysiol: 18 Nov 2020; epub ahead of print | PMID: 33210777
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Abstract

Diagnostic yield and accuracy in a tertiary referral syncope unit validating the ESC guideline on syncope: a prospective cohort study.

de Jong JSY, Blok MRS, Thijs RD, Harms MPM, ... van Dijk N, de Lange FJ
Aims 
To assess in patients with transient loss of consciousness the diagnostic yield, accuracy, and safety of the structured approach as described in the ESC guidelines in a tertiary referral syncope unit.
Methods and results 
Prospective cohort study including 264 consecutive patients (≥18 years) referred with at least one self-reported episode of transient loss of consciousness and presenting to the syncope unit between October 2012 and February 2015. The study consisted of three phases: history taking (Phase 1), autonomic function tests (AFTs) (Phase 2), and after 1.5-year follow-up with assessment by a multidisciplinary committee (Phase 3). Diagnostic yield was assessed after Phases 1 and 2. Empirical diagnostic accuracy was measured for diagnoses according to the ESC guidelines after Phase 3. The diagnostic yield after Phase 1 (history taking) was 94.7% (95% CI: 91.1-97.0%, 250/264 patients) and increased to 97.0% (93.9-98.6%, 256/264 patients) after Phase 2. The overall diagnostic accuracy (as established in Phase 3) of the Phases 1 and 2 diagnoses was 90.6% (95% CI: 86.2-93.8%, 232/256 patients). No life-threatening conditions were missed. Three patients died, two unrelated to the cause of transient loss of consciousness, and one whom remained undiagnosed.
Conclusion 
A clinical work-up at a tertiary syncope unit using the ESC guidelines has a high diagnostic yield, accuracy, and safety. History taking (Phase 1) is the most important diagnostic tool. Autonomic function tests never changed the Phase 1 diagnosis but helped to increase the certainty of the Phase 1 diagnosis in many patients and yield additional diagnoses in patients who remained undiagnosed after Phase 1. Diagnoses were inaccurate in 9.4%, but no serious conditions were missed. This is adequate for clinical practice.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 20 Nov 2020; epub ahead of print
de Jong JSY, Blok MRS, Thijs RD, Harms MPM, ... van Dijk N, de Lange FJ
Europace: 20 Nov 2020; epub ahead of print | PMID: 33219671
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Abstract

Incidence, epidemiology, diagnosis and prognosis of atrio-oesophageal fistula following percutaneous catheter ablation: a French nationwide survey.

Gandjbakhch E, Mandel F, Dagher Y, Hidden-Lucet F, Rollin A, Maury P
Aims
Rate, incidence, risk factors, and optimal management of atrio-oesophageal fistula (AOF) after catheter ablation for atrial fibrillation (AF) remain obscure.
Methods and results
All French centres performing AF ablation were identified and surveys were sent concerning the number of procedures, eventual cases of AOF, and characteristics of such cases. Eighty-two of the 103 centres (80%) performing AF ablation in France were included, with a total of 129 286 AF ablations since 2006 (93% of the whole procedures in France). Thirty-three AOF were reported (reported rate 0.026% per procedure) with a stable reported annual incidence despite the increasing number of procedures. Sensitivity of computed tomography (CT) scan for AOF was 81%. Mortality was 60%, significantly lower in case of surgical corrective therapy (31 vs. 93%, P = 0.001).
Conclusion
The reported rate of AOF after AF ablation in this nationwide survey was 0.026%, with a stable reported annual incidence over time. A normal CT scan does not rule out the diagnosis and should be repeated in case of suspicion. Prognosis remains poor with a mortality of 60% and crucially dependant of immediate surgical correction. No clear protective strategy has been proven effective.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 20 Nov 2020; epub ahead of print
Gandjbakhch E, Mandel F, Dagher Y, Hidden-Lucet F, Rollin A, Maury P
Europace: 20 Nov 2020; epub ahead of print | PMID: 33221901
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Impact:
Abstract

Changing paradigms: from prevention of thromboembolic events to improved survival in patients with atrial fibrillation.

Escobar C, Camm AJ

Atrial fibrillation is associated with a five-fold increase in the risk of stroke. Current guidelines recommend the use of the CHA2DS2-VASc score to stratify the risk of stroke. In addition, guidelines recommend the identification of the conditions that increase the risk of haemorrhage to be modified and thus decrease the risk of bleeding. Nevertheless, many patients with a high thromboembolic risk are prescribed antiplatelet treatment or do not receive any antithrombotic therapy. In addition, therapeutic inertia is common in anticoagulated patients taking vitamin K antagonists, and underdosing is an emerging problem with direct oral anticoagulants, probably because many physicians consider the risk of stroke and the risk of major bleeding to be equal. It is necessary to develop a new approach to risk stratification, an approach that moves from morbidity to mortality, i.e., from stratification of the risk of stroke and major bleeding to stratification of the risk of mortality associated with stroke and the risk of mortality associated with bleeding. In this article, we propose a novel risk stratification approach based on the mortality associated with stroke and bleeding, illustrated by data derived from the literature.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 21 Nov 2020; epub ahead of print
Escobar C, Camm AJ
Europace: 21 Nov 2020; epub ahead of print | PMID: 33221894
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Impact:
Abstract

Clinical outcomes and programming strategies of implantable cardioverter-defibrillator devices in paediatric hypertrophic cardiomyopathy: a UK National Cohort Study.

Norrish G, Chubb H, Field E, McLeod K, ... Mangat J, Kaski JP
Aims
Sudden cardiac death (SCD) is the most common mode of death in paediatric hypertrophic cardiomyopathy (HCM). This study describes the implant and programming strategies with clinical outcomes following implantable cardioverter-defibrillator (ICD) insertion in a well-characterized national paediatric HCM cohort.
Methods and results
Data from 90 patients undergoing ICD insertion at a median age 13 (±3.5) for primary (n = 67, 74%) or secondary prevention (n = 23, 26%) were collected from a retrospective, longitudinal multi-centre cohort of children (<16 years) with HCM from the UK. Seventy-six (84%) had an endovascular system [14 (18%) dual coil], 3 (3%) epicardial, and 11 (12%) subcutaneous system. Defibrillation threshold (DFT) testing was performed at implant in 68 (76%). Inadequate DFT in four led to implant adjustment in three patients. Over a median follow-up of 54 months (interquartile range 28-111), 25 (28%) patients had 53 appropriate therapies [ICD shock n = 45, anti-tachycardia pacing (ATP) n = 8], incidence rate 4.7 per 100 patient years (95% CI 2.9-7.6). Eight inappropriate therapies occurred in 7 (8%) patients (ICD shock n = 4, ATP n = 4), incidence rate 1.1/100 patient years (95% CI 0.4-2.5). Three patients (3%) died following arrhythmic events, despite a functioning device. Other device complications were seen in 28 patients (31%), including lead-related complications (n = 15) and infection (n = 10). No clinical, device, or programming characteristics predicted time to inappropriate therapy or lead complication.
Conclusion
In a large national cohort of paediatric HCM patients with an ICD, device and programming strategies varied widely. No particular strategy was associated with inappropriate therapies, missed/delayed therapies, or lead complications.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 21 Nov 2020; epub ahead of print
Norrish G, Chubb H, Field E, McLeod K, ... Mangat J, Kaski JP
Europace: 21 Nov 2020; epub ahead of print | PMID: 33221861
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Abstract

Clinical characterization of the first Belgian SCN5A founder mutation cohort.

Sieliwonczyk E, Alaerts M, Robyns T, Schepers D, ... Saenen J, Loeys B
Aims
We identified the first Belgian SCN5A founder mutation, c.4813 + 3_4813 + 6dupGGGT. To describe the clinical spectrum and disease severity associated with this mutation, clinical data of 101 SCN5A founder mutation carriers and 46 non-mutation carrying family members from 25 Belgian families were collected.
Methods and results
The SCN5A founder mutation was confirmed by haplotype analysis. The clinical history and electrocardiographic parameters of the mutation carriers and their family members were gathered and compared. A cardiac electrical abnormality was observed in the majority (82%) of the mutation carriers. Cardiac conduction defects, defined as PR or QRS prolongation on electrocardiogram (ECG), were most frequent, occurring in 65% of the mutation carriers. Brugada syndrome (BrS) was the second most prevalent phenotype identified in 52%, followed by atrial dysrythmia in 11%. Overall, 33% of tested mutation carriers had a normal sodium channel blocker test. Negative tests were more common in family members distantly related to the proband. Overall, 23% of the mutation carriers were symptomatic, with 8% displaying major adverse events. As many as 13% of the patients tested with a sodium blocker developed ventricular arrhythmia. One family member who did not carry the founder mutation was diagnosed with BrS.
Conclusion
The high prevalence of symptoms and sensitivity to sodium channel blockers in our founder population highlights the adverse effect of the founder mutation on cardiac conduction. The large phenotypical heterogeneity, variable penetrance, and even non-segregation suggest that other genetic (and environmental) factors modify the disease expression, severity, and outcome in these families.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 21 Nov 2020; epub ahead of print
Sieliwonczyk E, Alaerts M, Robyns T, Schepers D, ... Saenen J, Loeys B
Europace: 21 Nov 2020; epub ahead of print | PMID: 33221854
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Abstract

Effect of alcohol consumption on the risk of adverse events in atrial fibrillation: from the COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation (CODE-AF) registry.

Lim C, Kim TH, Yu HT, Lee SR, ... Lee YS, Joung B
Aims
The aim of this study is to determine the relationship between alcohol consumption and atrial fibrillation (AF)-related adverse events in the AF population.
Methods and results
A total of 9411 patients with nonvalvular AF in a prospective observational registry were categorized into four groups according to the amount of alcohol consumption-abstainer-rare, light (<100 g/week), moderate (100-200 g/week), and heavy (≥200 g/week). Data on adverse events (ischaemic stroke, transient ischaemic attack, systemic embolic event, or AF hospitalization including for AF rate or rhythm control and heart failure management) were collected for 17.4 ± 7.3 months. A Cox proportional hazard models was performed to calculate hazard ratios (HRs), and propensity score matching was conducted to validate the results. The heavy alcohol consumption group showed an increased risk of composite adverse outcomes [adjusted hazard ratio (aHR) 1.32, 95% confidence interval (CI) 1.06-1.66] compared with the reference group (abstainer-rare group). However, no significant increased risk for adverse outcomes was observed in the light (aHR 0.88, 95% CI 0.68-1.13) and moderate (aHR 0.91, 95% CI 0.63-1.33) groups. In subgroup analyses, adverse effect of heavy alcohol consumption was significant, especially among patients with low CHA2DS2-VASc score, without hypertension, and in whom β-blocker were not prescribed.
Conclusion
Our findings suggest that heavy alcohol consumption increases the risk of adverse events in patients with AF, whereas light or moderate alcohol consumption does not.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 22 Nov 2020; epub ahead of print
Lim C, Kim TH, Yu HT, Lee SR, ... Lee YS, Joung B
Europace: 22 Nov 2020; epub ahead of print | PMID: 33227134
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Abstract

Pediatric catheter ablation at the beginning of the 21st century: results from the European Multicenter Pediatric Catheter Ablation Registry \'EUROPA\'.

Krause U, Paul T, Bella PD, Gulletta S, ... Ferrari P, De Filippo P
Aims
Contemporary data from prospective multicentre registries on catheter ablation in pediatric patients are sparse. Aim of the European Pediatric Catheter Ablation Registry EUROPA was to contribute data to fill this gap of knowledge.
Methods and results
From July 2012 to June 2017, data on catheter ablation in pediatric patients (≤18 years of age) including a 1-year follow-up from five European pediatric EP centres were collected prospectively. A total of 683 patients (mean age 12.4 ± 3.9 years, mean body weight 50.2 ± 19 kg) were enrolled. Target tachycardia was WPW/atrioventricular-nodal re-entrant tachycardia (AVRT) in 380 (55.7%) patients, AVNRT in 230 (33.8%) patients, ventricular tachycardia (VT) in 24 (3.5) patients, focal atrial tachycardia (FAT) in 20 (2.9%) patients, IART in 14 (2%) patients, and junctional ectopic tachycardia in 3 (0.45) patients. Overall procedural success was 95.6%. Compared with all other substrates, success was significantly lower in FAT patients (80%, n = 16, P = 0.001). Mean procedure duration was 136 ± 67 min and mean fluoroscopy time was 4.9 ± 6.8 min. Major complications occurred in 0.7% of the patients. No persisting AV block requiring permanent pacing was reported. At 1-year follow-up (605/683 patients, 95%), tachycardia recurrence was reported in 7.8% of patients. Recurrence after VT ablation (33%) was significantly higher (P = 0.001) than after ablation of all other substrates.
Conclusion
The present study proves overall high efficacy and safety of catheter ablation of various tachycardia substrates in pediatric patients. Of note, complication rate was exceptionally low. Long-term success was high except for patients after VT ablation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Europace: 22 Nov 2020; epub ahead of print
Krause U, Paul T, Bella PD, Gulletta S, ... Ferrari P, De Filippo P
Europace: 22 Nov 2020; epub ahead of print | PMID: 33227133
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Abstract

Electrocardiographic predictors of infrahissian conduction disturbances in myotonic dystrophy type 1.

Joosten IBT, van Lohuizen R, den Uijl DW, Evertz R, ... Faber CG, Vernooy K
Aims
The aim of this study was to determine electrocardiographic (ECG) criteria predicting abnormal infrahissian conduction in patients with myotonic dystrophy type 1 (DM1), as these criteria could be used to identify the need for an electrophysiological study (EPS).
Methods and results
A retrospective multicentre study was conducted including DM1-affected individuals who underwent EPS between 2007 and 2018. For each individual, EPS indication, His-ventricle (HV) interval, resting ECG parameters prior to EPS, left ventricular ejection fraction (LVEF), neurological status, and DM1 DNA analysis results were collected. Electrocardiographic parameters of patients with a normal HV interval were compared with ECG parameters of patients with a prolonged HV interval. Logistic regression was performed to determine predictors for a prolonged HV interval of ≥70 ms on EPS and diagnostic accuracy of ECG parameters was ascertained. Among 100 DM1-affected individuals undergoing EPS, 47 had a prolonged HV interval. The sole presence of a PR interval >200 ms [odds ratio (OR) 8.45, confidence interval (CI) 2.64-27.04] or a QRS complex >120 ms (OR 9.91, CI 3.53-27.80) on ECG were independent predictors of a prolonged HV interval. The combination of both parameters had a positive predictive value of 78% for delayed infrahissian conduction on EPS. His-ventricle interval was independent of DM1 genetic mutation size, neuromuscular status, and LVEF.
Conclusion
The combination of a prolonged PR interval and widened QRS complex on ECG accurately predicts abnormal infrahissian conduction on EPS in patients with DM1. These ECG parameters could be used as a screening tool to determine the need for referral to a specialized multidisciplinary neuromuscular team with EPS capacity.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Europace: 04 Nov 2020; epub ahead of print
Joosten IBT, van Lohuizen R, den Uijl DW, Evertz R, ... Faber CG, Vernooy K
Europace: 04 Nov 2020; epub ahead of print | PMID: 33150426
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Impact:
Abstract

An irregular narrow complex tachycardia.

Zhang X, Yang R, Di Biase L

A 53 year-old gentleman with hypertension presented to the emergence room with sudden chest pain, associated with shortness of breath and dizziness. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print
Zhang X, Yang R, Di Biase L
J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print | PMID: 33205527
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Abstract

Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States.

Munir MB, Khan MZ, Darden D, Pasupula DK, ... Reeves R, Hsu JC
Objective
To determine trends in real-world utilization and in-hospital adverse events from Watchman implantation since its approval by the Food and Drug Administration in 2015.
Background
The risk of embolic stroke caused by atrial fibrillation is reduced by oral anticoagulants, but not all patients can tolerate long-term anticoagulation. Left atrial appendage occlusion with the Watchman device has emerged as an alternative therapy.
Methods
This was a retrospective cohort study utilizing data from National Inpatient Sample for calendar years 2015-2017. The outcomes assessed in this study were associated complications, in-hospital mortality, and resource utilization trends after Watchman implantation. Trends analysis were performed using analysis of variance. Multivariable adjusted logistic regression analysis was performed to determine predictors of mortality.
Results
A total of 17 700 patients underwent Watchman implantation during the study period. There was a significantly increased trend in the number of Watchman procedures performed over the study years (from 1195 in 2015 to 11 165 devices in 2017, p < .01). A significant decline in the rate of complications (from 26.4% in 2015% to 7.9% in 2017, p < .01) and inpatient mortality (from 1.3% in 2015% to 0.1% in 2017, p < .01) were noted. Predictors of in-hospital mortality included a higher CHA DS -VASc score (odds ratio [OR]: 2.61 per 1-point increase, 95% confidence interval [CI]: 1.91-3.57), chronic blood loss anemia (OR: 3.63, 95% CI: 1.37-9.61) and coagulopathy (OR: 4.90, 95% CI: 2.32-10.35).
Conclusion
In contemporary United States clinical practice, Watchman utilization has increased significantly since approval in 2015, while complications and in-patient mortality have declined.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print
Munir MB, Khan MZ, Darden D, Pasupula DK, ... Reeves R, Hsu JC
J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print | PMID: 33155356
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Abstract

Sequential ultrahigh-density contact mapping of persistent atrial fibrillation: An efficient technique for driver identification.

Lațcu DG, Enache B, Hasni K, Wedn AM, ... Pathak A, Saoudi N
Introduction
Literature supports the existence of drivers as maintainers of atrial fibrillation (AF). Whether ultrahigh density (UHD) contact mapping may detect them is unknown.
Methods
We sequentially mapped the left atrial (LA) activation during spontaneous persistent AF and performed circumferential pulmonary vein isolation (CPVI), followed by remapping and ablation of potential drivers (rotational and focal propagation sites) with Rhythmia™ in 90 patients. The time reference was an LA appendage (LAA) electrogram (EGM). Regions with uniform color were defined as \"organized.\" Only patients (51) with no previous ablation were considered for acute results and follow-up reporting.
Results
LA maps (175 ± 28 ml, 43578 ± 18013 EGM) were acquired in 23 ± 7 min. In all post-CPVI maps potential drivers (7.3 ± 3.2/patient) were visualized: 85% with rotational propagation and continuous low voltage in the center; the remaining with focal propagation and an organized EGM at the site of earliest activation. The RF delivery time for extra-PV driver ablation was 12.2 ± 7.9 min. There was a progressive increase of AF organization: the LAA cycle length prolonged, the number of potential drivers decreased, and the organized LA surface in AF increased from 14 ± 6% to 28 ± 16% (p = .0007). Termination of AF without cardioversion was obtained in 67%. AF recurrence rate at 15 ± 7.3 months was 17.6% after the first procedure.
Conclusions
Sequential UHD contact activation mapping of persistent AF allows visualization of potential drivers. A sequential strategy of CPVI followed by ablation of potential drivers with limited RF time resulted in an increasing organization of AF and good acute and long-term results.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print
Lațcu DG, Enache B, Hasni K, Wedn AM, ... Pathak A, Saoudi N
J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print | PMID: 33155347
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Impact:
Abstract

Esophageal deviation with vacuum suction and mechanical deflection during ablation of atrial fibrillation: First in man evaluation.

Aguinaga L, Palazzo A, Bravo A, Lizarraga G, ... Daoud EG, Weiss R

Deviation of the esophagus during atrial fibrillation (AF) ablation can reduce esophageal injury. This study reports upon a novel esophageal retractor that utilizes vacuum suction and mechanical deflection to deviate the esophagus. The device was used in seven patients undergoing cryoballoon AF ablation. The esophagus was deviated 31.9 ± 4.4 mm to the right and 28.2 ± 5.9 mm to the left. Endoscopy at 4.4 ± 1.5 days postablation showed no esophageal injury. This study demonstrates the safe and effective deviation of the esophagus without a trailing edge with an esophageal retractor utilizing vacuum suction and mechanical deflection.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print
Aguinaga L, Palazzo A, Bravo A, Lizarraga G, ... Daoud EG, Weiss R
J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print | PMID: 33155334
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Impact:
Abstract

High-power short duration and low-power long duration in atrial fibrillation ablation: A meta-analysis.

Kewcharoen J, Techorueangwiwat C, Kanitsoraphan C, Leesutipornchai T, ... Bunch TJ, Navaravong L
Background
Multiple strategies have advocation for power titration and catheter movement during atrial fibrillation (AF) ablation. Comparative favoring evidence regarding the efficacy, logistics, and safety of a higher-power, shorter duration (HPSD) ablation strategy compared to a lower-power, longer duration (LPLD) ablation strategy is insubstantial. We performed a meta-analysis to compare arrhythmia-free survival, procedure times, and complication rates between the two strategies.
Methods
We searched MEDLINE, EMBASE, and Cochrane Library from inception to September 2020. We included studies comparing patients who underwent HPSD and LPLD strategies for AF ablation and reporting either of the following outcomes: Freedom from atrial tachyarrhythmia (AT) including AF and atrial flutter, procedure time, or periprocedural complications. We combined data using the random-effects model to calculate the odds ratio (OR) and weight mean difference (WMD) with a 95% confidence interval (CI).
Results
Ten studies from 2006 to 2020 involving 2274 patients were included (1393 patients underwent HPSD strategy and 881 patients underwent LPLD strategy). HPSD strategy was not associated with increased freedom from AT at 12-month follow-up (OR = 1.54, 95% CI: 0.99 to 2.40, p = .054). In the subgroup analysis of the randomized controlled trial, the HPSD strategy was associated with increased freedom from AT compared to the LPLD strategy (OR = 3.12, 95% CI: 1.18 to 8.20, p = .02). There was a significant reduction in the HPSD group for the total procedure (WMD = 49.60, 95% CI: 29.76 to 69.44) and ablation (WMD = 17.92, 95% CI: 13.63 to 22.22) times, but not for fluoroscopy time (WMD = 1.15, 95% CI: -0.67 to 2.97). HPSD was not associated with a reduction in esophageal ulcer/atrioesophageal fistula (OR = 0.35, 95% CI: 0.12 to 1.06) or pericardial effusion/cardiac tamponade rates (OR = 1.16, 95% CI: 0.35 to 3.81).
Conclusions
When compared to the LPLD strategy, the HPSD strategy does not improve recurrent AT nor reduce periprocedural complication risks. However, subgroup analysis of the randomized controlled trial showed that HPSD significantly reduces AT recurrence. An HPSD strategy can significantly reduce total procedure and ablation times.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print
Kewcharoen J, Techorueangwiwat C, Kanitsoraphan C, Leesutipornchai T, ... Bunch TJ, Navaravong L
J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print | PMID: 33155303
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Abstract

Atrio-ventricular synchronous pacing with a single chamber leadless pacemaker: Programming and trouble shooting for common clinical scenarios.

El-Chami MF, Bhatia NK, Merchant FM

Micra leadless pacemaker has progressed from a single chamber pacemaker that can deliver VVIR pacing to a pacing device that can provide atrio-ventricular (AV) synchrony via a unique pacing algorithm that relies on identifying mechanical atrial contraction. This novel algorithm has its own limitations and intricacies. In this paper, we review this algorithm, suggest steps for troubleshooting and programming these devices and provide clinical examples of Micra AV cases that required changes in programming for adequate tracking of atrial activity.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
El-Chami MF, Bhatia NK, Merchant FM
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179814
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Impact:
Abstract

Occurrence of persistent atrial fibrillation during pacing for sinus node disease: The influence of His bundle pacing versus managed ventricular pacing.

Pastore G, Marcantoni L, Lanza D, Maines M, ... Roncon L, Zanon F
Introduction
In patients with sinus node disease (SND), the dual-chamber pacemaker (PM) is programmed in DDDR mode with an algorithm to avoid unnecessary right ventricular (RV) pacing. This pacing mode may prolong PR interval with consequently atrioventricular (AV) asynchrony which is associated with a higher risk of atrial fibrillation (AF). We evaluate whether preserving AV synchrony by setting a fixed AV delay during physiological RV pacing, that is, His bundle pacing (HBP), could reduce the risk of AF occurrence in comparison with a standard pacing mode with an algorithm to avoid unnecessary RV pacing (DDD-VPA).
Methods and results
We collected retrospective data from 313 consecutive patients who had undergone PM for SND. The first occurrence of persistent AF (>7 consecutive days) as a function of the pacing mode was evaluated. HBP and DDD-VPA were implemented in 82 and 231 patients, respectively. Persistent AF occurred in 128 (40.9%) patients over a median follow-up of 70 months (67-105). The DDD-VPA pacing mode was significantly correlated with the occurrence of persistent AF only when the basal PR was long (>180 ms). The risk of persistent AF was significantly lower in patients on HBP than in those on DDD-VPA, adjusted HR = .57 (95% CI, .36- .89, p=.014). Other independent predictors of persistent AF occurrence were: A history of AF (HR = 3.91; 95% CI, 2.48-6.19, p = .001), age, and long PR interval (HR = 2.98; 95% CI, 2.00-4.43, p=.001).
Conclusion
In SND patients and long basal PR interval, the HBP may reduce the risk of persistent AF in comparison with the DDD-VPA.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
Pastore G, Marcantoni L, Lanza D, Maines M, ... Roncon L, Zanon F
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179400
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Abstract

Focal and pseudo/rotational activations in human atrial fibrillation defined with automated periodicity mapping.

Nayyar S, Ha ACT, Timmerman N, Suszko A, Ragot D, Chauhan VS
Introduction
Defining atrial fibrillation (AF) wave propagation is challenging unless local signal features are discrete or periodic. Periodic focal or rotational activity may identify AF drivers. Our objective was to characterize AF propagation at sites with periodic activation to evaluate the prevalence and relationship between focal and rotational activation.
Methods
We included 80 patients (61 ± 10 years, persistent AF 49%) from the FaST randomized trial that compared the efficacy of adjunctive focal site ablation versus pulmonary vein isolation. Patients underwent left atrial (LA) activation mapping with a 20-pole circular catheter during spontaneous or induced AF. Five-second bipolar and unipolar electrograms in AF were analyzed. Periodic sites were identified by spectral analysis of the bipolar electrogram. Activation maps of periodic sites were constructed using an automated, validated tracking algorithm, and classified into three patterns: focal sites (FS), rotation (RO), or pseudo-rotation (pRO).
Results
The most common propagation pattern at periodic sites was FS for 5-s in all patients (4.9 ± 1.9 per patient). RO and pRO were observed in two and seven patients, respectively, but were all transient (3-5 cycles). Activation from a FS evolved into transient RO/pRO in five patients. No patient had autonomous RO/pRO activations. Patients with RO/pRO had greater LA surface area with periodicity (78 ± 7 vs. 63 ± 16%, p = .0002) and shorter LA periodicity CL (166 ± 10 vs. 190±28 ms, p = .0001) than the rest.
Conclusion
Using automated, regional AF periodicity mapping, FS is more prevalent and temporally stable than RO/pRO. Most RO/pRO evolve from neighboring FS. These findings and their implications for AF maintenance require verification with global, panoramic mapping.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
Nayyar S, Ha ACT, Timmerman N, Suszko A, Ragot D, Chauhan VS
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179399
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