Topic: Electrophysiology

Abstract

Antiplatelet therapy in patients with atrial fibrillation: a systematic review and meta-analysis of randomized trials.

Benz AP, Johansson I, Dewilde WJM, Lopes RD, ... Eikelboom JW, Connolly SJ
Aims
The aim of this study was to systematically assess the effects of antiplatelets on clinical outcomes in patients with atrial fibrillation (AF), treated and not-treated with oral anticoagulation.
Methods and results
We searched MEDLINE, Embase, and CENTRAL from inception until September 2020. From 5446 citations, we selected randomized trials allocating patients with AF to antiplatelet therapy vs. control. We applied random-effects models for meta-analysis and assessed potential effect modification with background anticoagulation use. Eighteen trials including 21 518 participants met our prespecified eligibility criteria. In 10 studies without background anticoagulation, antiplatelets reduced all-cause stroke [486/6165 (events/patients) vs. 621/6061; risk ratio (RR) 0.77, 95% confidence interval (CI) 0.69-0.86, I2 = 0%]. In eight studies with background anticoagulation, there was a signal for an increase in all-cause stroke with antiplatelets (97/4608 vs. 72/4684; RR 1.33, 95% CI 0.98-1.79, I2 = 0%, P-value for interaction <0.001). A similar pattern emerged for ischaemic stroke. Irrespective of background anticoagulation use, antiplatelets increased major bleeding (509/10 402 vs. 328/10 496; RR 1.54, 95% CI 1.35-1.77, I2 = 0%) and intracranial haemorrhage (107/10 221 vs. 65/10 232; RR 1.64, 95% CI 1.20-2.24, I2 = 0%), and reduced myocardial infarction (201/9679 vs. 260/9751; RR 0.79, 95% CI 0.65-0.94, I2 = 0%, all P-values for interaction ≥0.36). Antiplatelets did not affect mortality (1221/10 299 vs. 1211/10 287; RR 1.02, 95% CI 0.89-1.17, I2 = 29%, P-value for interaction = 0.23).
Conclusions
In patients with AF not receiving oral anticoagulation, antiplatelet therapy modestly reduced stroke. There was a corresponding signal for harm when used on top of anticoagulation. Irrespective of background anticoagulation use, antiplatelet therapy significantly increased bleeding, moderately reduced myocardial infarction, and did not affect mortality.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Cardiovasc Pharmacother: 29 Sep 2022; 8:648-659
Benz AP, Johansson I, Dewilde WJM, Lopes RD, ... Eikelboom JW, Connolly SJ
Eur Heart J Cardiovasc Pharmacother: 29 Sep 2022; 8:648-659 | PMID: 34142118
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Abstract

Gut microbiota, dysbiosis and atrial fibrillation. Arrhythmogenic mechanisms and potential clinical implications.

Gawałko M, Agbaedeng TA, Saljic A, Müller DN, ... Dobrev D, Linz D
Recent preclinical and observational cohort studies have implicated imbalances in gut microbiota composition as a contributor to atrial fibrillation (AF). The gut microbiota is a complex and dynamic ecosystem containing trillions of microorganisms, which produces bioactive metabolites influencing host health and disease development. In addition to host-specific determinants, lifestyle-related factors such as diet and drugs are important determinants of the gut microbiota composition. In this review, we discuss the evidence suggesting a potential bidirectional association between AF and gut microbiota, identifying gut microbiota-derived metabolites as possible regulators of the AF substrate. We summarize the effect of gut microbiota on the development and progression of AF risk factors, including heart failure, hypertension, obesity, and coronary artery disease. We also discuss the potential anti-arrhythmic effects of pharmacological and diet-induced modifications of gut microbiota composition, which may modulate and prevent the progression to AF. Finally, we highlight important gaps in knowledge and areas requiring future investigation. Although data supporting a direct relationship between gut microbiota and AF are very limited at the present time, emerging preclinical and clinical research dealing with mechanistic interactions between gut microbiota and AF is important as it may lead to new insights into AF pathophysiology and the discovery of novel therapeutic targets for AF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Cardiovasc Res: 24 Aug 2022; 118:2415-2427
Gawałko M, Agbaedeng TA, Saljic A, Müller DN, ... Dobrev D, Linz D
Cardiovasc Res: 24 Aug 2022; 118:2415-2427 | PMID: 34550344
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Abstract

Early response of right-ventricular function to percutaneous mitral valve repair.

Sugiura A, Shamekhi J, Goto T, Spieker M, ... Becher MU, of the Heart Failure Network Rhineland
Background
The change in right-ventricular function (RVF) after transcatheter mitral valve repair is still poorly understood. We assessed the early response of RVF to the MitraClip procedure and its clinical relevance.
Methods
We analyzed consecutive patients who underwent a MitraClip procedure to treat MR between August 2010 and March 2019 in the Heart Failure Network Rhineland registry. RVF was assessed before and after the procedure. Impaired RVF was defined as an RV fractional area change (RVFAC) < 35% or tricuspid annular plane systolic excursion (TAPSE) < 16 mm.
Results
816 eligible patients (77 ± 9 years, 58.5% male) were included in the analysis. Baseline values of RVF were: RVFAC 38.6 (IQR 29.7-46.7) % and TAPSE 17.0 (IQR 14.0-21.0) mm. At a median time of 3 (IQR 2-5) days after the procedure, the RVF remained normal in 34% (n = 274), normalized in 17% (n = 140), deteriorated in 15% (n = 125), and was persistently impaired in 34% (n = 277) of patients. The RVF response was significantly associated with a composite outcome of all-cause mortality and hospitalization due to heart failure within a 2-year follow-up. Compared to stable/normal RVF, the adjusted hazard ratios for the outcome were 1.78 (95% CI 1.10-2.86) for normalized RVF, 1.89 (95% CI 1.34-3.15) for deteriorated RVF, and 2.25 (95% CI 1.47-3.44) for persistently impaired RVF. Changes in TAPSE and RVFAC as continuous variables were significantly correlated with the outcome.
Conclusion
An early change in RVF following transcatheter mitral valve repair is predictive of mortality and hospitalization due to heart failure during follow-up. Early response of RVF after MitraClip and its clinical significance. An acute, early change in RVF can be observed following the MitraClip procedure, which is associated with the risk of mortality and hospitalization for HF.

© 2021. The Author(s).

Clin Res Cardiol: 01 Aug 2022; 111:859-868
Sugiura A, Shamekhi J, Goto T, Spieker M, ... Becher MU, of the Heart Failure Network Rhineland
Clin Res Cardiol: 01 Aug 2022; 111:859-868 | PMID: 34669015
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Abstract

Using multimarker screening to identify biomarkers associated with cardiovascular death in patients with atrial fibrillation.

Pol T, Hijazi Z, Lindbäck J, Oldgren J, ... Siegbahn A, Wallentin L
Aims
Atrial fibrillation (AF) is associated with higher mortality. Biomarkers may improve the understanding of key pathophysiologic processes in AF that lead to death. Using a new multiplex analytic technique, we explored the association between 268 biomarkers and cardiovascular (CV) death in anticoagulated patients with AF.
Methods and results
A case-cohort design with 1.8- to 1.9-year follow-up. The identification cohort included 517 cases and 4057 randomly selected patients from ARISTOTLE. The validation cohort included 277 cases and 1042 randomly selected controls from RE-LY. Plasma collected at randomization was analysed with conventional immunoassays and the OLINK proximity extension assay panels: CVDII, CVDIII, and Inflammation. Association between biomarkers and CV death was evaluated using Random Survival Forest, Boruta, and adjusted Cox-regression analyses. The biomarkers most strongly and consistently associated with CV death were as follows (hazard ratio for inter-quartile comparison [95% CI]): N-terminal pro-B-type natriuretic peptide [NT-proBNP; 1.63 (1.37-1.93)], cardiac troponin T [cTnT-hs; 1.60 (1.35-1.88)], interleukin-6 [IL-6; 1.29 (1.13-1.47)], growth differentiation factor-15 [GDF-15; 1.30 (1.10-1.53)], fibroblast growth factor 23 [FGF-23; 1.21 (1.10-1.33)], urokinase receptor [uPAR; 1.38 (1.16-1.64)], trefoil factor 3 [TFF3; 1.27 (1.10-1.46)], tumour necrosis factor receptor 1 [TNFR1; 1.21 (1.01-1.45)], TNF-related apoptosis-inducing ligand receptor 2 [TRAILR2; 1.18 (1.04-1.34)], and cathepsin L1 [CTSL1; 1.22 (1.07-1.39)].
Conclusion
In this comprehensive screening of 268 biomarkers in anticoagulated patients with AF, the underlying mechanisms most strongly associated with CV death were cardiorenal dysfunction (NT-proBNP, cTnT-hs, CTSL1, TFF3), oxidative stress (GDF-15), inflammation (IL-6, GDF-15), calcium balance, vascular and renal dysfunction (FGF-23), fibrinolysis (suPAR), and apoptosis (TNFR1, TRAILR2). These findings provide novel insights into pathophysiologic aspects associated with CV death in AF.
Clinicaltrials.gov identifier
NCT00412984 and NCT00262600.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Cardiovasc Res: 20 Jul 2022; 118:2112-2123
Pol T, Hijazi Z, Lindbäck J, Oldgren J, ... Siegbahn A, Wallentin L
Cardiovasc Res: 20 Jul 2022; 118:2112-2123 | PMID: 34358298
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Abstract

Treatment of atrial fibrillation with doxapram: TASK-1 potassium channel inhibition as a novel pharmacological strategy.

Wiedmann F, Beyersdorf C, Zhou XB, Kraft M, ... Katus HA, Schmidt C
Aims
TASK-1 (K2P3.1) two-pore-domain potassium channels are atrial-specific and significantly up-regulated in atrial fibrillation (AF) patients, contributing to AF-related electrical remodelling. Inhibition of TASK-1 in cardiomyocytes of AF patients was shown to counteract AF-related action potential duration shortening. Doxapram was identified as a potent inhibitor of the TASK-1 channel. In this study, we investigated the antiarrhythmic efficacy of doxapram in a porcine model of AF.
Methods and results
Doxapram successfully cardioverted pigs with artificially induced episodes of AF. We established a porcine model of persistent AF in domestic pigs via intermittent atrial burst stimulation using implanted pacemakers. All pigs underwent catheter-based electrophysiological investigations prior to and after 14 days of doxapram treatment. Pigs in the treatment group received intravenous administration of doxapram once per day. In doxapram-treated AF pigs, the AF burden was significantly reduced. After 14 days of treatment with doxapram, TASK-1 currents were still similar to values of sinus rhythm animals. Doxapram significantly suppressed AF episodes and normalized cellular electrophysiology by inhibition of the TASK-1 channel. Patch-clamp experiments on human atrial cardiomyocytes, isolated from patients with and without AF could reproduce the TASK-1 inhibitory effect of doxapram.
Conclusion
Repurposing doxapram might yield a promising new antiarrhythmic drug to treat AF in patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Cardiovasc Res: 22 Jun 2022; 118:1728-1741
Wiedmann F, Beyersdorf C, Zhou XB, Kraft M, ... Katus HA, Schmidt C
Cardiovasc Res: 22 Jun 2022; 118:1728-1741 | PMID: 34028533
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Abstract

Efficacy and safety of direct oral anticoagulant in morbidly obese patients with atrial fibrillation: systematic review and meta-analysis.

Thangjui S, Kewcharoen J, Yodsuwan R, Trongtorsak A, ... Winans ARM, Bischof E
Aims
We conducted a systematic review and meta-analysis on three outcomes. We assessed the efficacy and safety of direct oral anticoagulants (DOAC) compared to vitamin K antagonists (VKA) in morbidly obese patients with atrial fibrillation (AF). We compared the efficacy and safety of DOAC in obese patients and non-obese patients with AF. Finally, we updated the current knowledge of outcomes of AF patients with obesity compared with normal-weight patients regardless of anticoagulation type.
Methods and results
Using PubMed and Embase, we searched for literature published from inception to August 2020 for studies conducted in morbidly obese patients with AF who used DOACs and/or VKA for stroke or systemic embolism (stroke/SE) prevention that report efficacy and/or safety data. GRADE assessment was performed to determine the quality of the meta-analysis results. Direct oral anticoagulant was not statistically different from VKA in reducing stroke/SE with relative risk (RR) of 0.85 [95% confidence interval (CI): 0.56-1.29; very low certainty evidence]. Major bleeding risk was lower in the DOAC groups with RR of 0.62 (95% CI: 0.48-0.80; low certainty evidence). Obese patients with AF who used DOACs had lower risk of stroke/SE and similar major bleeding risk compared to non-obese patients with RR of 0.77 (95% CI: 0.70-0.84; low certainty evidence) and 1.02 (95% CI: 0.94-1.09; low certainty evidence), respectively. Obese patients with AF who used any type of anticoagulant had lower risk of stroke/SE compared to normal-weight patients with RR of 0.62 (95% CI: 0.57-0.69; low certainty evidence).
Conclusion
The use of DOACs in morbidly obese patients may be reasonable if needed, and more dedicated studies are needed to make a more robust recommendation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Cardiovasc Pharmacother: 08 Jun 2022; 8:325-335
Thangjui S, Kewcharoen J, Yodsuwan R, Trongtorsak A, ... Winans ARM, Bischof E
Eur Heart J Cardiovasc Pharmacother: 08 Jun 2022; 8:325-335 | PMID: 33730164
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Abstract

Anticoagulation in atrial fibrillation and liver disease: a pooled-analysis of >20 000 patients.

Chen S, Pürerfellner H, Meyer C, Sommer P, ... Chun JKR, Schmidt B
Aims
Anticoagulation for atrial fibrillation patients with liver disease represents a clinical dilemma. We sought to evaluate the efficacy/safety of different anticoagulation, i.e. vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in such patient group.
Methods and results
This was a pooled-analysis enrolling up-to-date clinical data. Two subsets: subset A (VKA vs. Non-Anticoagulation) and subset B (NOACs vs. VKA) were pre-specified. The study outcomes were ischaemic stroke (IS)/thromboembolism (TE), major bleeding (MB), intracranial bleeding (ICB), gastrointestinal bleeding (GIB), and all-cause mortality. A total of 20 042 patients\' data were analysed (subset A: N = 10 275, subset B: N = 9767). Overall mean age: 71 ± 11 years, mean CHA2DS2-VASc score: 4.0 ± 1.8, mean HAS-BLED score: 3.6 ± 1.2. The majority of the patients had Child-Pugh category (A-B). As compared with Non-Anticoagulation, VKA seemed to reduce the risk of IS/TE [odds ratio (OR): 0.60, P = 0.05], but heighten the risk of all-bleeding events including MB (OR: 2.81, P = 0.01), ICB (OR: 1.60, P = 0.01), and GIB (OR: 3.32, P = 0.01). When compared with VKA, NOACs had similar efficacy in reducing the risk of IS/TE (OR: 0.82, P = 0.64), significantly lower risk of MB (OR: 0.54, P = 0.0003) and ICB (OR: 0.35, P < 0.0001), and trend towards reduced risk of GIB (OR: 0.72, P = 0.12) and all-cause mortality (OR: 0.79, P = 0.35). The favourable effects were maintained in subgroups of individual NOAC.
Conclusions
VKA appears to reduce the risk of IS/TE but increase all-bleeding events. NOACs have similar effect in reducing the risk of IS/TE and have significantly lower risk of MB and ICB as compared with VKA. NOACs seem to be associated with better clinical outcome than VKA in patients with mild-moderate liver disease.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Cardiovasc Pharmacother: 08 Jun 2022; 8:336-345
Chen S, Pürerfellner H, Meyer C, Sommer P, ... Chun JKR, Schmidt B
Eur Heart J Cardiovasc Pharmacother: 08 Jun 2022; 8:336-345 | PMID: 33871577
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Abstract

Weekend vs. weekday admission and clinical outcomes in heart failure patients with and without atrial fibrillation in Taiwan.

Hu WS, Lin CL
Aims
We conducted this study to explore the associations of weekend and weekday admission with the clinical events among heart failure (HF) patients with and without comorbid atrial fibrillation (AF).
Methods and results
In this study, we recruited 57 919 HF patients without AF hospitalized on weekends and 57 919 HF patients without AF hospitalized on weekdays. There were 21407 and 21407 HF patients with AF hospitalized on weekends and weekdays, respectively. The outcomes of interest included all-cause mortality, cardiovascular (CV) death, and HF recurrence requiring admission. The Cox proportional hazard regression model was applied to estimate the hazard ratio. Variables found to be statistically significant in a univariable Cox proportional hazard regression model were further examined in a multivariable Cox proportional hazard regression model. The cumulative incidence curves were obtained by the Kaplan-Meier method and assessed by the log-rank test. HF patients with AF and hospitalized on weekends had the highest incidence rates of rehospitalization due to HF (233.8 per 1000 person-years) and CV death (23.9 per 1000 person-years) among four groups. The Kaplan-Meier method shows that HF patients with AF had the higher cumulative incidence of rehospitalization due to HF than the patients without AF.
Conclusion
HF patients with AF and hospitalized on weekends are at highest risk of HF recurrence requiring hospitalization among these four groups.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Pharmacother: 08 Jun 2022; 8:346-352
Hu WS, Lin CL
Eur Heart J Cardiovasc Pharmacother: 08 Jun 2022; 8:346-352 | PMID: 34180528
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Abstract

Discontinuation of direct oral anticoagulants among patients with atrial fibrillation according to gender and cohabitation status: a nationwide cohort study.

Binding C, Olesen JB, Lee CJ, Lip GYH, ... Gislason G, Bonde AN
Aims
The aim of this study was to evaluate the risk of discontinuing treatment with direct oral anticoagulants (DOACs) among patients with atrial fibrillation (AF) according to cohabitation status and gender.
Methods and results
Using the Danish national registers, we identified 32 364 patients with AF aged 40-90 years undergoing treatment with DOACs. The study period was from 2013 to 2017, and patients were followed for 2 years, or until death, outcome, or emigration. The main outcome was discontinuation of DOAC treatment for at least 30 days. The absolute 2-year risk of DOAC discontinuation was highest among men living alone [35.7%, 95% confidence interval (CI): 37.3-34.1%]. Men living alone had a 4.6% (95% CI: 6.4-2.8%) higher absolute risk of discontinuation and a 12% [hazard ratio (HR): 1.12, 95% CI: 1.04-1.20] higher relative risk of discontinuation compared with men living with a partner. Female patients living alone likewise had a higher absolute risk of DOAC discontinuation (2.6%, 95% CI: 4.4-0.09%) compared with female patients living with a partner, yet no statistically significant difference in relative risk. In an analysis evaluating gender, we found male gender to be associated with a significantly higher relative risk of DOAC discontinuation (HR: 1.33, 95% CI: 1.26-1.40) compared with female gender (P-value for interaction with cohabitant status = 0.5996).
Conclusion
In this nationwide population study, male gender and living alone were associated with a higher risk of DOAC discontinuation among patients with AF.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Cardiovasc Pharmacother: 08 Jun 2022; 8:353-362
Binding C, Olesen JB, Lee CJ, Lip GYH, ... Gislason G, Bonde AN
Eur Heart J Cardiovasc Pharmacother: 08 Jun 2022; 8:353-362 | PMID: 34415024
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Abstract

Impact of atrial fibrillation pattern on outcomes after left atrial appendage closure: lessons from the prospective LAARGE registry.

Kany S, Brachmann J, Lewalter T, Akin I, ... Kirchhof P, Rillig A
Background
Non-paroxysmal (NPAF) forms of atrial fibrillation (AF) have been reported to be associated with an increased risk for systemic embolism or death.
Methods
Comparison of procedural details and long-term outcomes in patients (pts) with paroxysmal AF (PAF) against controls with NPAF in the prospective, multicentre observational registry of patients undergoing LAAC (LAARGE).
Results
A total of 638 pts (PAF 274 pts, NPAF 364 pts) were enrolled. In both groups, a history of PVI was rare (4.0% vs 1.6%, p = 0.066). The total CHA2DS2-VASc score was lower in the PAF group (4.4 ± 1.5 vs 4.6 ± 1.5, p = 0.033), while HAS-BLED score (3.8 ± 1.1 vs 3.9 ± 1.1, p = 0.40) was comparable. The rate of successful implantation was equally high (97.4% vs 97.8%, p = 0.77). In the three-month echo follow-up, LA thrombi (2.1% vs 7.3%, p = 0.12) and peridevice leak > 5 mm (0.0% vs 7.1%, p = 0.53) were numerically higher in the NPAF group. Overall, in-hospital complications occurred in 15.0% of the PAF cohort and 10.7% of the NPAF cohort (p = 0.12). In the one-year follow-up, unadjusted mortality (8.4% vs 14.0%, p = 0.039) and combined outcome of death, stroke and systemic embolism (8.8% vs 15.1%, p = 0.022) were significantly higher in the NPAF cohort. After adjusting for CHA2DS2-VASc and previous bleeding, NPAF was associated with increased death/stroke/systemic embolism (HR 1.67, 95% CI 1.02-2.72, p = 0.041).
Conclusion
Atrial fibrillation type did not impair periprocedural safety or in-hospital MACE patients undergoing LAAC. However, after one year, NPAF was associated with higher mortality.

© 2021. The Author(s).

Clin Res Cardiol: 01 May 2022; 111:511-521
Kany S, Brachmann J, Lewalter T, Akin I, ... Kirchhof P, Rillig A
Clin Res Cardiol: 01 May 2022; 111:511-521 | PMID: 34043052
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Abstract

Complications and mortality after catheter ablation of ventricular arrhythmias: risk in VT ablation (RIVA) score.

Mathew S, Fink T, Feickert S, Inaba O, ... Kuck KH, Ouyang F
Aims
Catheter ablation of ventricular arrhythmias (VA) has proven to be an effective therapeutic option for secondary arrhythmia prophylaxis. We sought to assess the procedural efficacy, safety and in-hospital mortality of a large patient cohort with and without structural heart disease undergoing VA ablation.
Methods
A total of 1417 patients (804 patients with structural heart disease) undergoing 1792 endo- and epicardial procedures were analyzed. Multivariable risk factor analysis for occurrence of major complications and intrahospital mortality was obtained and a score to allow preprocedural risk assessment for patients undergoing VA ablation procedures was established.
Results
Major complication occurred in 4.4% of all procedures and significantly more often in patients with structural heart disease than in structurally normal hearts (6.0 vs. 1.8%). The frequency of these periprocedural complications was significantly different between procedures with sole right ventricular and a combination of RV and LV access (0.5 vs. 3.1%). The most common complication was cardiac tamponade in 46 cases (3.0%). Intrahospital death was observed in 32 patients (1.8%). Logistic regression model revealed presence of ischemic heart disease, epicardial ablation, presence of oral anticoagulation or dual antiplatelet therapy as independent risk factors for the occurrence of complications or intrahospital death, while a history of previous heart surgery was an independent predictor with a decreased risk. Based on this analysis a risk score incorporating 5 standard variables was established to predict the occurrence of complications and intrahospital mortality.
Conclusions
Safety of VA catheter ablation mainly relies on patient baseline characteristics and the type of access into the ventricles or epicardial space.

© 2021. The Author(s).

Clin Res Cardiol: 01 May 2022; 111:530-540
Mathew S, Fink T, Feickert S, Inaba O, ... Kuck KH, Ouyang F
Clin Res Cardiol: 01 May 2022; 111:530-540 | PMID: 34318341
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Abstract

Mobile health solutions for atrial fibrillation detection and management: a systematic review.

Hermans ANL, Gawalko M, Dohmen L, van der Velden RMJ, ... Pluymaekers NAHA, Linz D
Aim
We aimed to systematically review the available literature on mobile Health (mHealth) solutions, including handheld and wearable devices, implantable loop recorders (ILRs), as well as mobile platforms and support systems in atrial fibrillation (AF) detection and management.
Methods
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The electronic databases PubMed (NCBI), Embase (Ovid), and Cochrane were searched for articles published until 10 February 2021, inclusive. Given that the included studies varied widely in their design, interventions, comparators, and outcomes, no synthesis was undertaken, and we undertook a narrative review.
Results
We found 208 studies, which were deemed potentially relevant. Of these studies included, 82, 46, and 49 studies aimed at validating handheld devices, wearables, and ILRs for AF detection and/or management, respectively, while 34 studies assessed mobile platforms/support systems. The diagnostic accuracy of mHealth solutions differs with respect to the type (handheld devices vs wearables vs ILRs) and technology used (electrocardiography vs photoplethysmography), as well as application setting (intermittent vs continuous, spot vs longitudinal assessment), and study population.
Conclusion
While the use of mHealth solutions in the detection and management of AF is becoming increasingly popular, its clinical implications merit further investigation and several barriers to widespread mHealth adaption in healthcare systems need to be overcome. Mobile health solutions for atrial fibrillation detection and management: a systematic review.

© 2021. The Author(s).

Clin Res Cardiol: 01 May 2022; 111:479-491
Hermans ANL, Gawalko M, Dohmen L, van der Velden RMJ, ... Pluymaekers NAHA, Linz D
Clin Res Cardiol: 01 May 2022; 111:479-491 | PMID: 34549333
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Abstract

Lessons learned from catheter ablation of ventricular arrhythmias in patients with a fully magnetically levitated left ventricular assist device.

Bergau L, Sommer P, Hamriti ME, Morshuis M, ... Sohns C, Fox H
Introduction
Data on catheter ablation of ventricular arrhythmias (VA) are scarce in patients with left ventricular assist devices (LVADs) and current evidence predominantly consists of case reports with outdated LVAD. This prospective observational study reports our experience in terms of catheter ablation of VAs in patients with novel 3rd generation LVADs.
Methods and results
Between 2018 and 2020, nine consecutive patients undergoing a total number of ten ablation procedures for VAs were analyzed. The mean duration between LVAD implantation and catheter ablation was 23 ± 16 months. Acute procedural success was achieved in all patients. VA substrates were not related to the LVAD scarring (cannula) site in the majority of patients. All procedures were conducted without any relevant procedure-related complications. In terms of follow-up, only one patient presented with a repeat episode of electrical storm requiring ICD-shocks 16 months after the initial ablation procedure. Four patients suffered of singular VA effectively treated with antitachycardia pacing via their ICD. The remainder were free of any VA relapse (n = 4). Two non-procedure-related deaths occurred during follow-up.
Conclusions
Catheter ablation of VAs in patients with 3rd generation LVAD is feasible and leads to satisfying clinical results in terms of freedom from VA recurrence and quality of life. The majority of arrhythmia substrates in these patients are not directly related to the LVAD cannulation site and may represent a progress of heart failure.

© 2021. The Author(s).

Clin Res Cardiol: 01 May 2022; 111:574-582
Bergau L, Sommer P, Hamriti ME, Morshuis M, ... Sohns C, Fox H
Clin Res Cardiol: 01 May 2022; 111:574-582 | PMID: 34709450
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Abstract

Time series proteome profile analysis reveals a protective role of citrate synthase in angiotensin II-induced atrial fibrillation.

Teng F, Han X, Yu P, Li PB, Li HH, Zhang YL
Background
Angiotensin (Ang) II and elevated blood pressure are considered to be the main risk factors for atrial fibrillation. However, the proteome profiles and key mediators/signaling pathways involved in the development of Ang II-induced atrial fibrillation remain unclear.
Methods
Male wild-type C57BL/6 mice (10-week old) were infused with Ang II (2000 ng/kg per min) for 1, 2, or 3 weeks, respectively. Time series proteome profiling of atrial tissues was performed using isobaric tags for relative and absolute quantitation and liquid chromatography coupled with tandem mass spectrometry.
Results
We identified a total of 1566 differentially expressed proteins (DEPs) in the atrial tissues at weeks 1, 2, and 3 after Ang II infusion. These DEPs were predominantly involved in mitochondrial oxidation-reduction and tricarboxylic acid cycle in Ang II-infused atria. Moreover, coexpression network analysis revealed that citrate synthase, a rate-limiting enzyme in the tricarboxylic acid cycle, was localized at the center of the mitochondrial oxidation-reduction process, and its expression was significantly downreguated in Ang II-infused atria at different time points. Cardiomyocyte-specific overexpresion of citrate synthase markedly reduced atrial fibrillation susceptibility and atrial remodeling in mice. These beneficial effects were associated with increased ATP production and mitochondrial oxidative phosphorylation system complexes I-V expression and inhibition of oxidative stress.
Conclusion
The current study defines the dynamic changes of the DEPs involved in Ang II-induced atrial fibrillation, and identifies that citrate synthase plays a protective role in regulating atrial fibrillation development, and increased citrate synthase expression may represent a potential therapeutic option for atrial fibrillation treatment.

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.

J Hypertens: 31 Mar 2022; 40:765-775
Teng F, Han X, Yu P, Li PB, Li HH, Zhang YL
J Hypertens: 31 Mar 2022; 40:765-775 | PMID: 35013064
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Impact:
Abstract

Renal decline in patients with non-valvular atrial fibrillation treated with rivaroxaban or warfarin: A population-based study from the United Kingdom.

González Pérez A, Balabanova Y, Sáez ME, Brobert G, García Rodríguez LA
Background
Reports suggest that renal decline is greater among patients with non-valvular atrial fibrillation (NVAF) treated chronically with warfarin vs. some non-vitamin K antagonist oral anticoagulants.
Methods and results
Using primary care electronic health records from the United Kingdom we followed adults with NVAF and who started rivaroxaban (20 mg/day, N = 5338) or warfarin (N = 6314), excluding those with estimated glomerular filtration rate (eGFR) <50 ml/min/1.73m2, end-stage renal disease (ESRD) or no eGFR or serum creatinine (SCr) values recorded in the previous year. Outcomes were: doubling SCr levels, ≥30% decline in eGFR and progression to ESRD. We calculated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome. Average eGFR slope was estimated using mixed model regression. After a mean follow-up 2.5 years, the number of incident cases of adverse renal events within the two cohorts was: doubling SCr (n = 322), ≥30% decline in eGFR (n = 1179), and progression to ESRD (n = 22). Adjusted HRs (95% CIs) for the renal outcomes among rivaroxaban vs. warfarin users were: doubling SCr, 0.63 (0.49-0.81); ≥30% decline in eGFR, 0.76 (0.67-0.86); ESRD, 0.77 (0.29-2.04). Similar results were observed among patients with diabetes or heart failure. Estimated mean decline in renal function over the study period was 2.03 ml/min/1.73 m2/year among warfarin users and 1.65 ml/min/1.73 m2/year among rivaroxaban users (p = 0.03).
Conclusions
We found clear evidence that patients with NVAF, preserved renal function at baseline and treated with rivaroxaban had a markedly reduced risk and rate of renal decline compared with those treated with warfarin.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Int J Cardiol: 31 Mar 2022; 352:165-171
González Pérez A, Balabanova Y, Sáez ME, Brobert G, García Rodríguez LA
Int J Cardiol: 31 Mar 2022; 352:165-171 | PMID: 35122912
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Impact:
Abstract

An unprecedented cause of cardiac resynchronization with defibrillator (CRT-D) malfunction \"A beheaded generator assembly\".

Prasitlumkum N, Ding K, Doyle K, Pai RG, Lo R
Cardiac resynchronization with defibrillator (CRT-D) malfunction can be due to various reasons, including wire injury, insulation break, battery problems, or patient factors. Undesired outcomes can be dramatically elevated in those settings, prompting early detection and proper troubleshooting. To diagnose, clinical correlation and device interrogation are vital. However, it is not uncommon to find general troubleshooting options insufficient, as highlighted in this case report. Here, we presented an unusual \"head assembly separation,\" as the main reason for abnormal device parameters.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 31 Mar 2022; 33:769-772
Prasitlumkum N, Ding K, Doyle K, Pai RG, Lo R
J Cardiovasc Electrophysiol: 31 Mar 2022; 33:769-772 | PMID: 35118754
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Impact:
Abstract

Trends in the pharmacological management of atrial fibrillation in UK general practice 2008-2018.

Phillips K, Subramanian A, Thomas GN, Khan N, ... Fabritz L, Adderley NJ
Objective
The pharmacological management of atrial fibrillation (AF) comprises anticoagulation, for stroke prophylaxis, and rate or rhythm control drugs to alleviate symptoms and prevent heart failure. The aim of this study was to investigate trends in the proportion of patients with AF prescribed pharmacological therapies in the UK between 2008 and 2018.
Methods
Eleven sequential cross-sectional analyses were performed yearly from 2008 to 2018. Data were derived from an anonymised UK primary care database. Outcomes were the proportion of patients with AF prescribed anticoagulants, rhythm and rate control drugs in the whole cohort, those at high risk of stroke and those with coexisting heart failure.
Results
Between 2008 and 2018, the proportion of patients prescribed anticoagulants increased from 45.3% (95% CI 45.0% to 45.7%) to 71.1% (95% CI 70.7% to 71.5%) driven by increased prescription of non-vitamin K antagonist anticoagulants. The proportion of patients prescribed rate control drugs remained constant between 2008 and 2018 (69.3% (95% CI 68.9% to 69.6%) to 71.6% (95% CI 71.2% to 71.9%)). The proportion of patients prescribed rhythm control therapy by general practitioners (GPs) decreased from 9.5% (95% CI 9.3% to 9.7%) to 5.4% (95% CI 5.2% to 5.6%).
Conclusions
There has been an increase in the proportion of patients with AF appropriately prescribed anticoagulants following National Institute for Health and Care Excellence and European Society of Cardiology guidelines, which correlates with improvements in mortality and stroke outcomes. Beta-blockers appear increasingly favoured over digoxin for rate control. There has been a steady decline in GP prescribing rates for rhythm control drugs, possibly related to concerns over efficacy and safety and increased availability of AF ablation.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Mar 2022; 108:517-522
Phillips K, Subramanian A, Thomas GN, Khan N, ... Fabritz L, Adderley NJ
Heart: 30 Mar 2022; 108:517-522 | PMID: 34226195
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Impact:
Abstract

Utility of the CHA2DS2-VASc score for predicting ischaemic stroke in patients with or without atrial fibrillation: a systematic review and meta-analysis.

Siddiqi TJ, Usman MS, Shahid I, Ahmed J, ... Rihal CS, Alkhouli M
Aims
Anticoagulants are the mainstay treatment for stroke prevention in patients with non-valvular atrial fibrillation (NVAF), and the CHA2DS2-VASc score is widely used to guide anticoagulation therapy in this cohort. However, utility of CHA2DS2-VASc in NVAF patients is debated, primarily because it is a vascular scoring system, which does not incorporate atrial fibrillation related parameters. Therefore, we conducted a meta-analysis to estimate the discrimination ability of CHA2DS2-VASc in predicting ischaemic stroke overall, and in subgroups of patients with or without NVAF.
Methods and results
PubMed and Embase databases were searched till June 2020 for published articles that assessed the discrimination ability of CHA2DS2-VASc, as measured by C-statistics, during mid-term (2-5 years) and long-term (>5 years) follow-up. Summary estimates were reported as random effects C-statistics with 95% confidence intervals (CIs). Seventeen articles were included in the analysis. Nine studies (n = 453 747 patients) reported the discrimination ability of CHA2DS2-VASc in NVAF patients, and 10 studies (n = 138 262 patients) in patients without NVAF. During mid-term follow-up, CHA2DS2-VASc predicted stroke with modest discrimination in the overall cohort [0.67 (0.65-0.69)], with similar discrimination ability in patients with NVAF [0.65 (0.63-0.68)] and in those without NVAF [0.69 (0.68-0.71)] (P-interaction = 0.08). Similarly, at long-term follow-up, CHA2DS2-VASc had modest discrimination [0.66 (0.63-0.69)], which was consistent among patients with NVAF [0.63 (0.54-0.71)] and those without NVAF [0.67 (0.64-0.70)] (P-interaction = 0.39).
Conclusion
This meta-analysis suggests that the discrimination power of the CHA2DS2-VASc score in predicting ischaemic stroke is modest, and is similar in the presence or absence of NVAF. More accurate stroke prediction models are thus needed for the NVAF population.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Eur J Prev Cardiol: 30 Mar 2022; 29:625-631
Siddiqi TJ, Usman MS, Shahid I, Ahmed J, ... Rihal CS, Alkhouli M
Eur J Prev Cardiol: 30 Mar 2022; 29:625-631 | PMID: 33693717
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Impact:
Abstract

The role of phosphorylation in atrial fibrillation: a focus on mass spectrometry approaches.

Safabakhsh S, Panwar P, Barichello S, Sangha SS, ... Petegem FV, Laksman Z
Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with significant increases in morbidity in the form of stroke and heart failure, and a doubling in all-cause mortality. The pathophysiology of AF is incompletely understood, and this has contributed to a lack of effective treatments and disease-modifying therapies. An important cellular process that may explain how risk factors give rise to AF includes post-translational modification of proteins. As the most commonly occurring post-translational modification, protein phosphorylation is especially relevant. Although many methods exist for studying protein phosphorylation, a common and highly resolute technique is mass spectrometry (MS). This review will discuss recent evidence surrounding the role of protein phosphorylation in the pathogenesis of AF. MS-based technology to study phosphorylation and uses of MS in other areas of medicine such as oncology will also be presented. Based on these data, future goals and experiments will be outlined that utilize MS technology to better understand the role of phosphorylation in AF and elucidate its role in AF pathophysiology. This may ultimately allow for the development of more effective AF therapies.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Cardiovasc Res: 25 Mar 2022; 118:1205-1217
Safabakhsh S, Panwar P, Barichello S, Sangha SS, ... Petegem FV, Laksman Z
Cardiovasc Res: 25 Mar 2022; 118:1205-1217 | PMID: 33744917
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Impact:
Abstract

Influence of sex on intracellular calcium homoeostasis in patients with atrial fibrillation.

Herraiz-Martínez A, Tarifa C, Jiménez-Sábado V, Llach A, ... Cinca J, Hove-Madsen L
Aims
Atrial fibrillation (AF) has been associated with intracellular calcium disturbances in human atrial myocytes, but little is known about the potential influence of sex and we here aimed to address this issue.
Methods and results
Alterations in calcium regulatory mechanisms were assessed in human atrial myocytes from patients without AF or with long-standing persistent or permanent AF. Patch-clamp measurements revealed that L-type calcium current (ICa) density was significantly smaller in males with than without AF (-1.15 ± 0.37 vs. -2.06 ± 0.29 pA/pF) but not in females with AF (-1.88 ± 0.40 vs. -2.21 ± 0.0.30 pA/pF). In contrast, transient inward currents (ITi) were more frequent in females with than without AF (1.92 ± 0.36 vs. 1.10 ± 0.19 events/min) but not in males with AF. Moreover, confocal calcium imaging showed that females with AF had more calcium spark sites than those without AF (9.8 ± 1.8 vs. 2.2 ± 1.9 sites/µm2) and sparks were wider (3.0 ± 0.3 vs. 2.2 ± 0.3 µm) and lasted longer (79 ± 6 vs. 55 ± 8 ms), favouring their fusion into calcium waves that triggers ITIs and afterdepolarizations. This was linked to higher ryanodine receptor phosphorylation at s2808 in women with AF, and inhibition of adenosine A2A or beta-adrenergic receptors that modulate s2808 phosphorylation was able to reduce the higher incidence of ITI in women with AF.
Conclusion
Perturbations of the calcium homoeostasis in AF is sex-dependent, concurring with increased spontaneous SR calcium release-induced electrical activity in women but not in men, and with diminished ICa density in men only.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Cardiovasc Res: 16 Mar 2022; 118:1033-1045
Herraiz-Martínez A, Tarifa C, Jiménez-Sábado V, Llach A, ... Cinca J, Hove-Madsen L
Cardiovasc Res: 16 Mar 2022; 118:1033-1045 | PMID: 33788918
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Impact:
Abstract

Comparative effectiveness and safety of non-vitamin K antagonists for atrial fibrillation in clinical practice: GLORIA-AF Registry.

Lip GYH, Kotalczyk A, Teutsch C, Diener HC, ... Huisman MV, GLORIA-AF Investigators
Background:
and purpose
Prospectively collected data comparing the safety and effectiveness of individual non-vitamin K antagonists (NOACs) are lacking. Our objective was to directly compare the effectiveness and safety of NOACs in patients with newly diagnosed atrial fibrillation (AF).
Methods
In GLORIA-AF, a large, prospective, global registry program, consecutive patients with newly diagnosed AF were followed for 3 years. The comparative analyses for (1) dabigatran vs rivaroxaban or apixaban and (2) rivaroxaban vs apixaban were performed on propensity score (PS)-matched patient sets. Proportional hazards regression was used to estimate hazard ratios (HRs) for outcomes of interest.
Results
The GLORIA-AF Phase III registry enrolled 21,300 patients between January 2014 and December 2016. Of these, 3839 were prescribed dabigatran, 4015 rivaroxaban and 4505 apixaban, with median ages of 71.0, 71.0, and 73.0 years, respectively. In the PS-matched set, the adjusted HRs and 95% confidence intervals (CIs) for dabigatran vs rivaroxaban were, for stroke: 1.27 (0.79-2.03), major bleeding 0.59 (0.40-0.88), myocardial infarction 0.68 (0.40-1.16), and all-cause death 0.86 (0.67-1.10). For the comparison of dabigatran vs apixaban, in the PS-matched set, the adjusted HRs were, for stroke 1.16 (0.76-1.78), myocardial infarction 0.84 (0.48-1.46), major bleeding 0.98 (0.63-1.52) and all-cause death 1.01 (0.79-1.29). For the comparison of rivaroxaban vs apixaban, in the PS-matched set, the adjusted HRs were, for stroke 0.78 (0.52-1.19), myocardial infarction 0.96 (0.63-1.45), major bleeding 1.54 (1.14-2.08), and all-cause death 0.97 (0.80-1.19).
Conclusions
Patients treated with dabigatran had a 41% lower risk of major bleeding compared with rivaroxaban, but similar risks of stroke, MI, and death. Relative to apixaban, patients treated with dabigatran had similar risks of stroke, major bleeding, MI, and death. Rivaroxaban relative to apixaban had increased risk for major bleeding, but similar risks for stroke, MI, and death.
Registration
URL: https://www.
Clinicaltrials
gov . Unique identifiers: NCT01468701, NCT01671007. Date of registration: September 2013.

© 2022. The Author(s).

Clin Res Cardiol: 15 Mar 2022; epub ahead of print
Lip GYH, Kotalczyk A, Teutsch C, Diener HC, ... Huisman MV, GLORIA-AF Investigators
Clin Res Cardiol: 15 Mar 2022; epub ahead of print | PMID: 35294625
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Impact:
Abstract

Dabigatran versus vitamin K antagonists for atrial fibrillation in clinical practice: final outcomes from Phase III of the GLORIA-AF registry.

Huisman MV, Teutsch C, Lu S, Diener HC, ... Lip GYH, GLORIA-AF Investigators
Background
Prospectively collected, routine clinical practice-based data on antithrombotic therapy in non-valvular atrial fibrillation (AF) patients are important for assessing real-world comparative outcomes. The objective was to compare the safety and effectiveness of dabigatran versus vitamin K antagonists (VKAs) in patients with newly diagnosed AF.
Methods and results
GLORIA-AF is a large, prospective, global registry program. Consecutive patients with newly diagnosed AF and CHA2DS2-VASc scores ≥ 1 were included and followed for 3 years. To control for differences in patient characteristics, the comparative analysis for dabigatran versus VKA was performed on a propensity score (PS)-matched patient set. Missing data were multiply imputed. Proportional-hazards regression was used to estimate hazard ratios (HRs) for outcomes of interest. Between 2014 and 2016, 21,300 eligible patients were included worldwide: 3839 patients were prescribed dabigatran and 4836 VKA with a median age of 71.0 and 72.0 years, respectively; > 85% in each group had a CHA2DS2-VASc-score ≥ 2. The PS-matched comparative analysis for dabigatran and VKA included on average 3326 pairs of matched initiators. For dabigatran versus VKAs, adjusted HRs (95% confidence intervals) were: stroke 0.89 (0.59-1.34), major bleeding 0.61 (0.42-0.88), all-cause death 0.78 (0.63-0.97), and myocardial infarction 0.89 (0.53-1.48). Further analyses stratified by PS and region provided similar results.
Conclusions
Dabigatran was associated with a 39% reduced risk of major bleeding and 22% reduced risk for all-cause death compared with VKA. Stroke and myocardial infarction risks were similar, confirming a more favorable benefit-risk profile for dabigatran compared with VKA in clinical practice. Clinical trial registration https://www.
Clinicaltrials
gov . NCT01468701, NCT01671007.

© 2022. The Author(s).

Clin Res Cardiol: 15 Mar 2022; epub ahead of print
Huisman MV, Teutsch C, Lu S, Diener HC, ... Lip GYH, GLORIA-AF Investigators
Clin Res Cardiol: 15 Mar 2022; epub ahead of print | PMID: 35294623
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Impact:
Abstract

Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation.

D\'Ancona G, Arslan F, Safak E, Weber D, Al Ammareen R, Ince H
Aims
Comparing actual management costs in patients with non-valvular atrial fibrillation (AF) treated with percutaneous left atrial appendage closure (LAAC) or OAC only.
Methods and results
Patients undergoing percutaneous LAAC and AF patients treated with OAC only were matched for gender, age, and diagnosis related groups (DRG) clinical complexity level (CCL). Costs for cardiovascular outpatient clinic visits and hospitalizations were derived from the actual reimbursement records. Between 1/2012 and 12/2016, 8478 patients were referred: 7801 (92%) managed with OAC and 677 (8%) with percutaneous LAAC. Matching resulted in 558 patients (279 per group) for final analysis. Age was 74.9 ± 7.5 years, 244 were female (43.7%), and DRG CCL was 1.8 ± 1.1. Annualized management cost before percutaneous LAAC was € 3110 (IQR: € 1281-8127). After 4.5 ± 1.4 years follow-up, annualized management cost was € 1297 (IQR: € 607-2735) in OAC patients and € 1013 (IQR: € 0-4770) in patients after percutaneous LAAC (p = 0.003). Percutaneous LAAC was the strongest independent determinant to reduce follow-up costs (B = -0.8; CI: -1.09 ̶̶̶̶̶ -0.6; p < 0.0001). Estimated 3-year survival was 92% in percutaneous LAAC and 90% in OAC patients (p = 0.7).
Conclusion
Percutaneous LAAC significantly reduces management costs. Management costs are significantly higher for patients treated with only OAC compared to patients after percutaneous LAAC. In spite of their complex comorbid profile, percutaneous LAAC patients show a follow-up survival rate similar to patients solely treated with OAC. Future studies are necessary to investigate the potential net economic and clinical benefit of percutaneous LAAC in patients treated with OAC only.

Copyright © 2021 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Mar 2022; 351:61-64
D'Ancona G, Arslan F, Safak E, Weber D, Al Ammareen R, Ince H
Int J Cardiol: 14 Mar 2022; 351:61-64 | PMID: 34929249
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Impact:
Abstract

The risk and timing of acute ischemic stroke after electrical cardioversion for atrial fibrillation in Taiwan: A nationwide population-based cohort study.

Huang CK, Wang JC, Chung CH, Chen SJ, Liao WI, Chien WC
Background
There is a positive association between electrical cardioversion (ECV) and acute ischemic stroke (AIS). Although 4 weeks of anticoagulation therapy after ECV in atrial fibrillation (AF) patients is generally suggested by current guidelines to reduce the risk of AIS, limited studies have been conducted in Asian populations to determine the risk and timing of AIS after ECV for AF in recent years. Therefore, we aim to use the National Health Insurance Research Database (NHIRD) in Taiwan to determine the risk and timing of AIS after ECV for AF.
Methods
The data analyzed in this nationwide population-based retrospective cohort study were obtained from the NHIRD in Taiwan. The outcome in this study was the cumulative incidence of AIS in patients with AF during 7-day and 30-day follow-up periods after the patients underwent ECV.
Results
Our analysis included 39,697 patients with AF, of whom 5723 received ECV and 5723 were propensity score-matched controls. Compared to the controls, patients who received ECV exhibited a significantly increased incidence of 7-day AIS development (adjusted hazard ratio [HR] = 1.524, p = 0.003). In contrast, the incidence of 30-day AIS development showed no significant increase (adjusted HR = 1.301, p = 0.426).
Conclusions
AF patients who underwent ECV had a higher incidence of 7-day AIS development but not 30-day AIS development. Considering the timing of AIS development after ECV in AF patients, the optimal duration of antithrombotic therapy after ECV deserves further investigation.

Copyright © 2021 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Mar 2022; 351:55-60
Huang CK, Wang JC, Chung CH, Chen SJ, Liao WI, Chien WC
Int J Cardiol: 14 Mar 2022; 351:55-60 | PMID: 34954280
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Impact:
Abstract

Investigating the association between P wave duration and atrial fibrillation recurrence after radiofrequency ablation in early persistent atrial fibrillation patients.

Miao Y, Xu M, Yang L, Zhang C, Liu H, Shao X
Background
In the present study, we aimed to explore the association between P wave duration, as the measured time from the start point of the P wave to the end point, and atrial fibrillation recurrence after transcatheter radiofrequency ablation in patients with early persistent atrial fibrillation.
Methods
Patients with early persistent atrial fibrillation who underwent the first radiofrequency ablation procedure were retrospectively analyzed. The electrocardiographic, echocardiographic and clinical data of the enrolled patients before and after operation were collected and recorded. After adjusting confounding factors and performing stratified analysis, the association between the P wave duration and the atrial fibrillation recurrence of patients with early persistent atrial fibrillation after radiofrequency ablation was explored.
Results
The proportions of atrial fibrillation recurrence of the low, medium, and high P wave duration groups were 6.4%, 19.7%, and 47.0%, respectively. After potential confounding factors were adjusted, the risk of atrial fibrillation recurrence gradually increased with the increase of P wave duration (odds ratio: 1.093, 95% confidence interval: 1.063-1.124, p < 0.001). This trend was statistically significant (odds ratio: 1.099, 95% confidence interval: 1.052-1.149, p < 0.001), especially in comparison of high vs. low (odds ratio: 16.99, 95% confidence interval: 4.75-60.78, p < 0.001). Curve fitting showed that there was a linear and positive association between the P wave duration and the risk of atrial fibrillation recurrence. This association was consistent in different subgroups based on gender, drinking, history of smoking, hypertension, diabetes mellitus, peripheral artery disease, stroke or transient ischemia attack, hyperlipidemia, heart failure, and heart rate, suggesting that there was no significant interaction between different grouping parameters and the association (p for interaction range = 0.217-0.965).
Conclusions
In patients with early persistent atrial fibrillation who underwent radiofrequency ablation procedure for the first time and converted to sinus rhythm, the P wave duration within 72 h after the procedure was independently associated with the risk of atrial fibrillation recurrence, and such association was linear and positive.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Mar 2022; 351:48-54
Miao Y, Xu M, Yang L, Zhang C, Liu H, Shao X
Int J Cardiol: 14 Mar 2022; 351:48-54 | PMID: 34954277
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Impact:
Abstract

Incidence and Predictors of Bleeding in Patients With Cancer and Atrial Fibrillation.

Raposeiras Roubín S, Abu Assi E, Muñoz Pousa I, Domínguez Erquicia P, ... Gonzalez Bermudez I, Íñiguez Romo A
Despite patients with cancer having a higher incidence of atrial fibrillation (AF), little is known about the predictors of outcomes in this population. This study aimed to assess the incidence and predictors of bleeding in patients with AF and cancer. The study population comprised 16,056 patients from a Spanish health area diagnosed with AF between 2014 and 2018 (1,137 with cancer). Competing risk analysis were used to evaluate the association of cancer and bleeding. Discrimination and calibration of bleeding risk scores were assessed by the concordance statistic and the Brier score, respectively. During a median follow-up of 4.9 years, the incidence of bleeding in patients with cancer was 13.2 per 100 patients/year. After multivariate adjustment, a significant association between cancer and bleeding was detected (subdistribution hazard ratio [sHR] 1.18, 95% CI 1.07 to 1.30, p = 0.001), specifically in patients with active cancer or previous radiotherapy. Early age, male gender, diabetes, and anticoagulation were independent predictors of bleeding. However, only anticoagulation with vitamin K antagonist (sHR 1.36, 95% CI 1.03 to 1.78, p = 0.026), not with direct oral anticoagulants (sHR 1.25, 95% CI 0.84 to 1.85, p = 0.270), was associated with bleeding. Discrimination and calibration of Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, and Drugs/alcohol concomitantly (HAS-BLED), AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA), and Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age ≥75 years), Reduced platelet count or function, Rebleeding risk, Hypertension, Anaemia, Genetic factors, Excessive fall risk and Stroke (HEMORR2HAGES) scores were poor in patients with cancer (concordance statistic <0.6 and Brier score >0.1). In summary, cancer was associated with an increased risk of bleeding in patients with AF. The predictive ability of bleeding risk scores was poor in this population. Anticoagulation with vitamin K antagonist but not with direct oral anticoagulants, was an independent predictor of bleeding in patients with cancer.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2022; 167:139-146
Raposeiras Roubín S, Abu Assi E, Muñoz Pousa I, Domínguez Erquicia P, ... Gonzalez Bermudez I, Íñiguez Romo A
Am J Cardiol: 14 Mar 2022; 167:139-146 | PMID: 35027138
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Impact:
Abstract

Restoring Sinus Rhythm Reverses Cardiac Remodeling and Reduces Valvular Regurgitation in Patients With Atrial Fibrillation.

Soulat-Dufour L, Lang S, Addetia K, Ederhy S, ... Lang RM, Cohen A
Background
Cardiac chamber remodeling in atrial fibrillation (AF) reflects the progression of cardiac rhythm and may affect functional regurgitation.
Objectives
The purpose of this study was to explore the 3-dimensional echocardiographic variables of cardiac cavity remodeling and the impact on functional regurgitation in patients with AF with/without sinus rhythm restoration at 12 months.
Methods
A total of 117 consecutive patients hospitalized for AF were examined using serial 3-dimensional transthoracic echocardiography at admission, at 6 months, and at 12 months (337 examinations).
Results
During follow-up, 47 patients with active restoration of sinus rhythm (SR) (through cardioversion and/or ablation) had a decrease in all atrial indexed volumes (Vi), end-systolic (ES) right ventricular (RV) Vi, an increase in end-diastolic (ED) left ventricular Vi, and an improvement in 4-chambers function (P < 0.05). Patients with absence/failure of restoration of SR (n = 39) had an increase in ED left atrial Vi and ED/ES RV Vi without modification of 4-chambers function, except for a decrease in left atrial emptying fraction (P < 0.05). Patients with spontaneous restoration of SR (n = 31) had no changes in Vi or function. The authors found an improvement vs baseline in severity of functional regurgitation in patients with active restoration of SR (tricuspid and mitral regurgitation) and in spontaneous restoration of SR (tricuspid regurgitation) (P < 0.05). In multivariable analysis, right atrial and/or left atrial reverse remodeling exclusively correlated with intervention (cardioversion and/or ablation) during 12-month follow-up.
Conclusions
Management of AF should focus on restoration of SR to induce anatomical (all atrial Vi, ES RV Vi) and/or functional (4 chambers) cardiac cavity reverse remodeling and reduce severity of functional regurgitation. (Thromboembolic and Bleeding Risk Stratification in Patients With Non-valvular Atrial Fibrillation [FASTRHAC]; NCT02741349).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Mar 2022; 79:951-961
Soulat-Dufour L, Lang S, Addetia K, Ederhy S, ... Lang RM, Cohen A
J Am Coll Cardiol: 14 Mar 2022; 79:951-961 | PMID: 35272799
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Impact:
Abstract

Dronedarone for the Treatment of Atrial Fibrillation with Concomitant Heart Failure with Preserved and Mildly Reduced Ejection Fraction: Post-Hoc Analysis of the ATHENA Trial.

Vaduganathan M, Piccini JP, Camm AJ, Crijns HJGM, ... Wieloch M, Hohnloser SH
Aims
Limited therapeutic options are available for the management of atrial fibrillation/flutter (AF/AFL) with concomitant heart failure with preserved and mildly reduced ejection fraction. (HFpEF and HFmrEF). Dronedarone reduces the risk of cardiovascular events in patients with AF, but sparse data are available examining its role in patients with AF complicated by HFpEF and HFmrEF.
Methods and results
ATHENA was an international, multicenter trial that randomized 4,628 patients with paroxysmal or persistent AF/AFL and cardiovascular risk factors to dronedarone 400 mg twice daily versus placebo. We evaluated patients with 1) symptomatic HFpEF and HFmrEF (defined as LVEF>40%, evidence of structural heart disease, and New York Heart Association class II/III or diuretic use), 2) HF with reduced ejection fraction (HFrEF) or left ventricular dysfunction (LVEF≤40%), and 3) those without HF. We assessed effects of dronedarone vs placebo on death or cardiovascular hospitalization (primary endpoint), other key efficacy endpoints, and safety. Overall, 534 (12%) had HFpEF or HFmrEF, 422 (9%) had HFrEF or LV dysfunction, and 3,672 (79%) did not have HF. Patients with HFpEF and HFmrEF had a mean age of 73±9 years, 37% were women, and had a mean LVEF of 57±9%. Over 21±5 months mean follow-up, dronedarone consistently reduced risk of death or cardiovascular hospitalization (hazard ratio 0.76; 95% confidence interval 0.69-0.84) without heterogeneity based on HF status (Pinteraction >0.10). This risk reduction in the primary endpoint was consistent across the range of LVEF (as a continuous function) in HF without heterogeneity (Pinteraction =0.71). Rates of death, cardiovascular hospitalization, and HF hospitalization each directionally favored dronedarone vs. placebo in HFpEF and HFmrEF, but these treatment effects were not statistically significant.
Conclusions
Dronedarone is associated with reduced cardiovascular events in patients with paroxysmal or persistent AF/AFL and HF across the spectrum of LVEF, including among those with HFpEF and HFmrEF. These data support a rationale for a future dedicated and powered clinical trial to affirm the net clinical benefit of dronedarone in this population.

This article is protected by copyright. All rights reserved.

Eur J Heart Fail: 14 Mar 2022; epub ahead of print
Vaduganathan M, Piccini JP, Camm AJ, Crijns HJGM, ... Wieloch M, Hohnloser SH
Eur J Heart Fail: 14 Mar 2022; epub ahead of print | PMID: 35293087
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Impact:
Abstract

How should I treat patients with subclinical atrial fibrillation and atrial high-rate episodes? Current evidence and clinical importance.

Kreimer F, Mügge A, Gotzmann M
Long-term and continuous ECG monitoring using cardiac implantable electronic devices and insertable cardiac monitors has improved the capability of detecting subclinical atrial fibrillation (AF) and atrial high-rate episodes. Previous studies demonstrated a high prevalence (more than 20%) in patients with cardiac implantable electronic devices or insertable cardiac monitors. Subclinical AF and atrial high-rate episodes are often suspected as the cause of prior or potential future ischemic stroke. However, the clinical significance is still uncertain, and the evidence is limited. This review aims to present and discuss the current evidence on the clinical impact of subclinical AF and atrial high-rate episodes. It focuses particularly on the association between the duration of the episodes and major clinical outcomes like thromboembolic events. As subclinical AF and atrial high-rate episodes are presumed to be associated with ischemic strokes, detection will be particularly important in patients with cryptogenic stroke and in high-risk patients for thromboembolism. In this context, it is also interesting whether there is a temporal relationship between the detection of subclinical AF and atrial high-rate episodes and the occurrence of thromboembolic events. In addition, the review will examine the question whether there is a need for a therapy with oral anticoagulation.

© 2022. The Author(s).

Clin Res Cardiol: 14 Mar 2022; epub ahead of print
Kreimer F, Mügge A, Gotzmann M
Clin Res Cardiol: 14 Mar 2022; epub ahead of print | PMID: 35292844
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Impact:
Abstract

Glycemic control and atrial fibrillation: an intricate relationship, yet under investigation.

Papazoglou AS, Kartas A, Moysidis DV, Tsagkaris C, ... Papadakis M, Giannakoulas G
Atrial fibrillation (AF) and diabetes mellitus (DM) constitute two major closely inter-related chronic cardiovascular disorders whose concurrent prevalence rates are steadily increasing. Although, the pathogenic mechanisms behind the AF and DM comorbidity are still vague, it is now clear that DM precipitates AF occurrence. DM also affects the clinical course of established AF; it is associated with significant increase in the incidence of stroke, AF recurrence, and cardiovascular mortality. The impact of DM on AF management and prognosis has been adequately investigated. However, evidence on the relative impact of glycemic control using glycated hemoglobin levels is scarce. This review assesses up-to-date literature on the association between DM and AF. It also highlights the usefulness of glycated hemoglobin measurement for the prediction of AF and AF-related adverse events. Additionally, this review evaluates current anti-hyperglycemic treatment in the context of AF, and discusses AF-related decision-making in comorbid DM. Finally, it quotes significant remaining questions and sets some future strategies with the potential to effectively deal with this prevalent comorbidity.

© 2022. The Author(s).

Cardiovasc Diabetol: 13 Mar 2022; 21:39
Papazoglou AS, Kartas A, Moysidis DV, Tsagkaris C, ... Papadakis M, Giannakoulas G
Cardiovasc Diabetol: 13 Mar 2022; 21:39 | PMID: 35287684
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Abstract

Epicardial fat and atrial fibrillation: the perils of atrial failure.

Poggi AL, Gaborit B, Schindler TH, Liberale L, Montecucco F, Carbone F
Obesity is a heterogeneous condition, characterized by different phenotypes and for which the classical assessment with body mass index may underestimate the real impact on cardiovascular (CV) disease burden. An epidemiological link between obesity and atrial fibrillation (AF) has been clearly demonstrated and becomes even more tight when ectopic (i.e. epicardial) fat deposition is considered. Due to anatomical and functional features, a tight paracrine cross-talk exists between epicardial adipose tissue (EAT) and myocardium, including the left atrium (LA). Alongside-and even without-mechanical atrial stretch, the dysfunctional EAT may determine a pro-inflammatory environment in the surrounding myocardial tissue. This evidence has provided a new intriguing pathophysiological link with AF, which in turn is no longer considered a single entity but rather the final stage of atrial remodelling. This maladaptive process would indeed include structural, electric, and autonomic derangement that ultimately leads to overt disease. Here, we update how dysfunctional EAT would orchestrate LA remodelling. Maladaptive changes sustained by dysfunctional EAT are driven by a pro-inflammatory and pro-fibrotic secretome that alters the sinoatrial microenvironment. Structural (e.g. fibro-fatty infiltration) and cellular (e.g. mitochondrial uncoupling, sarcoplasmic reticulum fragmentation, and cellular protein quantity/localization) changes then determine an electrophysiological remodelling that also involves the autonomic nervous system. Finally, we summarize how EAT dysfunction may fit with the standard guidelines for AF. Lastly, we focus on the potential benefit of weight loss and different classes of CV drugs on EAT dysfunction, LA remodelling, and ultimately AF onset and recurrence.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.

Europace: 10 Mar 2022; epub ahead of print
Poggi AL, Gaborit B, Schindler TH, Liberale L, Montecucco F, Carbone F
Europace: 10 Mar 2022; epub ahead of print | PMID: 35274140
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Abstract

Preoperative Personalization of Atrial Fibrillation Ablation Strategy to Prevent Esophageal Injury: Impact of Changes in Esophageal Position.

Nakatani Y, Nuñez-Garcia M, Cheniti G, Sridi-Cheniti S, ... Jais P, Cochet H
Introduction
Due to changes in esophageal position, preoperative assessment of the esophageal location may not mitigate the risk of esophageal injury in catheter ablation for atrial fibrillation (AF). This study aimed to assess esophageal motion and its impact on AF ablation strategies.
Methods and results
Ninety-seven AF patients underwent 2 computed tomography (CT) scans. The area at risk of esophageal injury (AAR) was defined as the left atrial surface ≤3 mm from the esophagus. On CT1, ablation lines were drawn blinded to the esophageal location to create 3 ablation sets: individual pulmonary vein isolation (PVI), wide antral circumferential ablation (WACA), and WACA with linear ablation (WACA+L). Thereafter, ablation lines for WACA and WACA+L were personalized to avoid the AAR. Rigid registration was performed to align CT1 onto CT2, and the relationship between ablation lines and the AAR on CT2 was analyzed. The esophagus moved by 3.6 [2.7 to 5.5] mm. The AAR on CT2 was 8.6 ± 3.3 cm2 , with 77% overlapping that on CT1. High body mass index was associated with the AAR mismatch (standardized β 0.382, P <0.001). Without personalization, AARs on ablation lines for individual PVI, WACA, and WACA+L were 0 [0-0.4], 0.8 [0.5-1.2], 1.7 [1.2-2.0] cm2 . Despite the esophageal position change, the personalization of ablation lines for WACA and WACA+L reduced the AAR on lines to 0 [0-0.5] and 0.7 [0.3-1.0] cm2 (P <0.001 for both).
Conclusion
The personalization of ablation lines based on a preoperative CT reduced ablation to the AAR despite changes in esophageal position. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 10 Mar 2022; epub ahead of print
Nakatani Y, Nuñez-Garcia M, Cheniti G, Sridi-Cheniti S, ... Jais P, Cochet H
J Cardiovasc Electrophysiol: 10 Mar 2022; epub ahead of print | PMID: 35274776
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Impact:
Abstract

Smartphone detection of atrial fibrillation using photoplethysmography: a systematic review and meta-analysis.

Gill S, Bunting KV, Sartini C, Cardoso VR, ... Gkoutos GV, Kotecha D
Objectives
Timely diagnosis of atrial fibrillation (AF) is essential to reduce complications from this increasingly common condition. We sought to assess the diagnostic accuracy of smartphone camera photoplethysmography (PPG) compared with conventional electrocardiogram (ECG) for AF detection.
Methods
This is a systematic review of MEDLINE, EMBASE and Cochrane (1980-December 2020), including any study or abstract, where smartphone PPG was compared with a reference ECG (1, 3 or 12-lead). Random effects meta-analysis was performed to pool sensitivity/specificity and identify publication bias, with study quality assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) risk of bias tool.
Results
28 studies were included (10 full-text publications and 18 abstracts), providing 31 comparisons of smartphone PPG versus ECG for AF detection. 11 404 participants were included (2950 in AF), with most studies being small and based in secondary care. Sensitivity and specificity for AF detection were high, ranging from 81% to 100%, and from 85% to 100%, respectively. 20 comparisons from 17 studies were meta-analysed, including 6891 participants (2299 with AF); the pooled sensitivity was 94% (95% CI 92% to 95%) and specificity 97% (96%-98%), with substantial heterogeneity (p<0.01). Studies were of poor quality overall and none met all the QUADAS-2 criteria, with particular issues regarding selection bias and the potential for publication bias.
Conclusion
PPG provides a non-invasive, patient-led screening tool for AF. However, current evidence is limited to small, biased, low-quality studies with unrealistically high sensitivity and specificity. Further studies are needed, preferably independent from manufacturers, in order to advise clinicians on the true value of PPG technology for AF detection.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 10 Mar 2022; epub ahead of print
Gill S, Bunting KV, Sartini C, Cardoso VR, ... Gkoutos GV, Kotecha D
Heart: 10 Mar 2022; epub ahead of print | PMID: 35277454
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Impact:
Abstract

Oral anticoagulants in patients with atrial fibrillation at low stroke risk: a multicentre observational study.

Komen JJ, Pottegård A, Mantel-Teeuwisse AK, Forslund T, ... Kjerpeseth LJ, Klungel OH
Aims
There is currently no consensus on whether atrial fibrillation (AF) patients at low risk for stroke (one non-sex-related CHA2DS2-VASc point) should be treated with an oral anticoagulant.
Methods and results
We conducted a multi-country cohort study in Sweden, Denmark, Norway, and Scotland. In total, 59 076 patients diagnosed with AF at low stroke risk were included. We assessed the rates of stroke or major bleeding during treatment with a non-vitamin K antagonist oral anticoagulant (NOAC), a vitamin K antagonist (VKA), or no treatment, using inverse probability of treatment weighted (IPTW) Cox regression. In untreated patients, the rate for ischaemic stroke was 0.70 per 100 person-years and the rate for a bleed was also 0.70 per 100 person-years. Comparing NOAC with no treatment, the stroke rate was lower [hazard ratio (HR) 0.72; 95% confidence interval (CI) 0.56-0.94], and the rate for intracranial haemorrhage (ICH) was not increased (HR 0.84; 95% CI 0.54-1.30). Comparing VKA with no treatment, the rate for stroke tended to be lower (HR 0.81; 95% CI 0.59-1.09), and the rate for ICH tended to be higher during VKA treatment (HR 1.37; 95% CI 0.88-2.14). Comparing NOAC with VKA treatment, the rate for stroke was similar (HR 0.92; 95% CI 0.70-1.22), but the rate for ICH was lower during NOAC treatment (HR 0.63; 95% CI 0.42-0.94).
Conclusion
These observational data suggest that NOAC treatment may be associated with a positive net clinical benefit compared with no treatment or VKA treatment in patients at low stroke risk, a question that can be tested through a randomized controlled trial.
Key question
What is the association between anticoagulant treatment and stroke and bleeding rate, in patients with one non-sex-related risk factor for stroke?
Key findings

Take-home message
These observational data suggest that NOAC treatment may be associated with a positive net clinical benefit compared with no treatment or VKA treatment in patients at low stroke risk, a hypothesis that can be tested through a randomized controlled trial.

© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology.

Eur Heart J: 09 Mar 2022; epub ahead of print
Komen JJ, Pottegård A, Mantel-Teeuwisse AK, Forslund T, ... Kjerpeseth LJ, Klungel OH
Eur Heart J: 09 Mar 2022; epub ahead of print | PMID: 35265981
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Abstract

Evaluation of antithrombotic use and COVID-19 outcomes in a nationwide atrial fibrillation cohort.

Handy A, Banerjee A, Wood AM, Dale C, ... Sofat R, CVD-COVID-UK Consortium
Objective
To evaluate antithrombotic (AT) use in individuals with atrial fibrillation (AF) and at high risk of stroke (CHA2DS2-VASc score ≥2) and investigate whether pre-existing AT use may improve COVID-19 outcomes.
Methods
Individuals with AF and CHA2DS2-VASc score ≥2 on 1 January 2020 were identified using electronic health records for 56 million people in England and were followed up until 1 May 2021. Factors associated with pre-existing AT use were analysed using logistic regression. Differences in COVID-19-related hospitalisation and death were analysed using logistic and Cox regression in individuals with pre-existing AT use versus no AT use, anticoagulants (AC) versus antiplatelets (AP), and direct oral anticoagulants (DOACs) versus warfarin.
Results
From 972 971 individuals with AF (age 79 (±9.3), female 46.2%) and CHA2DS2-VASc score ≥2, 88.0% (n=856 336) had pre-existing AT use, 3.8% (n=37 418) had a COVID-19 hospitalisation and 2.2% (n=21 116) died, followed up to 1 May 2021. Factors associated with no AT use included comorbidities that may contraindicate AT use (liver disease and history of falls) and demographics (socioeconomic status and ethnicity). Pre-existing AT use was associated with lower odds of death (OR=0.92, 95% CI 0.87 to 0.96), but higher odds of hospitalisation (OR=1.20, 95% CI 1.15 to 1.26). AC versus AP was associated with lower odds of death (OR=0.93, 95% CI 0.87 to 0.98) and higher hospitalisation (OR=1.17, 95% CI 1.11 to 1.24). For DOACs versus warfarin, lower odds were observed for hospitalisation (OR=0.86, 95% CI 0.82 to 0.89) but not for death (OR=1.00, 95% CI 0.95 to 1.05).
Conclusions
Pre-existing AT use may be associated with lower odds of COVID-19 death and, while not evidence of causality, provides further incentive to improve AT coverage for eligible individuals with AF.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 09 Mar 2022; epub ahead of print
Handy A, Banerjee A, Wood AM, Dale C, ... Sofat R, CVD-COVID-UK Consortium
Heart: 09 Mar 2022; epub ahead of print | PMID: 35273122
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Abstract

Anatomy of the Proximal Septal Vein in Patients with Focal Intramural Ventricular Arrhythmias.

Tam TK, Liang JJ, Ghannam M, Latchamsetty R, ... Morady F, Bogun F
Background
Focal ventricular arrhythmias (VA) originating from the intramural myocardium of the basal septum are difficult to localize and ablate. Proximal septal veins emptying into the great cardiac vein can reach close to the origin of intramural arrhythmias.
Objective
To assess characteristics of proximal septal coronary veins in patients with intramural VAs.
Methods and results
From among 84 consecutive patients with intramural VAs, 29 patients (age 60±11years, 16 males, ejection fraction 47±13%) underwent preprocedural cardiac computed tomographic angiography (CTA). In 14 of these patients the intramural site of origin (SOO) was identified with multipolar catheters. The intramural SOO could not be accessed with mapping catheters in the other 15 patients while mapping the coronary venous system. The CTA identified sizable proximal septal veins in all patients in whom the SOO could be accessed with mapping catheters. In the patients in whom the intramural SOO was not identified, the proximal septal veins were often either small (< 2 mm at branching site) or non-existent (n=9, p=0.001). The proximal septal veins in patients in whom the SOO was identified were larger than in the patients in whom the SOO could not be identified (3.0±0.6 mm vs 2.1±0.9 mm, p=0.01).
Conclusions
Preprocedural imaging with CTAs can be beneficial in identifying the anatomy of proximal septal coronary veins that allow adequate mapping of patients with suspected intramural VAs. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print
Tam TK, Liang JJ, Ghannam M, Latchamsetty R, ... Morady F, Bogun F
J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print | PMID: 35262245
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Abstract

Genetically Based Atrial Fibrillation: Current Considerations for Diagnosis and Management.

Pensa AV, Baman JR, Puckelwartz MJ, Wilcox JE
Atrial fibrillation (AF) is the most common atrial arrhythmia and is subcategorized into numerous clinical phenotypes. Given its heterogeneity, investigations into the genetic mechanisms underlying AF have been pursued in recent decades, with predominant analyses focusing on early onset or lone AF. Linkage analyses, genome wide association studies (GWAS), and single gene analyses have led to the identification of rare and common genetic variants associated with AF risk. Significant overlap with genetic variants implicated in dilated cardiomyopathy syndromes, including truncating variants of the sarcomere protein titin, have been identified through these analyses, in addition to other genes associated with cardiac structure and function. Despite this, widespread utilization of genetic testing in AF remains hindered by the unclear impact of genetic risk identification on clinical outcomes and the high prevalence of variants of unknown significance (VUS). However, genetic testing is a reasonable option for patients with early onset AF and in those with significant family history of arrhythmia. While many knowledge gaps remain, emerging data support genotyping to inform selection of AF therapeutics. In this review we highlight the current understanding of the complex genetic basis of AF and explore the overlap of AF with inherited cardiomyopathy syndromes. We propose a set of criteria for clinical genetic testing in AF patients and outline future steps for the integration of genetics into AF care. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print
Pensa AV, Baman JR, Puckelwartz MJ, Wilcox JE
J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print | PMID: 35262243
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Abstract

In vivo Lesion Index (LSI) validation in percutaneous radiofrequency catheter ablation.

Themistoclakis S, Calzolari V, De Mattia L, China P, ... Thiene G, Tondo C
Introduction
Lesion Index (LSI) has been developed to predict lesion efficacy during radiofrequency (RF) catheter ablation. However, its value in predicting lesions size has still to be established. The aim of our study was to assess the lesions size reproducibility for pre-specified values of LSI reached during RF delivery in an in vivo beating heart.
Methods
Ablation lesions were created with different values of LSI in 7 domestic pigs by means of a contact force sensing catheter (TactiCathTM , Abbott). Lesions were identified during RF delivery by means of a 3D mapping system (EnSiteTM Precision, Abbott) and measured after heart explantation. Histology was carried out after gross examination on the first 3 lesions to confirm the accuracy of the macroscopic evaluation.
Results
A total of 64 myocardial lesions were created. Thirty-nine lesions were excluded from the analysis for the following reasons: histological confirmation of macroscopic lesion measurement (n=3), transmurality (n=24), unfavorable anatomic position (n=10), not macroscopically identifiable (n=2). In a final set of 25 non-transmural lesions, injury width and depth were respectively 4.6±0.6 mm and 2.6±0.8 mm for LSI=4, 7.3±0.8 mm and 4.7±0.6 mm for LSI=5, and 8.6±1.2 mm and 7.2±1.1 mm for LSI=6. A strong linear correlation was observed between LSI and lesion width (r=0.87, p<0.00001) and depth (r=0.89, p<0.00001). Multiple linear regression analysis identified LSI as the only ablation parameter that significantly predicted lesion width (p<0.001) and depth (p<0.001).
Conclusion
In our in vivo study, LSI proved highly predictive of lesion size and depth. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print
Themistoclakis S, Calzolari V, De Mattia L, China P, ... Thiene G, Tondo C
J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print | PMID: 35262242
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Abstract

Atrial Structural Remodeling in Patients With Atrial Fibrillation Is a Diffuse Fibrotic Process: Evidence From High-Density Voltage Mapping and Atrial Biopsy.

Yamaguchi T, Otsubo T, Takahashi Y, Nakashima K, ... Takahashi N, Node K

Background:
Low-voltage areas (LVAs) in the atria of patients with atrial fibrillation are considered local fibrosis. We hypothesized that voltage reduction in the atria is a diffuse process associated with fibrosis and that the presence of LVAs reflects a global voltage reduction. Methods and Results We examined 140 patients with atrial fibrillation and 13 patients with a left accessory pathway (controls). High-density bipolar voltage mapping was performed using a grid-mapping catheter during high right atrial pacing. Global left atrial (LA) voltage (VGLA) in the whole LA and regional LA voltage (VRLA) in 6 anatomic regions were evaluated with the mean of the highest voltage at a sampling density of 1 cm2. Patients with atrial fibrillation were categorized into quartiles by VGLA. LVAs were evaluated at voltage cutoffs of 0.1, 0.5, 1.0, and 1.5 mV. Twenty-eight patients with atrial fibrillation also underwent right atrial septum biopsy, and the fibrosis extent was quantified. Voltage at the biopsy site (Vbiopsy) was recorded. VGLA results by category were Q1 (<4.2 mV), Q2 (4.2-5.6 mV), Q3 (5.7-7.0 mV), and Q4 (≥7.1 mV). VRLA at any region was reduced as VGLA decreased. VGLA and VRLA did not differ between Q4 and controls. The presence of LVAs increased as VGLA decreased at any voltage cutoff. Biopsies revealed 11±6% fibrosis, which was inversely correlated with both Vbiopsy and VGLA (r=-0.71 and -0.72, respectively). Vbiopsy was correlated with VGLA (r=0.82).
Conclusions:
Voltage reduction in the LA is a diffuse process associated with fibrosis. Presence of LVAs reflects diffuse voltage reduction of the LA.




J Am Heart Assoc: 08 Mar 2022:e024521; epub ahead of print
Yamaguchi T, Otsubo T, Takahashi Y, Nakashima K, ... Takahashi N, Node K
J Am Heart Assoc: 08 Mar 2022:e024521; epub ahead of print | PMID: 35261287
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Impact:
Abstract

Trimetazidine Alleviates Postresuscitation Myocardial Dysfunction and Improves 96-Hour Survival in a Ventricular Fibrillation Rat Model.

Li J, Qi Y, Wang J, Dai C, Chen B, Li Y

Background:
Myocardial dysfunction is a critical cause of post-cardiac arrest hemodynamic instability and circulatory failure that may lead to early mortality after resuscitation. Trimetazidine is a metabolic agent that has been demonstrated to provide protective effects in myocardial ischemia. However, whether trimetazidine protects against postresuscitation myocardial dysfunction is unknown. Methods and Results Cardiopulmonary resuscitation was initiated after 8 minutes of untreated ventricular fibrillation in Sprague-Dawley rats. Animals were randomized to 4 groups immediately after resuscitation (n=15/group): (1) normothermia control (NTC); (2) targeted temperature management; (3) trimetazidine-normothermia; (4) trimetazidine-targeted temperature management. TMZ was administered at a single dose of 10 mg/kg in rats with trimetazidine. The body temperature was maintained at 34.0°C for 2 hours and then rewarmed to 37.5°C in rats with targeted temperature management. Postresuscitation hemodynamics, 96-hours survival, and pathological analysis were assessed. Heart tissues and blood samples of additional rats (n=6/group) undergoing the same experimental procedure were collected to measure myocardial injury, inflammation and oxidative stress-related biomarkers with ELISA-based quantification assays. Compared with normothermia control, tumor necrosis factor-α, and cardiac troponin-I were significantly reduced, whereas the left ventricular ejection fraction and 96-hours survival rates were significantly improved in the 3 experimental groups. Furthermore, inflammation and oxidative stress-related biomarkers together with collagen volume fraction were significantly decreased in rats undergoing postresuscitation interventions.
Conclusions:
Trimetazidine significantly alleviates postresuscitation myocardial dysfunction and improves survival by decreasing oxidative stress and inflammation in a ventricular fibrillation rat model. A single dose of trimetazidine administrated immediately after resuscitation can effectively improve cardiac function, whether used alone or combined with targeted temperature management.




J Am Heart Assoc: 08 Mar 2022:e023378; epub ahead of print
Li J, Qi Y, Wang J, Dai C, Chen B, Li Y
J Am Heart Assoc: 08 Mar 2022:e023378; epub ahead of print | PMID: 35261264
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Impact:
Abstract

CHARACTERIZATION OF THE RIGHT VENTRICULAR SUBSTRATE PARTICIPATING IN POST INFARCTION VENTRICULAR TACHYCARDIA.

Walsh KA, Daw JM, Lin A, Guandalini G, ... Marchlinski FE, Santangeli P
Background
The right ventricle (RV) is uncommonly implicated in post-infarction ventricular tachycardia (VT). The prevalence and features of RV substrate participating in post-infarction VT are undefined.
Objectives
To characterize critical RV substrate (CRVS) involvement in patients with post-infarction VT.
Methods
We retrospectively reviewed 1279 patients with post-infarction VT undergoing catheter ablation at our center from January 2000 through May 2020. Cases with CRVS defined by conclusive demonstration of participation in VT with activation, entrainment and/or pace mapping during sinus rhythm were identified.
Results
CRVS was identified in 27/1279 (2.1%), age 65±13 years, 96% males, median LV EF 25%, 93% with LBBB morphology VT. CRVS was identified by RV activation and/or entrainment mapping (n=19) or by presence of low-voltage abnormal electrograms with excellent pace-map for the targeted VT and non-inducibility following ablation (n=8). VT termination during RV ablation occurred in 15 patients. After a median follow-up of 20 months (interquartile range 9-53 months) and a median of 2 procedures (interquartile range 1-3), 22/27 (80%) patients had no VT recurrence and 11 (41%) died.
Conclusion
The RV contains critical substrate elements of post-infarction VT in at least 2.1% of cases. RV mapping should be considered in cases where LV mapping fails to demonstrate adequate targets, particularly in patients with LBBB morphology VT.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 08 Mar 2022; epub ahead of print
Walsh KA, Daw JM, Lin A, Guandalini G, ... Marchlinski FE, Santangeli P
Heart Rhythm: 08 Mar 2022; epub ahead of print | PMID: 35276321
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Impact:
Abstract

Intramyocardial mapping of ventricular premature depolarizations via septal venous perforators: Differentiating the superior intraseptal region from left ventricular summit origins.

Guandalini GS, Santangeli P, Schaller R, Pothineni NVK, ... Marchlinski FE, Garcia FC
Background
The intramyocardial aspect of the left ventricular summit (LVS) can be mapped by advancing a unipolar guidewire into septal perforator branches of the anterior intraventricular vein (AIV).
Objective
To differentiate between ventricular premature depolarizations (VPDs) with a basal superior intraseptal (SIS) site of origin and those originating from the epicardial LVS using septal intramyocardial mapping.
Methods
A retrospective cohort of patients with suspected LVS VPDs who underwent SIS unipolar mapping were reviewed for their clinical characteristics, mapping findings and procedural outcomes.
Results
SIS mapping was successful in 44 out of 47 cases (93.6%). VPD origin was SIS (defined as earliest activation from intraseptal wire) in 20 patients (45.5%, median 23ms pre-QRS). Procedural success was similar in patients with (group 1) and without (group 2) SIS origin (respectively, 84% vs. 87.5%, p = 0.842). Of the 10 patients in group 1 without pre-systolic endocardial activation, 5 (11.3% of all 44 cases) were successfully ablated from the LV endocardium, using an anatomical approach targeting the endocardium closest to the earliest intraseptal activation site.
Conclusion
A significant proportion, 45.5%, of VPDs that appear to arise from the LV summit can be demonstrated to have a SIS origin using septal perforator venous mapping. A significant minority (11.3%) of these can be ablated from the endocardium by targeting from an anatomic vantage point closest to the earliest intraseptal activation site. The described strategy may help differentiate true LVS VPDs from those with SIS sites of origin.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 08 Mar 2022; epub ahead of print
Guandalini GS, Santangeli P, Schaller R, Pothineni NVK, ... Marchlinski FE, Garcia FC
Heart Rhythm: 08 Mar 2022; epub ahead of print | PMID: 35278700
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Abstract

Disentangling the association between kidney function and atrial fibrillation: A bidirectional Mendelian randomization study.

Geurts S, van der Burgh AC, Bos MM, Ikram MA, ... Chaker L, Kavousi M
Background
The potential bidirectional causal association between kidney function and atrial fibrillation (AF) remains unclear.
Methods
We conducted a bidirectional two-sample Mendelian randomization (MR) analysis. From multiple genome-wide association studies (GWAS), we retrieved genetic variants associated with kidney function (estimated glomerular filtration rate based on creatinine (eGFRcreat), blood urea nitrogen (BUN), chronic kidney disease (CKD stage ≥G3): n = 1,045,620, eGFR based on cystatin C: n = 24,063-32,861, urine albumin to creatinine ratio (UACR), and microalbuminuria: n = 564,257), and AF (n = 1,030,836). The inverse-variance weighted method was used as our main analyses.
Results
MR analyses supported a causal effect of CKD (n = 9 SNPs, odds ratio (OR): 1.10, 95% confidence interval (CI): 1.04-1.17, p-value = 1.97 × 10-03), and microalbuminuria (n = 5 SNPs, OR: 1.26, 95% CI: 1.10-1.46, p-value = 1.38 × 10-03) on AF risk. We also observed a causal effect of AF on eGFRcreat (n = 97 SNPs, OR: 1.00, 95% CI: 1.00-1.00, p-value = 6.78 × 10-03), CKD (n = 107 SNPs, OR: 1.06, 95% CI: 1.03-1.09, p-value = 2.97 × 10-04), microalbuminuria (n = 83 SNPs, OR: 1.07, 95% CI: 1.04-1.09, p-value = 2.49 × 10-08), and a suggestive causal effect on eGFRcys (n = 103 SNPs, OR: 0.99, 95% CI: 0.99-1.00, p-value = 4.61 × 10-02). Sensitivity analyses, including weighted median estimator, MR-Egger, the MR pleiotropy residual sum and outlier test, and excluding genetic variants associated with possible confounders and/or horizontal mediators (myocardial infarction/coronary artery disease, heart failure) indicated that these findings were robust.
Conclusions
Our results indicated a bidirectional causal association between kidney function and AF. The shared genetic architecture between kidney dysfunction and AF might represent potential important therapeutic targets to prevent both conditions in the general population.

Copyright © 2022. Published by Elsevier B.V.

Int J Cardiol: 08 Mar 2022; epub ahead of print
Geurts S, van der Burgh AC, Bos MM, Ikram MA, ... Chaker L, Kavousi M
Int J Cardiol: 08 Mar 2022; epub ahead of print | PMID: 35278573
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Abstract

Association between ventricular repolarization parameters and cardiovascular death in patients of the SWISS-AF cohort.

Rivolta MW, Mainardi LT, Laureanti R, Sassi R, ... Auricchio A, Corino VDA
Background
The effect of the ventricular repolarization heterogeneity has not been systematically assessed in patients with atrial fibrillation (AF). Aim of this study is to assess ventricular repolarization heterogeneity as predictor of cardiovascular (CV) death and/or other CV events in patients with AF.
Methods
From the multicenter prospective Swiss-AF (Swiss Atrial Fibrillation) Cohort Study, we enrolled 1711 patients who were in sinus rhythm (995) or AF (716). Resting ECG recordings of 5-min duration were obtained at baseline. Parameters assessing ventricular repolarization were computed (QTc, Tpeak-Tend, J-Tpeak and V-index).
Results
During AF, the V-index was found repeatable (no differences when computed over the whole recording, on the first 2.5-min and on the last 2.5-min segments). During a mean follow-up time of 2.6 ± 1.0 years, 90 patients died for CV reasons. In bivariate Cox regression analysis (adjusted for age only), the V-index was associated with an increased risk of CV death, both in the subgroup of patients in sinus rhythm (SR) as well as those in AF. In multivariate analysis adjusted for clinical risk factors and medications, both prolonged QTc and V-index were independently associated with an increased risk of CV death (QTc: hazard ratio [HR] 2.78, 95% CI 1.79-4.32, p < 0.001; V-index: HR 1.73, 95% CI 1.12-2.69, p = 0.014).
Conclusions
QTc and V-index, measured in a single 5-min ECG recording, were independent predictors of CV death in a cohort of patients with AF and might be a valuable tool for further risk stratification to guide patient management. Clinical Trial Identifier Swiss-AF study: NCT02105844.

Copyright © 2022. Published by Elsevier B.V.

Int J Cardiol: 08 Mar 2022; epub ahead of print
Rivolta MW, Mainardi LT, Laureanti R, Sassi R, ... Auricchio A, Corino VDA
Int J Cardiol: 08 Mar 2022; epub ahead of print | PMID: 35278571
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Abstract

Artificial Intelligence and Atrial Fibrillation.

Sehrawat O, Kashou AH, Noseworthy PA
In the context of atrial fibrillation (AF), traditional clinical practices have thus far fallen short in several domains such as identifying patients at risk of incident AF or patients with concomitant undetected paroxysmal AF. Novel approaches leveraging artificial intelligence have the potential to provide new tools to deal with some of these old problems. In this review we focus on the roles of artificial intelligence-enabled ECG pertaining to AF, potential roles of deep learning (DL) models in the context of current knowledge gaps, as well as limitations of these models. One key area where DL models can translate to better patient outcomes is through automated ECG interpretation. Further, we overview some of the challenges facing AF screening and the harms and benefits of screening. In this context, a unique model was developed to detect underlying hidden AF from sinus rhythm and is discussed in detail with its potential uses. Knowledge gaps also remain regarding the best ways to monitor patients with embolic stroke of undetermined source (ESUS) and who would benefit most from oral anticoagulation. The AI-enabled AF model is one potential way to tackle this complex problem as it could be used to identify a subset of high-risk ESUS patients likely to benefit from empirical oral anticoagulation. Role of DL models assessing AF burden from long duration ECG data is also discussed as a way of guiding management. There is a trend towards the use of consumer-grade wristbands and watches to detect AF from photoplethysmography data. However, ECG currently remains the gold standard to detect arrythmias including AF. Lastly, role of adequate external validation of the models and clinical trials to study true performance is discussed. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 07 Mar 2022; epub ahead of print
Sehrawat O, Kashou AH, Noseworthy PA
J Cardiovasc Electrophysiol: 07 Mar 2022; epub ahead of print | PMID: 35258136
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Abstract

Strategies for Repeat Ablation for Atrial Fibrillation: A Multicentre Comparison of Non-Pulmonary Vein versus Pulmonary Vein Target Ablation.

Mol D, Mulder MJ, Veenstra R, Allaart CP, ... de Groot JR, de Jong JSSG
Introduction
Approximately 18% of patients with atrial fibrillation (AF) undergo a repeat ablation within 12 months after their index ablation. Despite the high prevalence, comparative studies on non-pulmonary vein (PV) target strategies in repeat AF ablation are scarce. Here, we describe 12 months efficacy of non-PV and PV target ablations as repeat ablation strategy.
Methods
A multicentre retrospective, descriptive study was conducted with data of 280 patients who underwent repeat AF ablation. Ablation strategy for repeat ablation was at operators\' discretion. Non-PV target ablation (n=140) included, PV re-isolation, posterior wall isolation, mitral line, roofline and/or complex fractionated atrial electrogram ablation. PV target ablation (n=140), included re-isolation and/or wide atrium circumferential ablation. Patients\' demographics and rhythm outcomes during 12-months follow-up were analysed.
Results
At 12 months, more atrial tachyarrhythmias were observed in the non-PV target group (48.6%) compared to the PV target group (29.3%,p=0.001). Similarly, a significantly higher AF and atrial tachycardia (AT) recurrence rate was observed after non-PV target ablation compared to PV target ablation (36.4% versus 22.1% and 22.9% versus 10.7%). After adjustment, a significantly higher risk of AT recurrence remained in the non-PV target group. Both groups significantly de-escalated anti-arrhythmic drug use, de-escalation was more profound after PV target ablation. Patients with isolated PVs during non-PV target ablation had a significantly higher risk for AF recurrence than those with reconnected PVs.
Conclusion
Compared to PV target ablation, non-PV target repeat ablation did not improve outcomes after 12 months, and was independently associated an increased risk for AT recurrences. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 07 Mar 2022; epub ahead of print
Mol D, Mulder MJ, Veenstra R, Allaart CP, ... de Groot JR, de Jong JSSG
J Cardiovasc Electrophysiol: 07 Mar 2022; epub ahead of print | PMID: 35257441
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Abstract

Remote and Wearable ECG Devices with Diagnostic Abilities in Adults: A State-of-the-Science Scoping Review.

Bouzid Z, Al-Zaiti SS, Bond R, Sejdic E
The electrocardiogram (ECG) records the electrical activity in the heart in real-time, providing an important opportunity to detecting various cardiac pathologies. The 12-lead ECG currently serves as the \"standard\" ECG acquisition technique for diagnostic purposes for many cardiac pathologies other than arrhythmias. However, the technical aspects of acquiring a 12-lead ECG are not easy and its usage is currently restricted to trained medical personnel, limiting the scope of its usefulness. Remote and wearable ECG devices have attempted to bridge this gap by enabling patients to take their own ECG using a simplified method at the expense of a reduced number of leads, usually a single-lead ECG. In this review article, we summarize the studies which investigate the use of remote ECG devices and their clinical utility in diagnosing cardiac pathologies. Eligible studies discussed FDA-cleared, commercially available devices that were validated on an adult population. We summarize technical logistics of signal quality and device reliability, dimensional and functional features, and diagnostic value. In summary, our synthesis shows that reduced-set ECG wearables have huge potential for long-term monitoring, particularly if paired with real-time notification techniques. Such capabilities make them primarily useful for abnormal rhythm detection and there is sufficient evidence that a remote ECG device can be more superior to traditional 12-lead ECG in diagnosing specific arrhythmias such as atrial fibrillation. However, this review identifies important challenges faced by this technology, highlighting the limited availability of clinical research examining their usefulness.

Copyright © 2022 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 07 Mar 2022; epub ahead of print
Bouzid Z, Al-Zaiti SS, Bond R, Sejdic E
Heart Rhythm: 07 Mar 2022; epub ahead of print | PMID: 35276320
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Abstract

Watchman FLX vs. Watchman 2.5 in a Dual-Center Left Atrial Appendage Closure Cohort: the WATCH-DUAL study.

Galea R, Mahmoudi K, Gräni C, Elhadad S, ... Amabile N, Räber L
Aims
No studies have compared Watchman 2.5 (W2.5) with Watchman FLX (FLX) devices to date. We aimed at comparing the FLX with W2.5 devices with respect to clinical outcomes, left atrial appendage (LAA) sealing properties and device-related thrombus (DRT).
Methods and results
All consecutive left atrial appendage closure (LAAC) procedures performed at two European centres between November 2017 and February 2021 were included. Procedure-related complications and net adverse cardiovascular events (NACE) at 6 months after LAAC were recorded. At 45-day computed tomography (CT) follow-up, intra- (IDL) and peri- (PDL) device leak, residual patent neck area (RPNA), and DRT were assessed by a Corelab. Out of 144 LAAC consecutive procedures, 71 and 73 interventions were performed using W2.5 and FLX devices, respectively. There were no differences in terms of procedure-related complications (4.2% vs. 2.7%, P = 0.626). At 45-day CT, the FLX was associated with lower frequency of IDL [21.3% vs. 40.0%; P = 0.032; odds ratio (OR): 0.375; 95% confidence interval (CI): 0.160-0.876; P = 0.024], similar rate of PDL (29.5% vs. 42.0%; P = 0.170), and smaller RPNA [6 (0-36) vs. 40 (6-115) mm2; P = 0.001; OR: 0.240; 95% CI: 0.100-0.577; P = 0.001] compared with the W2.5 group. At 45 days, rate of DRT as detected by CT and/or transoesophageal echocardiography (TOE), was higher with W2.5 (6.0% vs. 0%, P = 0.045). At 6-month follow-up, NACE did not differ between groups.
Conclusions
In this cohort of consecutive LAACs, FLX as compared to W2.5, was associated with similar procedure-related complications and 6-month NACE, but with improved LAA neck coverage, and lower IDL and DRT.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.

Europace: 06 Mar 2022; epub ahead of print
Galea R, Mahmoudi K, Gräni C, Elhadad S, ... Amabile N, Räber L
Europace: 06 Mar 2022; epub ahead of print | PMID: 35253840
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Abstract

Sedentary Behavior and Atrial Fibrillation in Older Women: The OPACH Study.

Boursiquot BC, Bellettiere J, LaMonte MJ, LaCroix AZ, Perez MV

Background:
Sedentary behavior is associated with cardiovascular disease, but its association with incident atrial fibrillation is not well studied. Our aim was to measure the association between objectively measured sedentary behavior and incident atrial fibrillation. Methods and Results Sedentary behavior was measured by a triaxial accelerometer worn on a belt for 1 week. Incident atrial fibrillation was ascertained from Medicare claims. The associations between total sedentary time (or patterns of sedentary behavior) and incident atrial fibrillation were assessed using Cox proportional hazards models adjusted for demographic and clinical covariates. Among 2675 participants (mean age, 78.2 years), there were 268 (10.0%) cases of incident atrial fibrillation at a rate of 31 cases per 1000 person-years. Greater total sedentary time was associated with a higher risk of incident atrial fibrillation after adjustment for age, race and ethnicity, body mass index, education, smoking history, hypertension, diabetes, stroke, heart disease, and other chronic conditions (quartile 4 versus quartile 1: hazard ratio, 1.20, [95% CI, 0.81-1.78]; P for trend=0.05). After adjusting for physical function and self-rated health, this was no longer statistically significant. Both longer mean sedentary bout duration and more continuous sedentary periods (versus frequent breaks in sedentary time) were also associated with higher risks of incident atrial fibrillation, but these associations were also attenuated with serial adjustment.
Conclusions:
Total sedentary time and prolonged patterns of sedentary accumulation were associated with a higher risk of atrial fibrillation in this prospective study of community-dwelling older women, but these associations were attenuated by adjustment for physical function and self-reported health. This suggests that associations between sedentary behavior and atrial fibrillation may be attributable to global measures of overall function and health.




J Am Heart Assoc: 04 Mar 2022:e023833; epub ahead of print
Boursiquot BC, Bellettiere J, LaMonte MJ, LaCroix AZ, Perez MV
J Am Heart Assoc: 04 Mar 2022:e023833; epub ahead of print | PMID: 35253465
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Abstract

Impact of oral anticoagulation on the association between frailty and clinical outcomes in people with atrial fibrillation: nationwide primary care records on treatment analysis.

Wilkinson C, Wu J, Clegg A, Nadarajah R, ... Todd O, Gale CP
Aims
People with atrial fibrillation (AF) frequently live with frailty, which increases the risk of mortality and stroke. This study reports the association between oral anticoagulation (OAC) and outcomes for people with frailty, and whether there is overall net benefit from treatment in people with AF.
Methods and results
Retrospective open cohort electronic records study. Frailty was identified using the electronic frailty index. Primary care electronic health records of 89 996 adults with AF and CHA2DS2-Vasc score of ≥2 were linked with secondary care and mortality data in the Clinical Practice Research Database (CPRD) from 1 January 1998 to 30 November 2018. The primary outcome was a composite of death, stroke, systemic embolism, or major bleeding. Secondary outcomes were stroke, major bleeding, all-cause mortality, transient ischaemic attack, and falls. Of 89 996 participants, 71 256 (79.2%) were living with frailty. The prescription of OAC increased with degree of frailty. For patients not prescribed OAC, rates of the primary outcome increased alongside frailty category. Prescription of OAC was associated with a reduction in the primary outcome for each frailty category [adjusted hazard ratio, 95% confidence interval, no OAC as reference; fit: vitamin K antagonist (VKA) 0.69, 0.64-0.75, direct oral anticoagulant (DOAC) 0.42, 0.33-0.53; mild frailty: VKA 0.52, 0.50-0.54, DOAC 0.57, 0.52-0.63; moderate: VKA 0.54, 0.52-0.56, DOAC 0.57, 0.52-0.63; severe: VKA 0.48, 0.45-0.51, DOAC 0.58, 0.52-0.65], with cumulative incidence function effects greater for DOAC than VKA.
Conclusion
Frailty among people with AF is common. The OAC was associated with a reduction in the primary endpoint across all degrees of frailty.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.

Europace: 03 Mar 2022; epub ahead of print
Wilkinson C, Wu J, Clegg A, Nadarajah R, ... Todd O, Gale CP
Europace: 03 Mar 2022; epub ahead of print | PMID: 35244709
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