Topic: Electrophysiology

Abstract

Pre-Diabetes Increases Stroke Risk in Patients With Nonvalvular Atrial Fibrillation.

Kezerle L, Tsadok MA, Akriv A, Senderey AB, ... Leventer-Roberts M, Haim M
Background
Diabetes mellitus (DM) increases the risk of embolism in nonvalvular atrial fibrillation (NVAF). The association between pre-diabetes and risk of ischemic stroke has not been studied separately in this population.
Objectives
The purpose of this study was to evaluate whether pre-diabetes is associated with increased risk of stroke and death in patients with NVAF.
Methods
We conducted a historical cohort study using the Clalit Health Services electronic medical records. The study population included all members aged ≥25 years, with a first diagnosis of NVAF between January 1, 2010, and December 31, 2016. We compared 3 groups of individuals: those with pre-diabetes, those with diabetes, and normoglycemic patients.
Results
A total of 44,451 cases were identified. The median age was 75 years, and 52.5% were women. During a mean follow-up of 38 months, the incidence rates of stroke (per 100 person-years) were: 1.14 in normoglycemic individuals, 1.40 in those with pre-diabetes, and 2.15 in those with diabetes. In both univariate and multivariate analyses, pre-diabetes was associated with an increased risk of stroke compared with normoglycemic persons (adjusted hazard ratio [adjHR]: 1.19; 95% confidence interval [CI]: 1.01 to 1.4) even after adjustment for CHA2DS2-Vasc risk factors and use of anticoagulants, while diabetes conferred an even higher risk (vs. normoglycemia (adjHR: 1.56; 95% CI: 1.37 to 1.79). The risk for mortality was higher for individuals with diabetes (adjHR: 1.47; 95% CI: 1.41 to 1.54) but not for those with pre-diabetes (adjHR: 0.98; 95% CI: 0.92 to 1.03).
Conclusions
In this cohort of patients with incident NVAF, pre-diabetes was associated with an increased risk of stroke even after accounting for other recognized risk factors.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 22 Feb 2021; 77:875-884
Kezerle L, Tsadok MA, Akriv A, Senderey AB, ... Leventer-Roberts M, Haim M
J Am Coll Cardiol: 22 Feb 2021; 77:875-884 | PMID: 33602470
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Impact:
Abstract

Paradoxical impact of socioeconomic factors on outcome of atrial fibrillation in Europe: trends in incidence and mortality from atrial fibrillation.

Al-Khayatt BM, Salciccioli JD, Marshall DC, Krahn AD, Shalhoub J, Sikkel MB
Aims
The aim of this study was to understand the changing trends in atrial fibrillation (AF) incidence and mortality across Europe from 1990 to 2017, and how socioeconomic factors and sex differences play a role.
Methods and results
We performed a temporal analysis of data from the 2017 Global Burden of Disease Database for 20 countries across Europe using Joinpoint regression analysis. Age-adjusted incidence, mortality, and mortality-to-incidence ratios (MIRs) to approximate case fatality rate are presented. Incidence and mortality trends were heterogenous throughout Europe, with Austria, Denmark, and Sweden experiencing peaks in incidence in the middle of the study period. Mortality rates were higher in wealthier countries with the highest being Sweden for both men and women (8.83 and 8.88 per 100 000, respectively) in 2017. MIRs were higher in women in all countries studied, with the disparity increasing the most over time in Germany (43.6% higher in women vs. men in 1990 to 74.5% higher in women in 2017).
Conclusion
AF incidence and mortality across Europe did not show a general trend, but unique patterns for some nations were observed. Higher mortality rates were observed in wealthier countries, potentially secondary to a survivor effect where patients survive long enough to suffer from AF and its complications. Outcomes for women with AF were worse than men, represented by higher MIRs. This suggests that there is widespread healthcare inequality between the sexes across Europe, or that there are biological differences between them in terms of their risk of adverse outcomes from AF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J: 20 Feb 2021; 42:847-857
Al-Khayatt BM, Salciccioli JD, Marshall DC, Krahn AD, Shalhoub J, Sikkel MB
Eur Heart J: 20 Feb 2021; 42:847-857 | PMID: 33495788
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Abstract

Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention: A North American Perspective: 2021 Update.

Angiolillo DJ, Bhatt DL, Cannon CP, Eikelboom JW, ... Tanguay JF, Faxon DP
A growing number of patients undergoing percutaneous coronary intervention (PCI) with stent implantation also have atrial fibrillation. This poses challenges for their optimal antithrombotic management because patients with atrial fibrillation undergoing PCI require oral anticoagulation for the prevention of cardiac thromboembolism and dual antiplatelet therapy for the prevention of coronary thrombotic complications. The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding. Over the last decade, a series of North American Consensus Statements on the Management of Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention have been reported. Since the last update in 2018, several pivotal clinical trials in the field have been published. This document provides a focused updated of the 2018 recommendations. The group recommends that in patients with atrial fibrillation undergoing PCI, a non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice. Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period (during inpatient stay, until time of discharge, up to 1 week after PCI, at the discretion of the treating physician), after which the default strategy is to stop aspirin and continue treatment with a P2Y12 inhibitor, preferably clopidogrel, in combination with a non-vitamin K antagonist oral anticoagulant (ie, double therapy). In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (ie, triple therapy) for up to 1 month. Double therapy should be given for 6 to 12 months with the actual duration depending on the ischemic and bleeding risk profile of the patient, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone.



Circulation: 08 Feb 2021; 143:583-596
Angiolillo DJ, Bhatt DL, Cannon CP, Eikelboom JW, ... Tanguay JF, Faxon DP
Circulation: 08 Feb 2021; 143:583-596 | PMID: 33555916
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Impact:
Abstract

Comparison of the Efficacy and Safety Outcomes of Edoxaban in 8040 Women Versus 13 065 Men With Atrial Fibrillation in the ENGAGE AF-TIMI 48 Trial.

Zelniker TA, Ardissino M, Andreotti F, O\'Donoghue ML, ... Giugliano RP, Merlini PA
Background
Female sex is an independent risk factor for stroke and systemic embolic events in patients with atrial fibrillation. This study aimed to examine the efficacy and safety profile of edoxaban in women versus men.
Methods
The ENGAGE AF-TIMI 48 trial (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) randomly assigned 21 105 patients (8040 women) with atrial fibrillation and CHADS2 score ≥2 either to a higher-dose edoxaban regimen, a lower-dose edoxaban regimen, or warfarin. The primary end points of the trial were the composite of stroke or systemic embolic events (efficacy), and International Society on Thrombosis and Haemostasis-defined major bleeding (safety).
Results
In comparison with men, women were older, had lower body weight, were more likely to have hypertension and renal dysfunction, but less likely to smoke, drink alcohol, or have diabetes or coronary artery disease. Pretreatment endogenous factor Xa activity was significantly higher in women than in men (92.5% versus 86.1%, P<0.001). Treatment with edoxaban in women resulted in greater peak edoxaban concentration and inhibition of endogenous factor Xa in comparison with men, resulting in similar endogenous factor Xa activity between the sexes 2 to 4 hours after dose. Treatment with higher-dose edoxaban regimen (versus warfarin) resulted in similar reduction in the risk of stroke/systemic embolic events (women: hazard ratio [HR], 0.87 [0.69-1.11], men: HR, 0.87 [0.71-1.06]; P-interaction=0.97) and major bleeding (women: HR, 0.74 [0.59-0.92], men: HR, 0.84 [0.72-0.99]; P-interaction=0.34) in women and men. However, women assigned to higher-dose edoxaban regimen experienced greater reductions in hemorrhagic stroke (HR, 0.30 [95% CI, 0.15-0.59] versus HR, 0.70 [95% CI, 0.46-1.06]), intracranial bleeding (HR, 0.20 [95% CI, 0.10-0.39] versus HR, 0.63 [95% CI, 0.44-0.89]), and life-threatening or fatal bleeding (HR, 0.25 [95% CI, 0.15-0.42] versus HR, 0.72 [95% CI, 0.54-0.96]) than men (each P-interaction<0.05).
Conclusions
Despite many differences in baseline characteristics between women and men and higher baseline endogenous factor Xa levels in women, the intensity of anticoagulation achieved with edoxaban between the sexes was similar. Treatment with higher-dose edoxaban regimen resulted in an even greater reduction in hemorrhagic stroke and several serious bleeding outcomes in women than in men, whereas the efficacy profile was similar between sexes.



Circulation: 15 Feb 2021; 143:673-684
Zelniker TA, Ardissino M, Andreotti F, O'Donoghue ML, ... Giugliano RP, Merlini PA
Circulation: 15 Feb 2021; 143:673-684 | PMID: 33587659
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Abstract

Ablation Versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results from the CABANA Trial.

Packer DL, Piccini JP, Monahan KH, Al-Khalidi HR, ... Lee KL, Mark DB
Background: In patients with heart failure (HF) and atrial fibrillation (AF), several clinical trials have reported improved outcomes, including freedom from AF recurrence, quality of life (QOL), and survival, with catheter ablation. This report describes the treatment-related outcomes of the AF patients with HF enrolled in the Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial.
Methods:
CABANA randomized 2204 patients with AF who were ≥65 years old or <65 with ≥1 risk factor for stroke at 126 sites to ablation with pulmonary vein isolation or drug therapy including rate/rhythm control drugs. Of these, 778 (35%) had NYHA class ≥ II at baseline and form the subject of this report. The CABANA primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest.
Results:
Of the 778 HF patients enrolled in CABANA, 378 were assigned to ablation and 400 to drug therapy. Ejection fraction (EF) at baseline was available for 571 patients (73%) and 9.3% of these had an EF <40%, while 11.7% had EFs between 40-50%. In the intention-to-treat analysis, the ablation arm had a 36% relative reduction in the primary composite endpoint (hazard ratio [HR] 0.64; 95% confidence interval [CI], 0.41 to 0.99) and a 43% relative reduction in all-cause mortality (HR 0.57; 95% CI, 0.33 to 0.96) compared to drug therapy alone over a median follow-up of 48.5 months. AF recurrence was decreased with ablation (HR 0.56; 95% CI, 0.42 to 0.74). The adjusted mean difference for the AF Effect on QOL (AFEQT) summary score averaged over the entire 60-month follow-up was 5.0 points favoring the ablation arm (95% CI, 2.5 to 7.4 points), and the Mayo AF-specific Symptom Inventory (MAFSI) frequency score difference was -2.0 points favoring ablation (95% CI, -2.9 to -1.2). Conclusions: In patients with atrial fibrillation enrolled in CABANA who had clinically diagnosed stable heart failure at trial entry, catheter ablation produced clinically important improvements in survival, freedom from AF recurrence, and quality of life relative to drug therapy. These results, obtained in a cohort most of whom had preserved left ventricular function, require independent trial verification. Clinical Trial Registration: URL: https://www.clinicaltrials.gov Unique Identifier: NCT00911508.




Circulation: 07 Feb 2021; epub ahead of print
Packer DL, Piccini JP, Monahan KH, Al-Khalidi HR, ... Lee KL, Mark DB
Circulation: 07 Feb 2021; epub ahead of print | PMID: 33554614
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Impact:
Abstract

Association Between Sex and Treatment Outcomes of Atrial Fibrillation Ablation Versus Drug Therapy: Results From the CABANA Trial.

Russo AM, Zeitler EP, Giczewska A, Silverstein AP, ... Poole JE, CABANA Investigators
Background
Among patients with atrial fibrillation (AF), women are less likely to receive catheter ablation and may have more complications and less durable results. Most information about sex-specific differences after ablation comes from observational data. We prespecified an examination of outcomes by sex in the 2204-patient CABANA trial (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation).
Methods
CABANA randomized patients with AF age ≥65 years or <65 years with ≥1 risk factor for stroke to a strategy of catheter ablation with pulmonary vein isolation versus drug therapy with rate/rhythm control agents. The primary composite outcome was death, disabling stroke, serious bleeding, or cardiac arrest, and key secondary outcomes included AF recurrence.
Results
CABANA randomized 819 (37%) women (ablation 413, drug 406) and 1385 men (ablation 695, drug 690). Compared with men, women were older (median age, 69 years versus 67 years for men), were more symptomatic (48% Canadian Cardiovascular Society AF Severity Class 3 or 4 versus 39% for men), had more symptomatic heart failure (42% with New York Heart Association Class ≥II versus 32% for men), and more often had a paroxysmal AF pattern at enrollment (50% versus 39% for men) (P<0.0001 for all). Women were less likely to have ancillary (nonpulmonary vein) ablation procedures performed during the index procedure (55.7% versus 62.2% in men, P=0.043), and complications from treatment were infrequent in both sexes. For the primary outcome, the hazard ratio for those who underwent ablation versus drug therapy was 1.01 (95% CI, 0.62-1.65) in women and 0.73 (95% CI, 0.51-1.05) in men (interaction P value=0.299). The risk of recurrent AF was significantly reduced in patients undergoing ablation compared with those receiving drug therapy regardless of sex, but the effect was greater in men (hazard ratio, 0.64 [95% CI, 0.51-0.82] for women versus hazard ratio, 0.48 [95% CI, 0.40-0.58] for men; interaction P value=0.060).
Conclusions
Clinically relevant treatment-related strategy differences in the primary and secondary clinical outcomes of CABANA were not seen between men and women, and there were no sex differences in adverse events. The CABANA trial results support catheter ablation as an effective treatment strategy for both women and men. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00911508.



Circulation: 15 Feb 2021; 143:661-672
Russo AM, Zeitler EP, Giczewska A, Silverstein AP, ... Poole JE, CABANA Investigators
Circulation: 15 Feb 2021; 143:661-672 | PMID: 33499668
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Impact:
Abstract

Hypertension Burden and the Risk of New-Onset Atrial Fibrillation: A Nationwide Population-Based Study.

Lee SR, Park CS, Choi EK, Ahn HJ, ... Oh S, Lip GYH
The association between the cumulative hypertension burden and the development of atrial fibrillation (AF) is unclear. We aimed to investigate the relationship between hypertension burden and the development of incident AF. Using the Korean National Health Insurance Service database, we identified 3 726 172 subjects who underwent 4 consecutive annual health checkups between 2009 and 2013, with no history of AF. During the median follow-up of 5.2 years, AF was newly diagnosed in 22 012 patients (0.59% of the total study population; 1.168 per 1000 person-years). Using the blood pressure (BP) values at each health checkup, we determined the burden of hypertension (systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg), stratified as 0 to 4 per the hypertension criteria. The subjects were grouped according to hypertension burden scale 1 to 4: 20% (n=742 806), 19% (n=704 623), 19% (n=713 258), 21% (n=766 204), and 21% (n=799 281). Compared with normal people, subjects with hypertension burdens of 1, 2, 3, and 4 were associated with an 8%, 18%, 26%, and 27% increased risk of incident AF, respectively. On semiquantitative analyses with further stratification of stage 1 (systolic BP of 130-139 mm Hg or diastolic BP of 80-89 mm Hg) and stage 2 (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg) hypertension, the risk of AF increased with the hypertension burden by up to 71%. In this study, both a sustained exposure and the degree of increased BP were associated with an increased risk of incident AF. Tailored BP management should be emphasized to reduce the risk of AF.



Hypertension: 02 Mar 2021; 77:919-928
Lee SR, Park CS, Choi EK, Ahn HJ, ... Oh S, Lip GYH
Hypertension: 02 Mar 2021; 77:919-928 | PMID: 33486985
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Abstract

The effects of cardiac stretch on atrial fibroblasts: Analysis of the evidence and potential role in atrial fibrillation.

Li X, Garcia-Elias A, Benito B, Nattel S
Atrial fibrillation (AF) is an important clinical problem. Chronic pressure/volume overload of the atria promotes AF, particularly via enhanced extracellular matrix (ECM) accumulation manifested as tissue fibrosis. Loading of cardiac cells causes cell-stretch that is generally considered to promote fibrosis by directly activating fibroblasts, the key cell-type responsible for ECM-production. The primary purpose of this article is to review the evidence regarding direct effects of stretch on cardiac fibroblasts, specifically: (i) the similarities and differences among studies in observed effects of stretch on cardiac-fibroblast function; (ii) the signaling-pathways implicated; and (iii) the factors that affect stretch-related phenotypes. Our review summarizes the most important findings and limitations in this area and gives an overview of clinical data and animal models related to cardiac stretch, with particular emphasis on the atria. We suggest that the evidence regarding direct fibroblast activation by stretch is weak and inconsistent, in part because of variability among studies in key experimental conditions that govern the results. Further work is needed to clarify whether, in fact, stretch induces direct activation of cardiac fibroblasts and if so, to elucidate the determining factors to ensure reproducible results. If mechanical load on fibroblasts proves not to be clearly profibrotic by direct actions, other mechanisms like paracrine influences, the effects of systemic mediators and/or the direct consequences of myocardial injury or death, might account for the link between cardiac stretch and fibrosis. Clarity in this area is needed to improve our understanding of AF pathophysiology and assist in therapeutic development.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions please email: [email protected]

Cardiovasc Res: 09 Feb 2021; epub ahead of print
Li X, Garcia-Elias A, Benito B, Nattel S
Cardiovasc Res: 09 Feb 2021; epub ahead of print | PMID: 33576384
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Abstract

Subclinical Atrial Fibrillation Burden and Adverse Clinical Outcomes in Patients With Permanent Pacemakers.

Park YJ, Kim JS, Park KM, On YK, Park SJ
Background:
and purpose
Unlike clinical atrial fibrillation (AF), the significance of subclinical AF (SCAF) burden in patients with permanent pacemakers has not been fully evaluated.
Methods
We investigated whether the SCAF burden was associated with increased risks of composite adverse outcomes, including progression to clinical AF, ischemic stroke, myocardial infarction, heart failure-related hospitalization, or cardiac death, in patients without previous AF. To quantify the 6-month SCAF burden, the total cumulative time spent in SCAF during every 6-month follow-up was summed.
Results
During the median 5.2-year follow-up, 496 consecutive permanent pacemaker patients were classified into the no SCAF (no SCAF episode in any device analysis; n=152), low-burden SCAF (6-month SCAF <24 hours in at least one device analysis; n=287), or high-burden SCAF (6-month SCAF ≥24 hours in at least 1 device analysis; n=57) groups. The risk of composite adverse outcomes was greatest in the high-burden SCAF group (P<0.001) and was primarily driven by progression to clinical AF (P<0.001) and ischemic stroke (P<0.001). The presence of high-burden SCAF, which always preceded ischemic stroke events, was independently associated with composite adverse outcomes (odds ratio=20.1 [95% CI, 7.60-52.7], P<0.001) and progression to clinical AF (odds ratio, 36.2 [95% CI, 15.9-87.8], P<0.001).
Conclusions
In permanent pacemaker patients without preexisting AF, the presence of high-burden SCAF was closely associated with increased risks of composite adverse outcomes, particularly progression to clinical AF and ischemic stroke. Therefore, prospective studies deserve to be performed on the optimal anticoagulation therapy for permanent pacemaker patients with both high-burden SCAF and high stroke risk.



Stroke: 15 Feb 2021:STROKEAHA120031822; epub ahead of print
Park YJ, Kim JS, Park KM, On YK, Park SJ
Stroke: 15 Feb 2021:STROKEAHA120031822; epub ahead of print | PMID: 33588601
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Impact:
Abstract

Comparative Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients.

Zhu W, Ye Z, Chen S, Wu D, ... Lip GYH, Liu C
Background:
and purpose
Several observational studies have compared the effect of the non-vitamin K antagonist oral anticoagulants to each other in patients with atrial fibrillation. However, confounding by indication is a major problem when comparing non-vitamin K antagonist oral anticoagulant treatments in some of these studies. This meta-analysis was conducted to compare the effectiveness and safety between non-vitamin K antagonist oral anticoagulant and non-vitamin K antagonist oral anticoagulant by only including the propensity score matching studies.
Methods
We systematically searched the PubMed and Ovid databases until May 2020 to identify relevant observational studies. Hazard ratios (HRs) and 95% CIs of the reported outcomes were collected and then pooled by a random-effects model complemented with an inverse variance heterogeneity or quality effects model.
Results
A total of 17 retrospective cohort studies were included in this meta-analysis. Compared with dabigatran use, the use of rivaroxaban was significantly associated with increased risks of stroke or systemic embolism (HR, 1.16 [95% CI, 1.05-1.29]) and major bleeding (HR, 1.32 [95% CI, 1.24-1.41]), whereas the use of apixaban was associated with a reduced risk of major bleeding (HR, 0.78 [95% CI, 0.67-0.90]) but not stroke or systemic embolism (HR, 0.84 [95% CI, 0.56-1.28]). Compared with rivaroxaban use, the use of apixaban was associated with a decreased risk of major bleeding (HR, 0.63 [95% CI, 0.54-0.73]) but not stroke or systemic embolism (HR, 0.83 [95% CI, 0.67-1.04]). Reanalyses with the inverse variance heterogeneity or quality effects model produced similar results as the random-effects model.
Conclusions
Current observational comparisons with propensity score matching methods suggest that apixaban might be a better choice compared with dabigatran or rivaroxaban for stroke prevention in atrial fibrillation patients.



Stroke: 17 Feb 2021:STROKEAHA120031007; epub ahead of print
Zhu W, Ye Z, Chen S, Wu D, ... Lip GYH, Liu C
Stroke: 17 Feb 2021:STROKEAHA120031007; epub ahead of print | PMID: 33596677
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Impact:
Abstract

Atrial Fibrillation Following Patent Foramen Ovale Closure: Systematic Review and Meta-Analysis of Observational Studies and Clinical Trials.

Chen JZ, Thijs VN
Background:
and purpose
Multiple studies evaluated whether patent foramen ovale (PFO) closure reduces the risk of ischemic stroke. One commonly reported complication of PFO closure is the development of atrial fibrillation (AF), which is itself a powerful stroke risk factor that requires specific management. This study aims to evaluate the frequency of AF in patients post-percutaneous closure of PFO and the clinical factors that predict AF detection.
Methods
Studies were identified by systematically searching EMBASE and MEDLINE databases on July 11, 2019. Meta-analysis of proportions was performed, assuming a random-effects model.
Results
A total of 6 randomized controlled trials and 26 observational studies were included, comprising 3737 and 9126 patients, respectively. After PFO closure, the rate of AF development was 3.7 patients per 100 patient-years of follow-up (95% CI, 2.6-4.9). The risk of AF development is concentrated in the first 45 days post-procedure (27.2 patients per 100 patient-years [95% CI, 20.1-34.81], compared with 1.3 patients per 100 patient-years [95% CI, 0.3-2.7]) after 45 days. Meta-regression by age suggested that studies with older patients reported higher rate of AF (P=0.001). In medically treated patients, the rate of AF development was 0.1 per 100 patient-years of follow-up (95% CI, 0.0-0.4). Closure of PFO is associated with increased risk of AF compared with medical management (odds ratio, 5.3 [95% CI, 2.5-11.41]; P<0.001).
Conclusions
AF is more common in PFO patients who had percutaneous closure compared with those who were medically treated. The risk of AF was higher in the first 45 days post-closure and in studies that included patients with increased age.



Stroke: 21 Feb 2021:STROKEAHA120030293; epub ahead of print
Chen JZ, Thijs VN
Stroke: 21 Feb 2021:STROKEAHA120030293; epub ahead of print | PMID: 33611943
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Impact:
Abstract

New Avenues for Optimal Treatment of Atrial Fibrillation and Stroke Prevention.

De Marchis GM, Sposato LA, Kühne M, Dittrich TD, ... Fischer U, Chaturvedi S
One in 3 individuals free of atrial fibrillation (AF) at index age 55 years is estimated to develop AF later in life. AF increases not only the risk of ischemic stroke but also of dementia, even in stroke-free patients. In this review, we address recent advances in the heart-brain interaction with focus on AF. Issues discussed are (1) the timing of direct oral anticoagulants start following an ischemic stroke; (2) the comparison of direct oral anticoagulants versus vitamin K antagonists in early secondary stroke prevention; (3) harms of bridging with heparin before direct oral anticoagulants; (4) importance of appropriate direct oral anticoagulants dosing; (5) screening for AF in high-risk populations, including the role of wearables; (6) left atrial appendage occlusion as an alternative to oral anticoagulation; (7) the role of early rhythm-control therapy; (8) effect of lifestyle interventions on AF; (9) AF as a risk factor for dementia. An interdisciplinary approach seems appropriate to address the complex challenges posed by AF.



Stroke: 24 Feb 2021:STROKEAHA120032060; epub ahead of print
De Marchis GM, Sposato LA, Kühne M, Dittrich TD, ... Fischer U, Chaturvedi S
Stroke: 24 Feb 2021:STROKEAHA120032060; epub ahead of print | PMID: 33626906
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Impact:
Abstract

Early Apixaban Use Following Stroke in Patients With Atrial Fibrillation: Results of the AREST Trial.

Labovitz AJ, Rose DZ, Fradley MG, Meriwether JN, ... Burgin WS, AREST Investigators
Background:
and purpose
It is unknown when to start anticoagulation after acute ischemic stroke (AIS) from atrial fibrillation (AF). Early anticoagulation may prevent recurrent infarctions but may provoke hemorrhagic transformation as AF strokes are typically larger and hemorrhagic transformation-prone. Later anticoagulation may prevent hemorrhagic transformation but increases risk of secondary stroke in this time frame. Our aim was to compare early anticoagulation with apixaban in AF patients with stroke or transient ischemic attack (TIA) versus warfarin administration at later intervals.
Methods
AREST (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation) was an open-label, randomized controlled trial comparing the safety of early use of apixaban at day 0 to 3 for TIA, day 3 to 5 for small-sized AIS (<1.5 cm), and day 7 to 9 for medium-sized AIS (≥1.5 cm, excluding full cortical territory), to warfarin, in a 1:1 ratio at 1 week post-TIA, or 2 weeks post-AIS.
Results
Although AREST ended prematurely after a national guideline focused update recommended direct oral anticoagulants over warfarin for AF, it revealed that apixaban had statistically similar yet generally numerically lower rates of recurrent strokes/TIA (14.6% versus 19.2%, P=0.78), death (4.9% versus 8.5%, P=0.68), fatal strokes (2.4% versus 8.5%, P=0.37), symptomatic hemorrhages (0% versus 2.1%), and the primary composite outcome of fatal stroke, recurrent ischemic stroke, or TIA (17.1% versus 25.5%, P=0.44). One symptomatic intracerebral hemorrhage occurred on warfarin, none on apixaban. Five asymptomatic hemorrhagic transformation occurred in each arm.
Conclusions
Early initiation of anticoagulation after TIA, small-, or medium-sized AIS from AF does not appear to compromise patient safety. Potential efficacy of early initiation of anticoagulation remains to be determined from larger pivotal trials.
Registration
URL: https://www.clinicaltrials.gov/; Unique identifier: NCT02283294.



Stroke: 24 Feb 2021:STROKEAHA120030042; epub ahead of print
Labovitz AJ, Rose DZ, Fradley MG, Meriwether JN, ... Burgin WS, AREST Investigators
Stroke: 24 Feb 2021:STROKEAHA120030042; epub ahead of print | PMID: 33626904
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Impact:
Abstract

Worldwide Survey of COVID-19 Associated Arrhythmias.

Coromilas EJ, Kochav S, Goldenthal I, Biviano A, ... Fernández-Vázquez F, Wan EY

Background:
- COVID-19 has led to over 1 million deaths worldwide and has been associated with cardiac complications including cardiac arrhythmias. The incidence and pathophysiology of these manifestations remain elusive. In this worldwide survey of patients hospitalized with COVID-19 who developed cardiac arrhythmias, we describe clinical characteristics associated with various arrhythmias, as well as global differences in modulations of routine electrophysiology practice during the pandemic. Methods - We conducted a retrospective analysis of patients hospitalized with COVID-19 infection worldwide with and without incident cardiac arrhythmias. Patients with documented atrial fibrillation (AF), atrial flutter (AFL), supraventricular tachycardia (SVT), non-sustained or sustained ventricular tachycardia (VT), ventricular fibrillation (VF), atrioventricular block (AVB), or marked sinus bradycardia (HR<40bpm) were classified as having arrhythmia. De-identified data was provided by each institution and analyzed. Results - Data was collected for 4,526 patients across 4 continents and 12 countries, 827 of whom had an arrhythmia. Cardiac comorbidities were common in patients with arrhythmia: 69% had hypertension, 42% diabetes mellitus, 30% had heart failure and 24% coronary artery disease. Most had no prior history of arrhythmia. Of those who did develop an arrhythmia, the majority (81.8%) developed atrial arrhythmias, 20.7% developed ventricular arrhythmias, and 22.6% had bradyarrhythmia. Regional differences suggested a lower incidence of AF in Asia compared to other continents (34% vs. 63%). Most patients in in North America and Europe received hydroxychloroquine, though the frequency of hydroxychloroquine therapy was constant across arrhythmia types. Forty-three percent of patients who developed arrhythmia were mechanically ventilated and 51% survived to hospital discharge. Many institutions reported drastic decreases in electrophysiology procedures performed.
Conclusions:
- Cardiac arrhythmias are common and associated with high morbidity and mortality among patients hospitalized with COVID-19 infection. There were significant regional variations in the types of arrhythmias and treatment approaches.




Circ Arrhythm Electrophysiol: 06 Feb 2021; epub ahead of print
Coromilas EJ, Kochav S, Goldenthal I, Biviano A, ... Fernández-Vázquez F, Wan EY
Circ Arrhythm Electrophysiol: 06 Feb 2021; epub ahead of print | PMID: 33554620
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Impact:
Abstract

Ongoing Risk of Ventricular Arrhythmias and All-cause Mortality at Implantable Cardioverter Defibrillator Generator Change: A Systematic Review and Meta-analysis.

Yuyun MF, Erqou SA, Peralta AO, Hoffmeister PS, ... Joseph J, Singh JP

Background:
- Uncertainty still surrounds implantable cardioverter defibrillator (ICD) generator change at time of elective replacement indicator (ERI), in primary prevention patients with improved left ventricular ejection fraction (LVEF) beyond guideline recommendations or without prior appropriate ICD therapies. Methods - We conducted a meta-analysis of studies assessing the risk of appropriate ICD therapies and all-cause mortality after generator change in patients with improved LVEF > 35% versus unimproved LVEF ≤ 35% or patients without versus with prior appropriate ICD therapies during the life of their first ICD generator. A systematic electronic search of PubMed, EMBASE, and Cochrane Library databases until December 31st, 2019 was performed. Estimates were combined using random-effects model meta-analyses. Results - In 15 studies that included 29730 patients, 25.3% had LVEF improvement >35% at time of generator change. The pooled annual incidence of appropriate ICD therapies was significantly lower in those with improved LVEF, compared to patients with unimproved LVEF: 4.6% versus 10.7%; risk ratio (RR) 0.50 (95% CI 0.36-0.68), p <0.0001. The pooled rate of all-cause mortality was 6.6% versus 10.9% per year, RR of 0.65 (95% CI 0.62-0.69), p < 0.0001. Risk of inappropriate shock was comparable between the two groups (p = 0.750). In 8 studies (N = 27209), the pooled incidence of ventricular arrhythmia (VA) was significantly lower in patients without prior ICD therapies (3.9% per annum), compared to those with prior ICD therapies (12.5 % per annum), RR of 0.37 (95% CI 0.33-0.41), P<0.001.
Conclusions:
- There was significant reduction in risk of ventricular arrhythmias and mortality in patients with improved versus unimproved LVEF or those who received versus those who did not receive appropriate ICD therapies during the life of their first ICD generator. However, we found a substantial residual outcome risk in these groups of patients.




Circ Arrhythm Electrophysiol: 05 Feb 2021; epub ahead of print
Yuyun MF, Erqou SA, Peralta AO, Hoffmeister PS, ... Joseph J, Singh JP
Circ Arrhythm Electrophysiol: 05 Feb 2021; epub ahead of print | PMID: 33554611
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Impact:
Abstract

Metformin Is Associated with a Lower Risk of Atrial Fibrillation and Ventricular Arrhythmias Compared to Sulfonylureas: An Observational Study.

Ostropolets A, Elias PA, Reyes MV, Wan EY, ... Hripcsak G, Morrow JP

Background:
- Type 2 diabetes (DM2) is one of the most common chronic disorders worldwide and is an important cause of cardiovascular disease. Studies investigating the risk of atrial and ventricular arrhythmias in diabetic patients taking different oral diabetes medications are sparse. Methods - We used IBM MarketScan® Medicare Supplemental Database to examine the risk of arrhythmias for patients on different oral diabetes medications by propensity score matching. Results - We found that patients on metformin monotherapy had significantly reduced risk of atrial arrhythmias, including atrial fibrillation, compared to monotherapy with DPP4 or TZD medications. Patients on metformin monotherapy had significantly reduced risk of atrial arrhythmias, ventricular arrhythmias, and bradycardia compared to monotherapy with sulfonylureas. Combination therapy with sulfonylureas and metformin had an increased risk of atrial arrhythmias compared to some other combinations.
Conclusions:
- Different oral diabetes medications have significantly different long-term risk of arrhythmia. Specifically, metformin is associated with reduced risk of atrial fibrillation and ventricular arrhythmias compared to sulfonylureas.




Circ Arrhythm Electrophysiol: 06 Feb 2021; epub ahead of print
Ostropolets A, Elias PA, Reyes MV, Wan EY, ... Hripcsak G, Morrow JP
Circ Arrhythm Electrophysiol: 06 Feb 2021; epub ahead of print | PMID: 33554609
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Impact:
Abstract

Familial Evaluation in Idiopathic Ventricular Fibrillation: Diagnostic Yield and Significance of J-Wave Syndromes.

Mellor GJ, Blom LJ, Groeneveld SA, Winkel BG, ... Hassink RJ, Behr ER

Background:
- Familial cascade screening is well established in patients with heritable cardiac disease and in cases of Sudden Arrhythmic Death Syndrome (SADS). The clinical benefit of family screening in idiopathic ventricular fibrillation (IVF) is unknown. Methods - Patients with IVF were identified from national and institutional registries. All underwent systematic and comprehensive clinical evaluation to exclude identifiable causes of cardiac arrest with a minimum requirement of ECG, cardiac (echocardiogram and/or MRI) and coronary imaging, exercise ECG and sodium channel blocker (SCB) provocation. Additional investigations including genetic testing were performed at the physician\'s discretion. First-degree relatives who were assessed with at least a 12-lead ECG were included in the final cohort. Results of additional investigations, performed at the physician\'s discretion, were also recorded. Results were coded as normal, abnormal or minor findings. Results - We identified 201 first-degree relatives of 96 IVF patients. In addition to a 12 lead ECG, echocardiography was performed in 159 (79%) and ≥ 1 additional investigation in 162 (80%) relatives. An inherited arrhythmia syndrome was diagnosed in 5 (3%) individuals from 4 (4%) families. Two relatives hosted the DPP6 risk haplotype identified in a single proband, one of whom received a primary prevention ICD. In three separate families an asymptomatic parent of the IVF proband developed a type 1 Brugada ECG pattern during SCB provocation. All were managed with lifestyle measures only. The Early Repolarisation ECG pattern (ER) was present in 16% probands and was more common in relatives in those families than those where the proband did not have ER (25% vs. 8%, p=0.04).
Conclusions:
- The yield of family screening in relatives of IVF probands is low when the proband is comprehensively investigated. The significance of J wave syndromes in relatives and the role for systematic SCB provocation are, however, uncertain and require further research.




Circ Arrhythm Electrophysiol: 06 Feb 2021; epub ahead of print
Mellor GJ, Blom LJ, Groeneveld SA, Winkel BG, ... Hassink RJ, Behr ER
Circ Arrhythm Electrophysiol: 06 Feb 2021; epub ahead of print | PMID: 33550818
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Impact:
Abstract

Electrical Substrate Ablation for Refractory Ventricular Fibrillation: Results of the AVATAR Study.

Krummen DE, Ho G, Hoffmayer KS, Schweis F, ... Rappel WJ, Narayan SM

Background:
- Refractory ventricular fibrillation (VF) is a challenging clinical entity, for which ablation of triggering premature ventricular complexes (PVCs) is described. When PVCs are infrequent and multifocal, the optimal treatment strategy is uncertain. Methods - We prospectively enrolled consecutive patients presenting with multiple ICD shocks for VF refractory to antiarrhythmic drug therapy, exhibiting infrequent (≤3%), multifocal PVCs (≥3 morphologies). Procedurally, VF was induced with rapid pacing and mapped, identifying sites of conduction slowing and rotation or rapid focal activation. VF electrical substrate ablation (VESA) was then performed. Outcomes were compared against reference patients with VF who were unable or unwilling to undergo catheter ablation. The primary outcome was a composite of ICD shock, electrical storm, or all-cause mortality. Results - VF was induced and mapped in 6 patients (60±10 y, LVEF 46±19%) with ischemic (n=3) and nonischemic cardiomyopathy. An average of 3.3±0.5 sites of localized reentry during VF were targeted for radiofrequency ablation (38.3±10.9 minutes) during sinus rhythm, rendering VF non-inducible with pacing. Freedom from the primary outcome was 83% in the VF ablation group versus 17% in 6 non-ablation reference patients at a median of 1.0 years (IQR 0.5-1.5 years, p=0.046) follow-up.
Conclusions:
- VESA is associated with a reduction in the combined endpoint compared with the non-ablation reference group. Additional work is required to understand the precise pathophysiologic changes which promote VF in order to improve preventative and therapeutic strategies.




Circ Arrhythm Electrophysiol: 06 Feb 2021; epub ahead of print
Krummen DE, Ho G, Hoffmayer KS, Schweis F, ... Rappel WJ, Narayan SM
Circ Arrhythm Electrophysiol: 06 Feb 2021; epub ahead of print | PMID: 33550811
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Impact:
Abstract

Pivotal Study of a Novel Motor Driven Endoscopic Ablation System.

Schmidt B, Petru J, Chun JKR, Sediva L, ... Chen S, Neuzil P

Background:
- The HeartLight™ endoscopic ablation system (HL-EAS), has proven similar efficacy as radiofrequency guided pulmonary vein isolation (PVI) in prospective randomized studies though longer procedure times were reported. Recently, the option of a new ablation mode (RAPID™) was added, during which the laser arc generator is swept around the PV antrum by an integrated motor drive at a pre-defined speed for continuous ablation. We sought to determine the performance of the new EAS (X3). Methods - The study was prospective, two center, and historically controlled (comparison to pivotal HL study). The primary endpoint was ablation time (time from insertion of the X3 catheter to the end of the last 30-minute wait period). Transtelephonic monitoring was performed from 90 days to 12 months after ablation. Results - A total of 60 patients were enrolled at two centers. Except one all PVs were treated with RAPID mode. Acute PVI was achieved in 225/228 of these PVs (98.7%). The ablation time, was significantly shorter with X3 than in the HL study (77.3 ± 25.8 min versus 173.8 ± 46.6 min; p<0.0001). Procedure time and fluoroscopy time were also significantly shorter (103.7 ± 32.3 min versus 236.0 ± 52.8min; p<0.0001; 6.9 ± 3.5 versus 35.6 ± 18.2; p<0.0001). PVI after the first circular lesion was achieved in 91.6% of PVs (206/225). Two strokes and one late pericardial effusion were noted in the treatment group that were not deemed device related. The 6-month and 12-month AF-Free rates for X3 compare favorably with the rates reported for HL, 89.5% versus 75.0% and 71.9% versus 61.1%, respectively.
Conclusions:
- The novel X3 generation EAS allows for rapid PVI by continuous lesion deployment. This was associated with a significant reduction in ablation and procedure times while maintaining the safety and chronic effectiveness in comparison to historical controls.




Circ Arrhythm Electrophysiol: 10 Feb 2021; epub ahead of print
Schmidt B, Petru J, Chun JKR, Sediva L, ... Chen S, Neuzil P
Circ Arrhythm Electrophysiol: 10 Feb 2021; epub ahead of print | PMID: 33570423
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Impact:
Abstract

Machine Learning-derived Fractal Features of Shape and Texture of the Left Atrium and Pulmonary Veins from Cardiac CT Scans are Associated with Risk of Recurrence of Atrial Fibrillation Post-ablation.

Firouznia M, Feeny AK, LaBarbera MA, McHale M, ... Chung MK, Madabhushi A

Background:
- We hypothesized that computerized morphologic analysis of the LA and pulmonary veins (PVs) via fractal measurements of shape and texture features of the LA myocardial wall could predict AF recurrence after ablation. Methods - Pre-ablation contrast CT scans were collected for 203 patients who underwent AF ablation. The LA body, PVs, and myocardial wall were segmented using a semi-automated region growing method. Twenty-eight fractal-based shape and texture-based features were extracted from resulting segments. The top features most associated with post-ablation recurrence were identified using feature selection and subsequently evaluated with a Random Forest classifier. Feature selection and classifier construction were performed on a discovery cohort (D1) of 137 patients; classifiers were subsequently validated on an independent set (D2) of 66 patients. Dedicated classifiers to capture the fractal and morphologic properties of LA body (CLA), PVs (CPV), and LA myocardial (CLAM) tissue were constructed, as well as a model (CAll) capturing properties of all segmented compartments. Fractal-based models were also compared against a model employing machine estimation of LA volume. To assess the effect of clinical parameters, such as AF type and catheter technique, a clinical model (Cclin) was also compared against CAll. Results - Statistically significant differences were observed for fractal features of CLA, CLAM and CAll in distinguishing AF recurrence (p<0.001) on D1. Using the five top features, CAll had the best prediction performance (AUC=0.81 [95% Confidence Interval (CI): 0.78-0.85]), followed by CPV (AUC=0.78 [95% CI: 0.74-0.80]) and CLA (AUC=0.70 [95% CI: 0.63-0.78]) on D2. The clinical parameter model Cclin yielded an AUC=0.70 [95% CI: 0.65-0.77], while the atrial volume model yielded an AUC=0.59. Combining CAll and Cclin on D2 improved the AUC to 0.87 [95% CI: 0.82-0.93].
Conclusions:
- Fractal measurements of the LA, PVs, and atrial myocardium on CT scans were associated with likelihood of post-ablation AF recurrence.




Circ Arrhythm Electrophysiol: 11 Feb 2021; epub ahead of print
Firouznia M, Feeny AK, LaBarbera MA, McHale M, ... Chung MK, Madabhushi A
Circ Arrhythm Electrophysiol: 11 Feb 2021; epub ahead of print | PMID: 33576688
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Impact:
Abstract

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

Pastori D, Biccirè FG, Lip GYH, Menichelli D, ... Gaudio C, Tanzilli G
Patients with atrial fibrillation (AF) have an increased risk of coronary artery disease (CAD) compared to patients without. Angiographic characteristics, clinical presentation and severity of CAD according to the presence of AF have been poorly described. We performed a retrospective study of 303 consecutive patients (mean age 69.6 ± 10.8 years; 23.1% women) with and without AF undergoing percutaneous coronary intervention. Data on (1) type of CAD presentation, (2) coronary involvement, and (3) number of diseased coronary vessels (≥70%/luminal narrowing) were collected. CHA2DS2-VASc and 2 major adverse cardiac event (MACE) scores were calculated. Presentation of CAD was ST-segment elevation myocardial infarction (STEMI) in 37.6% of patients, non-STEMI- unstable angina in 55.1%, and other in 7.3%. Non-STEMI-unstable angina was more common in AF (69.6% vs 46.6%, p <0.001), while STEMI was more in the non-AF (22.3% vs 46.6%, p <0.001) group. Left anterior descending artery (LAD) was the most common diseased vessel (70.6%) followed by right coronary artery (RCA, 56.4%) and obtuse marginal artery (36.6%). Patients with AF had a significantly lower RCA involvement (47.3% vs 61.8%, p = 0.016), with a trend for LAD (64.3% vs 74.3%, p = 0.069). At multivariable logistic regression analysis, AF remained inversely associated with RCA involvement (odds ratio [OR] 0.541, 95% confidence interval [CI] 0.335 to 0.874, p = 0.012) and with ≥3 vessel CAD (OR 0.470, 95% CI 0.272 to 0.810, p = 0.007). The 2MACE score was associated with diseased LAD (OR 1.301, 95% CI 1.103 to 1.535, p = 0.002) and with ≥3 vessel CAD (OR 1.330, 95% CI 1.330 to 1.140, p <0.001). In conclusion, patients with AF show lower RCA involvement and generally less severe CAD compared to non-AF ones. The 2MACE score was higher in LAD obstruction and identified patients with severe CAD.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:1-6
Pastori D, Biccirè FG, Lip GYH, Menichelli D, ... Gaudio C, Tanzilli G
Am J Cardiol: 14 Feb 2021; 141:1-6 | PMID: 33220321
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Impact:
Abstract

Oral anticoagulant use in patients with atrial fibrillation and mitral valve repair.

Nathan AS, Yang L, Geng Z, Dayoub EJ, ... Giri J, Groeneveld PW
Background
Patients with atrial fibrillation (AF) who have undergone mitral valve repair are at risk for thromboembolic strokes. Prior to 2019, only vitamin K antagonists were recommended for patients with AF who had undergone mitral valve repair despite the introduction of direct oral anticoagulants (DOAC) in 2010.
Objective
To characterize the use of anticoagulants in patients with AF who underwent surgical mitral valve repair (sMVR) or transcatheter mitral valve repair (tMVR).
Methods
We performed a retrospective cohort analysis of patients with AF undergoing sMVR or tMVR between 04/2014 and 12/2018 using Optum\'s de-identified Clinformatics® Data Mart Database. We identified anticoagulants prescribed within 90 days of discharge from hospitalization.
Results
Overall, 1997 patients with AF underwent valve repair: 1560 underwent sMVR, and 437 underwent tMVR. The mean CHA2DS2-VASc score among all patients was 4.1 (SD 1.9). The overall use of anticoagulation was unchanged between 2014 (72.2%) and 2018 (70.0%) (P = .49). Among patients who underwent sMVR or tMVR between April 2014 and December 2018, the use of VKA therapy decreased from 62.9% to 32.1% (P < .01 for trend) and the use of DOACs increased from 12.4% to 37.3% (P < .01 for trend).
Conclusions
Among patients with AF who underwent sMVR or tMVR between 2014 and 2018, roughly 30% of patients were not treated with any anticoagulant within 90 days of discharge, despite an elevated stroke risk in the cohort. The rate of DOAC use increased steadily over the study period but did not significantly increase the rate of overall anticoagulant use in this high-risk cohort.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am Heart J: 27 Feb 2021; 232:1-9
Nathan AS, Yang L, Geng Z, Dayoub EJ, ... Giri J, Groeneveld PW
Am Heart J: 27 Feb 2021; 232:1-9 | PMID: 33214129
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Impact:
Abstract

Meta-analysis of the Usefulness of Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure With Preserved Ejection Fraction.

Aldaas OM, Lupercio F, Darden D, Mylavarapu PS, ... Feld GK, Hsu JC
Catheter ablation improves clinical outcomes in atrial fibrillation (AF) patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, the role of catheter ablation in HF with a preserved ejection fraction (HFpEF) is less clear. We performed a literature search and systematic review of studies that compared AF recurrence at one year after catheter ablation of AF in patients with HFpEF versus those with HFrEF. Risk ratio (RR; where a RR <1.0 favors the HFpEF group) and mean difference (MD; where MD <0 favors the HFpEF group) 95% confidence intervals (CI) were measured for dichotomous and continuous variables, respectively. Six studies with a total of 1,505 patients were included, of which 764 (51%) had HFpEF and 741 (49%) had HFrEF. Patients with HFpEF experienced similar recurrence of AF 1 year after ablation on or off antiarrhythmic drugs compared with those with HFrEF (RR 1.01; 95% CI 0.76, 1.35). Fluoroscopy time was significantly shorter in the HFpEF group (MD -5.42; 95% CI -8.51, -2.34), but there was no significant difference in procedure time (MD 1.74; 95% CI -11.89, 15.37) or periprocedural adverse events between groups (RR 0.84; 95% CI 0.54,1.32). There was no significant difference in hospitalizations between groups (MD 1.18; 95% CI 0.90, 1.55), but HFpEF patients experienced significantly less mortality (MD 0.41; 95% CI 0.18, 0.94). In conclusion, based on the results of this meta-analysis, catheter ablation of AF in patients with HFpEF appears as safe and efficacious in maintaining sinus rhythm as in those with HFrEF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:66-73
Aldaas OM, Lupercio F, Darden D, Mylavarapu PS, ... Feld GK, Hsu JC
Am J Cardiol: 28 Feb 2021; 142:66-73 | PMID: 33290688
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Impact:
Abstract

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

Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J
Various predictors of atrial fibrillation (AF) recurrence have been shown based on the baseline characteristics before catheter ablation (CA). This study aimed to develop a novel scoring system for predicting very late recurrences of AF (VLRAFs) after an initial CA, taking the postprocedural clinical data into account and reassessing VLRAFs in 12-month patients\' condition using previously known preprocedural predictors of AF recurrences. We retrospectively studied 327 patients who underwent an initial CA with freedom from AF for over 12 months. We elucidated the predictors of VLRAFs and created a new score to predict VLRAFs in the discovery AF cohort (n = 181). Thereafter, we investigated whether the new scoring system could accurately predict VLRAFs in the validation AF cohort (n = 146). In the discovery AF cohort, VLRAFs were observed in 53 patients (29%) during the follow-up period (mean follow-up duration: 55 months). The univariate and multivariate Cox proportional-hazards model demonstrated that non-pulmonary vein foci, early recurrences of AF (ERAFs), atrial premature contraction (APC) burden ≥ 142/24 hours, and minimum prematurity index of the APCs ≤ 48% were associated with VLRAFs after CA. We created a new scoring system to predict VLRAFs, the n-PReDCt score (non-pulmonary vein: 1 point, early recurrences of AFs (Recurrences of AF in early phase after CA): 1 point, APC burden ≥ 142/24 hours: 1 point, and minimum prematurity index (= Coupling interval) of the APCs of ≤ 48%: 1 point). The n-PReDCt score was significantly associated with VLRAFs by a Kaplan-Meier analysis in the discovery AF and validation AF cohorts (p < 0.0001 and p < 0.0001, respectively).

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Feb 2021; 141:49-55
Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J
Am J Cardiol: 14 Feb 2021; 141:49-55 | PMID: 33217347
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Impact:
Abstract

Meta-Analysis Evaluating the Efficacy and Safety of Low-Intensity Warfarin for Patients >65 Years of Age With Non-Valvular Atrial Fibrillation.

Kang F, Ma Y, Cai A, Cheng X, ... Mai Z, Mai W
Nonvalvular atrial fibrillation (NVAF) is the most common arrhythmia. It is of a high disability and death rate, and seriously affects quality of life. Although New oral anticoagulants (NOACs) are recommended for anticoagulation therapy of atrial fibrillation, they are not widely used for the high cost and limited availability. Warfarin is effective and economical. The risk of thromboembolism and anticoagulant hemorrhage is higher in patients >65 years with NVAF. So, it is of great clinical significance to explore the optimal anticoagulation intensity of warfarin in patients >65 years of China, and other ethnicities. Some studies suggested that low-intensity international normalized ratio (INR) has similar antithrombotic efficacy comparing to standard-intensity INR, whereas bleeding risk was significantly reduced. But others showed conflicting results. We pooled the efficacy and safety data of low- and standard-intensity warfarin therapy for patients over 65 years with NVAF by meta-analysis, as to evaluate optimal INR intensity of warfarin therapy in patients over 65 years. We identified 18 studies providing data of 2105 patients receiving anticoagulation therapy with warfarin. On meta-analysis (odds ratio [OR] [95% confidence interval {CI}]), low-intensity INR conferred similar efficacy to standard intensity INR on all thrombosis (1.28 [0.90 to 1.81]), stroke (1.09 [0.67 to 1.77]), other thromboembolism ([peripheral and pulmonary embolism] 2.26 [0.89 to 5.79]), and all cause death (1.38 [0.94 to 2.02]). Low-intensity INR conferred better safety profile than standard intensity INR in major bleeding (intracranial and gastrointestinal hemorrhage) (0.32 [0.19 to 0.52]), minor bleeding (gum, nasal cavity and conjunctival hemorrhage, skin ecchymosis, hematuria, hemoptysis) (0.30 [0.20 to 0.45]), and all bleeding (0.30 [0.22 to 0.40]). In conclusion, low-intensity INR (1.5 to 2.0) of warfarin therapy is as effective as standard intensity INR (2.0 to 3.0) therapy in reducing thromboembolic risk in patients>65 years with NVAF, and has a safer profile of bleeding.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2021; 142:74-82
Kang F, Ma Y, Cai A, Cheng X, ... Mai Z, Mai W
Am J Cardiol: 28 Feb 2021; 142:74-82 | PMID: 33307015
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Impact:
Abstract

Rivaroxaban versus Warfarin in Patients with Atrial Fibrillation Enrolled in Latin America: Insights from ROCKET AF.

Blumer V, Rivera M, Corbalán R, Becker RC, ... Fox KAA, Patel MR
Background
ROCKET AF demonstrated the efficacy and safety of rivaroxaban compared with warfarin for the prevention of stroke and systemic embolism (SE) in patients with atrial fibrillation (AF). We examined baseline characteristics and outcomes in patients enrolled in Latin America compared with the rest of the world (ROW).
Methods
ROCKET AF enrolled 14,264 patients from 45 countries. Of these, 1878 (13.2%) were from 7 Latin American countries. The clinical characteristics and outcomes (adjusted by baseline characteristics) of these patients were compared with 12,293 patients from the ROW. Treatment outcomes of rivaroxaban compared with warfarin were also stratified by region.
Results
The annual rate of stroke/SE was similar in those from Latin American and ROW (p=0.63), but all-cause and vascular death were significantly higher than in ROW (HR 1.40, 95% CI 1.20-1.64; HR 1.38, 95% CI 1.14-1.68; p<0.001). Rates of major or non-major clinically relevant bleeding tended to be lower in Latin America (HR 0.89, 95% CI 0.80-1.0; p=0.05). Rates of stroke/SE were similar with rivaroxaban and warfarin in patients from Latin America and ROW (HR 0.83, 95% CI 0.54-1.29 vs. HR 0.89, 95% CI 0.75-1.07; interaction p=0.77).
Conclusions
Patients with AF in Latin America had similar rates of stroke/SE, higher rates of vascular death, and lower rates of bleeding compared with patients in the ROW. The effect of rivaroxaban compared with warfarin in Latin America was similar to the ROW. Further studies analyzing patient- and country-specific determinants of these regional differences in Latin America are warranted.

Copyright © 2021. Published by Elsevier Inc.

Am Heart J: 07 Feb 2021; epub ahead of print
Blumer V, Rivera M, Corbalán R, Becker RC, ... Fox KAA, Patel MR
Am Heart J: 07 Feb 2021; epub ahead of print | PMID: 33571477
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Impact:
Abstract

Transcatheter Embolic Coils to Treat Peri-Device Leaks after Left Atrial Appendage Closure.

Musikantow DR, Shivamurthy P, Croft LB, Kawamura I, ... Goldman ME, Reddy VY
Background
Left atrial appendage closure (LAAC) has proven to be an effective alternative to long term oral anticoagulation in the prevention of thromboembolic events in patients with atrial fibrillation. In a minority of patients, inadequate seal may result in persistent peri-device flow and inability of the appendage to fully thrombose - thereby representing a potential source for thromboembolism.
Objective
To study the use of endovascular coiling of the appendage to address persistent peri-device leak in patients undergoing LAAC with the Watchman device.
Methods
This is a retrospective, single-center analysis involving patients who underwent placement of a Watchman LAAC device and returned for endovascular coiling to address persistent device leak between 2018-2020. Baseline characteristics, procedural outcomes and follow-up echocardiograms were analyzed to demonstrate the feasibility and safety of this technique.
Results
Patients (N=20) were identified with a mean leak size of 3.8 ± 1.3 mm (range 2.5 - 7 mm) all of whom had a non-thrombosed appendage. Acute procedural success was achieved in 95% of patients. Complete or significant reduction in flow beyond the LAAC device was achieved in 61% and 33% of patients respectively. The one procedure-related adverse event was a pericardial effusion prior to coil deployment, requiring percutaneous drainage.
Conclusions
The clinical impact of residual peri-device leak post-Watchman implantation is a matter of continuing investigation. However, appendage coiling represents a new therapeutic tool to address this potential source for thromboembolism. Further studies should address the clinical impact of this technique, including the safety of discontinuing anticoagulation after successful coiling.

Copyright © 2021. Published by Elsevier Inc.

Heart Rhythm: 03 Feb 2021; epub ahead of print
Musikantow DR, Shivamurthy P, Croft LB, Kawamura I, ... Goldman ME, Reddy VY
Heart Rhythm: 03 Feb 2021; epub ahead of print | PMID: 33549807
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Impact:
Abstract

BLOOD BIOMARKERS TO DETECT NEW-ONSET ATRIAL FIBRILLATION AND CARDIOEMBOLISM IN ISCHEMIC STROKE PATIENTS.

Harpaz D, Bajpai R, Ng GJL, Soljak M, ... Tok AIY, Seet RCS
Background
Accumulating data suggest blood biomarkers could inform stroke etiology.
Objective
We investigated the performance of multiple blood biomarkers to elucidate stroke etiology with a focus on new-onset atrial fibrillation (AF) and cardioembolism.
Methods
Between January and December 2017, information on clinical, laboratory parameters and stroke characteristics were prospectively collected from ischemic stroke patients recruited from the National University Hospital, Singapore. Multiple blood biomarkers (NT-pro-brain derived peptides [NT-proBNP], D-dimer, S100β, neuron-specific enolase [NSE], vitamin D, cortisol, interleukin-6, insulin, uric acid and albumin) were measured in plasma. These variables were compared with stroke etiology, and the risk of new-onset AF and cardioembolism, using multivariable regression methods.
Results
From 515 ischemic stroke patients (mean age, 61 years; 71% men), 44 (8.5%) patients were diagnosed with new-onset AF and 75 (14.5%) patients had cardioembolism. The combination of two laboratory parameters (total cholesterol ≤169 mg/dl and triglycerides ≤44.5 mg/dl) and three biomarkers (NT-proBNP ≥294 pg/ml, S100β ≥64 pg/ml and cortisol ≥471 nmol/l) identified patients with new-onset AF (negative predictive value [NPV] 90%, positive predictive values [PPV] 73% and area under curve [AUC] 85%). The combination of two laboratory parameters (total cholesterol ≤169 mg/dl and triglycerides ≤44.5 mg/dl) and two biomarkers (NT-proBNP ≥507 pg/ml and S100β ≥65 pg/ml) identified those with cardioembolism (NPV 86%, PPV 78% and AUC 87%). Adding clinical predictors, however, did not improve the performance of these models.
Conclusion
Blood biomarkers could identify patients with increased likelihood of cardioembolism and direct the search for occult atrial fibrillation.

Copyright © 2021. Published by Elsevier Inc.

Heart Rhythm: 05 Feb 2021; epub ahead of print
Harpaz D, Bajpai R, Ng GJL, Soljak M, ... Tok AIY, Seet RCS
Heart Rhythm: 05 Feb 2021; epub ahead of print | PMID: 33561586
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Impact:
Abstract

The benefits of routine prophylactic femoral access during transvenous lead extraction.

Chung DU, Müller L, Ubben T, Yildirim Y, ... Pecha S, Hakmi S
Background
The number of patients with necessity for lead extraction has been rising in recent years. Despite significant advances in operator experience and technique, unexpected complications may occur. The prophylactic placement of femoral sheaths allows for immediate endovascular access for emergency procedures and may shorten response time in face of complications.
Objectives
The aim of this study was to assess the benefits of routine prophylactic femoral access in patients undergoing TLE and to evaluate methods, frequency and efficacy of the deployed emergency measures in those patients.
Methods
We conducted a retrospective analysis of patients who underwent TLE from January 2012 until February 2019. The data was analyzed in regards to procedural complications and deployment of emergency measures via femoral access.
Results
285 patients with a mean age of 65.3±15.5 years were included. Median lead dwell time was 84 [IQR: 58 - 144] months. Overall complication rate was 4.2% (n=12) with 1.8% major complications (n=5). Clinical success rate was 97.2%. Procedure-related mortality was 1.1% (n=3). Femoral sheaths were actively engaged in 9.1% (n=26) of cases, with deployment of snares being the most common intervention (n=10), followed by prophylactic- (n=6) or emergent placement (n=1) of occlusion balloons, temporary pacing (n=3), venous angioplasty (n=3), diagnostic venography (n=3) or implantation of an ECMO (n=1). We did not observe any femoral vascular complications due to prophylactic sheath placement.
Conclusion
The routine prophylactic placement of femoral sheaths enables to shorten response time and quickly establish control in face of various complications that may be encountered during TLE procedures.

Copyright © 2021. Published by Elsevier Inc.

Heart Rhythm: 08 Feb 2021; epub ahead of print
Chung DU, Müller L, Ubben T, Yildirim Y, ... Pecha S, Hakmi S
Heart Rhythm: 08 Feb 2021; epub ahead of print | PMID: 33577972
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Impact:
Abstract

Racial Disparities in the Utilization and In-Hospital Outcomes of Percutaneous Left Atrial Appendage Closure Among Patients with Atrial Fibrillation.

Vincent L, Grant J, Ebner B, Potchileev I, ... Colombo R, de Marchena E
Background
Select patients with atrial fibrillation and contraindication to anticoagulation may benefit from percutaneous left atrial appendage closure (pLAAC).
Objective
We sought to evaluate racial disparities in the nationwide utilization and outcomes of pLAAC.
Methods
We identified 16,830 hospitalizations for pLAAC between 2015-2017 using the National Inpatient Sample. Baseline characteristics, in-hospital mortality, complications, length of stay and discharge disposition were assessed between White and Black/African American (AA) populations.
Results
Black/AA patients represented 4.1% of nationwide pLAAC recipients and were younger, more likely to be female, and had greater prevalence of hypertension, heart failure, hyperlipidemia, obesity, chronic kidney disease and prior stroke history (p < 0.001 for all). Black/AA patients had significantly increased length of stay and non-routine discharge (p < 0.001 for both), but comparable in-hospital mortality to White patients. Black/AA patients suffered from greater post-operative stroke (0.7% vs. 0.2%), acute kidney injury (4.5% vs. 2.1%), bleeding requiring transfusion (4.5% vs. 1.4%) and venous thromboembolism (0.7% vs. 0.1%, p < 0.01 for all). After controlling for possible confounding factors, Black/AA race was independently associated with significantly increased odds of bleeding requiring blood transfusion, stroke, venous thromboembolism, and non-routine discharge.
Conclusion
Among pLAAC recipients nationwide, Black/AA populations were underrepresented and had greater complication rates, length of stay, and discharge complexity. This study highlights the importance of addressing ongoing racial disparities in both utilization and outcomes of pLAAC.

Copyright © 2021. Published by Elsevier Inc.

Heart Rhythm: 11 Feb 2021; epub ahead of print
Vincent L, Grant J, Ebner B, Potchileev I, ... Colombo R, de Marchena E
Heart Rhythm: 11 Feb 2021; epub ahead of print | PMID: 33588068
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Impact:
Abstract

Catheter Ablation of Ventricular Tachycardia in Ischemic Cardiomyopathy: Impact of Concomitant Amiodarone Therapy on Short and Long-Term Clinical Outcomes.

Di Biase L, Romero J, Du X, Mohanty S, ... Chen M, Natale A
Background
Substrate catheter ablation of scar-related ventricular tachycardia (VT) is a widely accepted therapeutic option in patients with ischemic cardiomyopathy (ICM).
Objective
Whether concomitant amiodarone therapy may affect procedural outcomes is unknown.
Methods
A total of 134 consecutive patients (89% male, age 66±10 years) with ICM undergoing catheter ablation of VT were included in this study. Patients were sorted by amiodarone therapy before ablation. In all patients, a substrate-based catheter ablation (endocardial +/- epicardial) in sinus rhythm abolishing all \"abnormal\" electrograms within the scar were performed. The endpoint was VT non-inducibility. Following the ablation procedure, all anti-arrhythmic medications were discontinued. All patients had an implantable cardioverter-defibrillator, and recurrences were analyzed through the device.
Results
In 84(63%) patients, the ablation was performed \"on\" amiodarone while the remaining 50(37%) were \"off\" amiodarone. Patients were comparable in their baseline characteristics. The mean scar size area was 143.6±44.9cm2 vs 139.2±36.8cm2 (p=0.56), respectively. In the \"off\" amiodarone group, more radiofrequency time was necessary to achieve non-inducibility when compared to the \"on\" group (68.1±20.1 min vs. 51.5±19.7 min, p<0.001). In addition, in the \"off\" amiodarone group, due to persistent VT inducibility, a higher number of patients required epicardial ablation when compared to the \"on\" group [i.e.,13/50(26%) vs. 5/84(6%), respectively, p=0.013]. During a mean follow-up of 23.9±11.6 months, the recurrence of any VT off anti-arrhythmic drugs was 44%(37/84) in the \"on\" amiodarone group and 22%(11/50) in the \"off\" group (p=0.013).
Conclusions
Higher VT recurrence at long-term follow-up after catheter ablation is observed in patients on amiodarone.

Copyright © 2021. Published by Elsevier Inc.

Heart Rhythm: 12 Feb 2021; epub ahead of print
Di Biase L, Romero J, Du X, Mohanty S, ... Chen M, Natale A
Heart Rhythm: 12 Feb 2021; epub ahead of print | PMID: 33592323
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Impact:
Abstract

An Individualised Ablation Strategy to Treat Persistent Atrial Fibrillation: Core-to-Boundary Approach Guided by Charge-Density Mapping.

Shi R, Chen Z, Pope MT, Zaman JA, ... Betts TR, Wong T
Background
Non-contact charge-density mapping allows rapid real-time global mapping of atrial fibrillation (AF) offering the opportunity of a personalised ablation strategy.
Objective
We compared the two-year outcome of an individualised strategy consisting of pulmonary vein isolation (PVI) plus Core-to-Boundary ablation (targeting the conduction pattern core with an extension to the nearest non-conducting boundary) guided by charge-density mapping, with an empirical PVI plus posterior wall electrical isolation (PWI) strategy.
Methods
Forty patients (62±12 years, 29 males) with persistent AF (10±5 months) prospectively underwent charge-density mapping guided PVI followed by Core-to-Boundary stepwise ablation until termination of AF or depletion of identified cores. Freedom from AF/atrial tachycardia (AT) at 24-months was compared with a propensity-score matched control group of 80 patients with empirical PVI+PWI guided by conventional contact mapping.
Results
Acute AF termination occurred in 8/40 patients following charge-density mapping guided PVI alone and in 21 of the remaining 32 patients following Core-to-Boundary ablation in the study cohort, compared with 8/80 (10%) in the control cohort; p<0.001. On average, 2.2±0.6 cores were ablated post-PVI before acute AF termination. At 24-months, freedom from AF/AT following a single procedure was 68% in the study group vs. 46% in the control group; p=0.043.
Conclusion
An individualised ablation strategy consisting of PVI plus Core-to-Boundary ablation guided by noncontact charge-density mapping is a feasible and effective strategy in treating persistent AF with a favourable 24-month outcome.

Copyright © 2021. Published by Elsevier Inc.

Heart Rhythm: 17 Feb 2021; epub ahead of print
Shi R, Chen Z, Pope MT, Zaman JA, ... Betts TR, Wong T
Heart Rhythm: 17 Feb 2021; epub ahead of print | PMID: 33610744
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Impact:
Abstract

Prognostic Value of Pre-operative Atrial Fibrillation in Patients With Secondary Mitral Regurgitation Undergoing MitraClip Implantation.

Godino C, Sisinni A, Pivato CA, Adamo M, ... Margonato A, MiZüBr registry
Limited data are available regarding the independent prognostic role of preoperative atrial fibrillation (AF) after transcatheter mitral valve repair with MitraClip. We sought to evaluate the impact of preoperative AF in patients with heart failure (HF) and concomitant secondary mitral regurgitation (MR) after MitraClip treatment. The study included 605 patients with significant secondary MR from a multicenter international registry. Patients were stratified into 2 groups according to the presence or absence of preoperative AF. Primary end point was 5-year overall death, secondary end points were 5-year cardiac death and first re-hospitalization for HF. To account for baseline differences, patients were propensity score matched 1:1. The overall prevalence of preoperative AF was 44%. At 5-year Kaplan-Meier analysis, compared with patients without AF, those with AF had significantly more adverse events in term of overall death (67% vs 43%; HR 1.84, log-rank p <0.001) and cardiac death (56% vs 29%; HR 2.11, log-rank p <0.001) and re-hospitalization for HF (63% vs 52%; HR 1.33, log-rank p = 0.048). Multivariate analysis identified AF as independent predictor of worse outcome in term of primary end point (HR 1.729, 95% C.I. 1.060 to 2.821; p = 0.028). After propensity score matching, patients with AF had higher rates of death and cardiac mortality but similar rates of re-hospitalization for HF. In conclusion, in patients with HF undergoing MitraClip treatment for secondary MR, preoperative AF is common and an unfavourable predictor of 5-year death and cardiac death. However, AF did not affect the frequency of re-hospitalization for HF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:51-59
Godino C, Sisinni A, Pivato CA, Adamo M, ... Margonato A, MiZüBr registry
Am J Cardiol: 14 Mar 2021; 143:51-59 | PMID: 33359201
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Abstract

Incidence and Mortality trends of Atrial Fibrillation/Atrial Flutter in the United States 1990 to 2017.

DeLago AJ, Essa M, Ghajar A, Hammond-Haley M, ... Salciccioli JD, Philips B
Atrial fibrillation (AF) and flutter (AFL) are the most common clinically significant arrhythmias in older adults with an increasing disease burden due to an aging population. However, up-to-date trends in disease burden and regional variation remain unknown. In an observational study utilizing the Global Burden of Disease (GBD) database, age-standardized mortality and incidence rates for AF overall and for each state in the United States (US) from 1990-2017 were determined. All analyses were stratified by sex. The relative change in age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) over the observation period were determined. Trends were analyzed using Joinpoint regression analysis. The mean ASIR per 100,000 population for men was 92 (+/-8) and for women was 62 (+/-5) in the US in 2017. The mean ASDR per 100,000 population for men was 5.8 (+/-0.3) and for women was 4.4 (+/-0.4). There were progressive increases in ASIR and ASDR in all but one state. The states with the greatest percentage change in incidence were New Hampshire (+13.5%) and Idaho (+16.0%) for men and women, respectively. The greatest change regarding mortality was seen in Mississippi (+26.3%) for men and Oregon (+53.8%) for women. In conclusion these findings provide updated evidence of increasing AF/AFL incidence and mortality on a national and regional level in the Unites States, with women experiencing greater increases in incidence and mortality rates. This study demonstrates that the public health burden related to AF in the United States is progressively worsening but disproportionately across states and among women.

Copyright © 2021. Published by Elsevier Inc.

Am J Cardiol: 24 Feb 2021; epub ahead of print
DeLago AJ, Essa M, Ghajar A, Hammond-Haley M, ... Salciccioli JD, Philips B
Am J Cardiol: 24 Feb 2021; epub ahead of print | PMID: 33640365
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Impact:
Abstract

Relationship between device-detected burden and duration of atrial fibrillation and risk of ischemic stroke.

Al-Gibbawi M, Ayinde HO, Bhatia NK, El-Chami MF, ... Merchant FM, Kiani S
Background
Wider availability of continuous rhythm monitoring has made feasible the incorporation of metrics of atrial fibrillation (AF) burden and duration into the decision to initiate anticoagulation. However, the relationship between thresholds of burden and duration and underlying risk factors at which anticoagulation should be considered remains unclear.
Objective
The purpose of this study was to evaluate the relationships of these metrics with each other and the outcome of stroke/transient ischemic attack (TIA).
Methods
We identified patients with cardiovascular implantable electronic devices (CIEDs) with atrial leads who had at least 1 interrogation in 2016 demonstrating nonpermanent AF and were not receiving oral anticoagulation (OAC). We evaluated the relationship between burden (ie, percentage of time spent in AF), the longest single episode of AF, and risk factors (ie, CHA2DS2-VASc score) in predicting risk of stroke/TIA.
Results
The study included 384 patients with mean follow-up of 3.2 ± 0.8 years and incidence of stroke/TIA of 14.8% during follow-up (∼4.6% per year). The burden of AF and the duration of longest episode demonstrated a significant positive correlation to each other but not CHA2DS2-VASc score. Importantly, although the CHA2DS2-VASc score was predictive of stroke/TIA, neither burden nor duration was associated with stroke/TIA.
Conclusion
Among patients with CIED-detected AF not receiving OAC, the amount of AF (measured by either burden or duration) does not seem to significantly impact stroke risk, whereas CHA2DS2-VASc score does. These data suggest that among patients with CIED-detected AF, once AF occurs, stroke risk seems to be predominantly driven by underlying risk factors.

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

Heart Rhythm: 27 Feb 2021; 18:338-346
Al-Gibbawi M, Ayinde HO, Bhatia NK, El-Chami MF, ... Merchant FM, Kiani S
Heart Rhythm: 27 Feb 2021; 18:338-346 | PMID: 33250442
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Impact:
Abstract

Intraprocedural dynamics of cardiac conduction during transcatheter aortic valve implantation: Assessment by simultaneous electrophysiological testing.

Reiter C, Lambert T, Kellermair J, Blessberger H, ... Nahler A, Steinwender C
Background
Transcatheter aortic valve implantation (TAVI) is an established treatment for patients with severe aortic stenosis and high to intermediate surgical risk. However, the proximity of the conduction system to the prosthesis landing zone bears the risk of atrioventricular conduction disorders. The underlying pathophysiology is not fully understood.
Objective
The purpose of this study was to characterize the impact of TAVI on the conduction system as assessed by simultaneous electrophysiological testing.
Methods
AH and HV intervals and QRS duration were measured using a quadripolar His catheter and surface electrocardiogram in 108 patients at baseline (BL), after balloon predilation (timepoint 1 [T1]), after implantation of the valve prosthesis (T2), and after postdilation, if deemed necessary (T3).
Results
Between BL and T2, significant increases of HV interval and QRS duration were observed, with a mean delta of +12.4 ms and +32.7 ms, respectively. Both balloon predilation and valve implantation had an impact on infranodal conduction. No significant increase of AH intervals was documented. The increase of QRS duration led to left bundle branch block (LBBB) in 57 patients (52.8%). Implantation depth positively correlated with QRS prolongation (ρ = 0.21, P = .042) but not with changes of AH or HV interval (ρ = -0.03, P = .762; and ρ = 0.15, P = .130, respectively).
Conclusion
Electrophysiological testing during TAVI shows impairment of infranodal atrioventricular conduction by balloon predilation and valve implantation. This impairment is positively correlated with valve implantation depth and results in an increase of QRS duration with mainly LBBB pattern on surface electrocardiogram.

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

Heart Rhythm: 27 Feb 2021; 18:419-425
Reiter C, Lambert T, Kellermair J, Blessberger H, ... Nahler A, Steinwender C
Heart Rhythm: 27 Feb 2021; 18:419-425 | PMID: 33250391
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Impact:
Abstract

Individual Patient Data from the Pivotal Randomized Controlled Trials of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation (COMBINE AF): Design and Rationale: From the COMBINE AF (A Collaboration between Multiple institutions to Better Investigate Non-vitamin K antagonist oral anticoagulant use in Atrial Fibrillation) Investigators.

Carnicelli AP, Hong H, Giugliano RP, Connolly SJ, ... Granger CB, COMBINE AF Investigators
Background
Non-vitamin K antagonist oral anticoagulants (NOACs) are the preferred class of medications for prevention of stroke and systemic embolism in patients with atrial fibrillation unless contraindications exist. Five large, international, randomized, controlled trials of NOACs versus either warfarin or aspirin have been completed to date.
Design
COMBINE AF incorporates de-identified individual patient data from 77,282 patients with atrial fibrillation at risk for stroke randomized to NOAC, warfarin, or aspirin from 5 pivotal randomized controlled trials. All patients randomized in the constituent trials are included. Variables common to ≥3 of the constituent trials are included in the master database. Individual trial data sets from the 4 coordinating centers were combined at the Duke Clinical Research Institute. The final database will be securely shared with the 4 academic coordinating centers. The combined master database will be used to perform statistical analyses aimed at better understanding underlying risk factors and outcomes in patients with atrial fibrillation treated with oral anticoagulants, with a special focus on patient subgroups and uncommon outcomes. The initial analysis from COMBINE AF will be a network meta-analysis investigating the relative efficacy and safety of pooled higher-dose NOACs versus pooled lower-dose NOACs versus warfarin with respect to multiple time-to-event efficacy and safety outcomes. COMBINE AF is registered with PROSPERO (CRD42020178771).
Conclusion
In conclusion, COMBINE AF provides a rich and robust database consisting of individual patient data and will offer opportunities to investigate oral anticoagulants across many patient subgroups. Data sharing and collaboration across academic institutions and investigators will serve as overarching themes.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am Heart J: 27 Feb 2021; 233:48-58
Carnicelli AP, Hong H, Giugliano RP, Connolly SJ, ... Granger CB, COMBINE AF Investigators
Am Heart J: 27 Feb 2021; 233:48-58 | PMID: 33296688
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Impact:
Abstract

Prognostic value of implantable defibrillator-computed respiratory disturbance index: The DASAP-HF study.

Boriani G, Pisanò ECL, Pieragnoli P, Locatelli A, ... Ricci RP, D\'Onofrio A
Background
Sleep apnea, as measured by polysomnography, is associated with adverse outcomes in heart failure. The DASAP-HF (Diagnosis and Treatment of Sleep Apnea in Patient With Heart Failure) study previously demonstrated that the respiratory disturbance index (RDI) computed by the ApneaScan algorithm (Boston Scientific) accurately identifies severe sleep apnea in implantable cardioverter-defibrillator (ICD) patients.
Objective
The purpose of the long-term study phase was to assess the incidence of clinical events after 24 months and investigate the association with RDI values.
Methods
Patients with left ventricular ejection fraction ≤35% implanted with an ICD were enrolled and followed-up for 24 months. The RDI calculated at 1 month after implantation was used to stratify patients (below or above 30 episodes/h). The endpoints were all-cause death and a combination of all-cause death or cardiovascular hospitalization.
Results
Of the 265 enrolled patients, 224 had usable RDI values. Severe sleep apnea (RDI ≥30 episodes/h) was diagnosed in 115 patients (51%). These patients were more frequently male (84% vs 72%; P = .030) and had higher creatinine levels. During median follow-up of 25 months, 19 patients (8%) died. Cardiovascular hospitalizations were reported in 19 patients (8%). The risk of all-cause death was higher in patients with RDI ≥30 episodes/h (hazard ratio [HR] 3.33; 95% confidence interval [CI] 1.35-8.21; P = .023), as well as the risk of all-cause death or cardiovascular hospitalization (HR 1.94; 95% CI 1.01-3.76; P = .048). At multivariate analysis, independent predictors of death were RDI ≥30 episodes/h (HR 4.02; 95% CI 1.16-13.97; P = .029) and creatinine levels (HR 2.36; 95% CI 1.26-4.42; P = .008).
Conclusion
In heart failure patients implanted with an ICD, higher RDI values are associated with death and cardiovascular hospitalizations. Device-detected severe sleep apnea independently predicts death.

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

Heart Rhythm: 27 Feb 2021; 18:374-381
Boriani G, Pisanò ECL, Pieragnoli P, Locatelli A, ... Ricci RP, D'Onofrio A
Heart Rhythm: 27 Feb 2021; 18:374-381 | PMID: 33283757
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Impact:
Abstract

Non-warfarin oral anticoagulant copayments and adherence in atrial fibrillation: A population-based cohort study.

Rome BN, Gagne JJ, Avorn J, Kesselheim AS
Background
In patients with atrial fibrillation, incomplete adherence to anticoagulants increases risk of stroke. Non-warfarin oral anticoagulants (NOACs) are expensive; we evaluated whether higher copayments are associated with lower NOAC adherence.
Methods
Using a national claims database of commercially-insured patients, we performed a cohort study of patients with atrial fibrillation who newly initiated a NOAC from 2012 to 2018. Patients were stratified into low (<$35), medium ($35-$59), or high (≥$60) copayments and propensity-score weighted based on demographics, insurance characteristics, comorbidities, prior health care utilization, calendar year, and the NOAC received. Follow-up was 1 year, with censoring for switching to a different anticoagulant, undergoing an ablation procedure, disenrolling from the insurance plan, or death. The primary outcome was adherence, measured by proportion of days covered (PDC). Secondary outcomes included NOAC discontinuation (no refill for 30 days after the end of NOAC supply) and switching anticoagulants. We compared PDC using a Kruskal-Wallis test and rates of discontinuation and switching using Cox proportional hazards models.
Results
After weighting patients across the 3 copayment groups, the effective sample size was 17,558 patients, with balance across 50 clinical and demographic covariates (standardized differences <0.1). Mean age was 62 years, 29% of patients were female, and apixaban (43%), and rivaroxaban (38%) were the most common NOACs. Higher copayments were associated with lower adherence (P < .001), with a PDC of 0.82 (Interquartile range [IQR] 0.36-0.98) among those with high copayments, 0.85 (IQR 0.41-0.98) among those with medium copayments, and 0.88 (IQR 0.41-0.99) among those with low copayments. Compared to patients with low copayments, patients with high copayments had higher rates of discontinuation (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.08-1.19; P < .001).
Conclusions
Among atrial fibrillation patients newly initiating NOACs, higher copayments in commercial insurance were associated with lower adherence and higher rates of discontinuation in the first year. Policies to lower or limit cost-sharing of important medications may lead to improved adherence and better outcomes among patients receiving NOACs.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am Heart J: 27 Feb 2021; 233:109-121
Rome BN, Gagne JJ, Avorn J, Kesselheim AS
Am Heart J: 27 Feb 2021; 233:109-121 | PMID: 33358690
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Impact:
Abstract

Risk markers of incident atrial fibrillation in patients with coronary heart disease.

Tomasdottir M, Held C, Hadziosmanovic N, Westerbergh J, ... Wallentin L, Hijazi Z
Background
In patients with coronary heart disease (CHD), atrial fibrillation (AF) is associated with increased morbidity and mortality. We investigated the associations between clinical risk factors and biomarkers with incident AF in patients with CHD.
Methods and results
Around 13,153 patients with optimally treated CHD included in the STabilization of Atherosclerotic plaque By Initiation of darapLadIb TherapY (STABILITY) trial with plasma samples obtained at randomization. Mean follow-up time was 3.5 years. The association between clinical risk factors and biomarkers with incident AF was estimated with Cox-regression models. Validation was performed in 1,894 patients with non-ST-elevation acute coronary syndrome included in the FRISC-II trial. The median (min-max) age was 64 years (range 26-92) and 2,514 (19.1%) were women. A total of 541 patients, annual incidence rate of 1.2%, developed AF during follow-up. In multivariable models, older age, higher levels of NT-proBNP, higher body mass index (BMI), male sex, geographic regions, low physical activity, and heart failure were independently associated with increased risk of incident AF with hazard ratios ranging from 1.04 to 1.79 (P ≤ .05). NT-proBNP improved the C-index from 0.70 to 0.71. In the validation cohort, age, BMI, and NT-proBNP were associated with increased risk of incident AF with similar hazard ratios.
Conclusions
In patients with optimally treated CHD, the incidence of new AF was 1.2% per year. Age, NT-proBNP as a marker of impaired cardiac function, and BMI were the strongest factors, independently and consistently associated with incident AF. Male sex and low physical activity may also contribute to the risk of AF in patients with CHD.

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

Am Heart J: 27 Feb 2021; 233:92-101
Tomasdottir M, Held C, Hadziosmanovic N, Westerbergh J, ... Wallentin L, Hijazi Z
Am Heart J: 27 Feb 2021; 233:92-101 | PMID: 33400910
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Impact:
Abstract

Ventricular tachycardia burden reduction after substrate ablation: predictors of recurrence.

Quinto L, Sanchez-Somonte P, Alarcón F, Garre P, ... Mont L, Roca-Luque I
Background
Substrate-based ventricular tachycardia (VT) ablation is a first-line treatment in patients with structural cardiac disease with sustained VT refractory to medical therapy. Despite technological improvements and increased knowledge of VT substrate, recurrence is still frequent. There is a lack of published data about the possible reduction in the VT burden after ablation despite recurrence.
Objective
To assess the VT burden reduction during long-term follow-up after substrate ablation and to identify predictors of VT recurrence.
Methods
We analyzed 234 consecutive procedures of VT ablation in 207 patients (age:63±14.9 years, males:92%, ischemic heart disease:65%) who underwent substrate ablation in a single center from 2013 to 2018.
Results
After a follow-up of 3.14±1.8 years, the VT recurrence rate was 41.4%. Overall, a 99.6% reduction in the VT burden (preprocedural:3.546[1.347-13.951] vs postprocedural:0.001[0-0.689] median VT episodes per year, p=0.001) and a 96.3 % decrease in ICD shocks (preprocedural:1.145[0.118-4.467] vs postprocedural:0.042[0-0.111] per year, p=0.017) were observed. In the subgroup of patients who experienced VT recurrences, the VT burden also decreased by 69.2 % (median of the VT episodes per year: preprocedural 2.876[1.105-8.801] vs postprocedural 0.882[0.505-2.283], p <0.001). Multivariable analysis showed persistence of late potentials (67% vs. 19%, HR 3.18[2.18-6.65], p<0.001) and lower LVEF (30[25-40] vs 39[30-50], p=0.022) were predictive of VT recurrence.
Conclusions
Despite high rate of recurrence in long-term follow-up, substrate-based VT ablation is related to a great reduction in the VT burden and a decrease in ICD therapies. A lower ejection fraction and persistence of late potentials are predictors of recurrence.

Copyright © 2021. Published by Elsevier Inc.

Heart Rhythm: 23 Feb 2021; epub ahead of print
Quinto L, Sanchez-Somonte P, Alarcón F, Garre P, ... Mont L, Roca-Luque I
Heart Rhythm: 23 Feb 2021; epub ahead of print | PMID: 33639298
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Impact:
Abstract

Oral Anticoagulants in Extremely High Risk Very Elderly (>90 years) Patients with Atrial Fibrillation.

Chao TF, Chiang CE, Chan YH, Liao JN, ... Lip GYH, Chen SA
Background
The prevalence and incidence of atrial fibrillation (AF) increase with age. Nonetheless, older patients are often denied oral anticoagulation (OAC), especially if they are \'very elderly\' (age ≥90 years) and perceived to be \'high risk\' of bleeding, for example, those with a history of intracranial haemorrhage (ICH), gastrointestinal bleeding (GIB) or chronic kidney disease (CKD).
Objective
We aimed to investigate the effectiveness and safety of OAC in this \'high risk\' very elderly group.
Methods
We used Taiwan National Health Insurance Research Database to identify \'high risk\' very elderly subjects taking OAC, whether warfarin or non-vitamin K antagonist OACs (NOACs), who were compared to non-OAC users for the composite net clinical endpoint of \'ischemic stroke, ICH, major bleeding or mortality\'.
Results
We studied 7,362 subjects (mean age 92.5 years), of which 1737 were taking NOACs, 670 warfarin and 4955 were non-OAC users. Compared to non-OAC users, warfarin use was associated with a higher risk of composite endpoint (adjusted hazard ratio[aHR] 1.163, 95%CI 1.052-1.287), while NOACs were associated with a lower risk (aHR 0.763, 0.702-0.830). After propensity matching, NOACs were associated with a lower risk of events compared to \"non-OAC use\' or \"warfarin\", while warfarin had a similar risk compared to non-OAC use.
Conclusions
Warfarin was associated with a similar and even higher risk of composite clinical outcomes compared to non-OAC use. NOACs were associated with a lower risk of composite endpoints compared to warfarin or non-OAC use, and should still be considered in these \'high risk\' very elderly AF patients.

Copyright © 2021. Published by Elsevier Inc.

Heart Rhythm: 24 Feb 2021; epub ahead of print
Chao TF, Chiang CE, Chan YH, Liao JN, ... Lip GYH, Chen SA
Heart Rhythm: 24 Feb 2021; epub ahead of print | PMID: 33640447
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Impact:
Abstract

Arrhythmias and Device Therapies in Patients with Cancer Therapy-Induced Cardiomyopathy.

Lee C, Maan A, Singh JP, Fradley MG
Our knowledge of associated cardiotoxicities from novel therapeutics in oncology continues to expand. These include arrhythmias from cancer-therapy induced cardiomyopathy (CCMP) resulting from both direct and indirect effects on cardiomyocytes and other mechanisms that can adversely impact cardiovascular outcomes and overall mortality. In this review, we focus on both the arrhythmias of various classes of oncologic agents as well as the use of cardiac implantable electronic devices (cardioverter-defibrillators, permanent pacemaker, and cardiac resynchronization therapy) in cardio-oncology patients.

Copyright © 2021. Published by Elsevier Inc.

Heart Rhythm: 24 Feb 2021; epub ahead of print
Lee C, Maan A, Singh JP, Fradley MG
Heart Rhythm: 24 Feb 2021; epub ahead of print | PMID: 33640446
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Abstract

Cybersecurity: The need for data and patient safety with cardiac implantable electronic devices.

Das S, Siroky GP, Lee S, Mehta D, Suri R
Remote monitoring of cardiac implantable electronic devices (CIEDs) has become routine practice as a result of the advances in biomedical engineering, the advent of interconnectivity between the devices through the Internet, and the demonstrated improvement in patient outcomes, survival, and hospitalizations. However, this increased dependency on the Internet of Things comes with risks in the form of cybersecurity lapses and possible attacks. Although no cyberattack leading to patient harm has been reported to date, the threat is real and has been demonstrated in research laboratory scenarios and echoed in patient concerns. The CIED universe comprises a complex interplay of devices, connectivity protocols, and sensitive information flow between the devices and the central cloud server. Various manufacturers use proprietary software and black-box connectivity protocols that are susceptible to hacking. Here we discuss the fundamentals of the CIED ecosystem, the potential security vulnerabilities, a historical overview of such vulnerabilities reported in the literature, and recommendations for improving the security of the CIED ecosystem and patient safety.

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

Heart Rhythm: 27 Feb 2021; 18:473-481
Das S, Siroky GP, Lee S, Mehta D, Suri R
Heart Rhythm: 27 Feb 2021; 18:473-481 | PMID: 33059076
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Abstract

Repeated exposure to transient obstructive sleep apnea-related conditions causes an atrial fibrillation substrate in a chronic rat model.

Linz B, Hohl M, Lang L, Wong DWL, ... Böhm M, Linz D
Background
High night-to-night variability in obstructive sleep apnea (OSA) is associated with atrial fibrillation (AF). Obstructive apneas are characterized by intermittent deoxygenation-reoxygenation and intrathoracic pressure swings during ineffective inspiration against occluded upper airways.
Objective
We elucidated the effect of repeated exposure to transient OSA conditions simulated by intermittent negative upper airway pressure (INAP) on the development of an AF substrate.
Methods
INAP (48 events/4 h; apnea-hypopnea index 12 events/h) was applied in sedated spontaneously breathing rats (2% isoflurane) to simulate mild-to-moderate OSA. Rats without INAP served as a control group (CTR). In an acute test series (ATS), rats were either killed immediately (n = 9 per group) or after 24 hours of recovery (ATS-REC: n = 5 per group). To simulate high night-to-night variability in OSA, INAP applications (n = 10; 24 events/4 h; apnea-hypopnea index 6/h) were repeated every second day for 3 weeks in a chronic test series (CTS).
Results
INAP increased atrial oxidative stress acutely, represented in decreases of reduced to oxidized glutathione ratio (ATS: INAP: 0.33 ± 0.05 vs CTR: 1 ± 0.26; P = .016), which was reversible after 24 hours (ATS-REC: INAP vs CTR; P = .274). Although atrial oxidative stress did not accumulate in the CTS, atrial histological analysis revealed increased cardiomyocyte diameters, reduced connexin 43 expression, and increased interstitial fibrosis formation (CTS: INAP 7.0% ± 0.5% vs CTR 5.1% ± 0.3%; P = .013), which were associated with longer inducible AF episodes (CTS: INAP: 11.65 ± 4.43 seconds vs CTR: 0.7 ± 0.33 seconds; P = .033).
Conclusion
Acute simulation of OSA was associated with reversible atrial oxidative stress. Cumulative exposure to these transient OSA-related conditions resulted in AF substrates and was associated with increased AF susceptibility. Mild-to-moderate OSA with high night-to-night variability may deserve intensive management to prevent atrial substrate development.

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

Heart Rhythm: 27 Feb 2021; 18:455-464
Linz B, Hohl M, Lang L, Wong DWL, ... Böhm M, Linz D
Heart Rhythm: 27 Feb 2021; 18:455-464 | PMID: 33080392
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Abstract

Identification of important risk factors for all-cause mortality of acquired long QT syndrome patients using random survival forests and non-negative matrix factorization.

Chen C, Zhou J, Yu H, Zhang Q, ... Tse G, Xia Y
Background
Acquired long QT syndrome (aLQTS) is often associated with poor clinical outcomes.
Objective
The purpose of this study was to examine the important predictors of all-cause mortality of aLQTS patients by applying both random survival forest (RSF) and non-negative matrix factorization (NMF) analyses.
Methods
Clinical characteristics and manually measured electrocardiographic (ECG) parameters were initially entered into the RSF model. Subsequently, latent variables identified using NMF were entered into the RSF as additional variables. The primary outcome was all-cause mortality.
Results
A total of 327 aLQTS patients were included. The RSF model identified 16 predictive factors with positive variable importance values: cancer, potassium, RR interval, calcium, age, JT interval, diabetes mellitus, QRS duration, QTp interval, chronic kidney disease, QTc interval, hypertension, QT interval, female, JTc interval, and cerebral hemorrhage. Increasing the number of latent features between ECG indices, which incorporated from n = 0 to n = 4 by NMF, maximally improved the prediction ability of the RSF-NMF model (C-statistic 0.77 vs 0.89).
Conclusion
Cancer and serum potassium and calcium levels can predict all-cause mortality of aLQTS patients, as can ECG indicators including JTc and QRS. The present RSF-NMF model significantly improved mortality prediction.

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

Heart Rhythm: 27 Feb 2021; 18:426-433
Chen C, Zhou J, Yu H, Zhang Q, ... Tse G, Xia Y
Heart Rhythm: 27 Feb 2021; 18:426-433 | PMID: 33127541
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Abstract

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

Squara F, Elbaum C, Garret G, Liprandi L, ... Moceri P, Ferrari E
Background
Electrical cardioversion is the first-line rhythm control therapy for symptomatic persistent atrial fibrillation (AF). Contemporary use of biphasic shock waveforms and anterior-posterior positioning of defibrillation electrodes have improved cardioversion efficacy; however, it remains unsuccessful in >10% of patients.
Objective
The purpose of this study was to assess the efficacy of applying active compression on defibrillation electrodes during AF cardioversion.
Methods
We performed a bicenter randomized study including patients referred for persistent AF cardioversion. Elective external cardioversion was performed by a standardized step-up protocol with increasing biphasic shock energy (50-100-150-200 J). Patients were randomly assigned to standard anterior-posterior defibrillation or to defibrillation with active compression applied over the anterior electrode. If sinus rhythm was not achieved at 200 J, a single crossover shock (200 J) was applied. Defibrillation threshold, total delivered energy, number of shocks, and success rate were compared between groups.
Results
We included 100 patients, 50 in each group. In the active compression group, defibrillation threshold was lower (103.1 ± 49.9 J vs 130.4 ± 47.7 J; P = .008), as well as total delivered energy (203 ± 173.3 J vs 309 ± 213.5 J; P = .0076) and number of shocks (2.2 ± 1.1 vs 2.9 ± 1.2; P = .0033), and cardioversion was more often successful (48 of 50 patients [96%] vs 42 of 50 patients [84%]; P = .0455) than that in the standard anterior-posterior group. Crossover from the compression group to the standard group was not successful (0 of 2 patients), whereas crossover from the standard group to the compression group was successful in 50% of patients (4 of 8).
Conclusion
Active compression applied to the anterior defibrillation electrode is more effective for persistent AF cardioversion than standard anterior-posterior cardioversion, with lower defibrillation threshold and higher success rate.

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

Heart Rhythm: 27 Feb 2021; 18:360-365
Squara F, Elbaum C, Garret G, Liprandi L, ... Moceri P, Ferrari E
Heart Rhythm: 27 Feb 2021; 18:360-365 | PMID: 33181323
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Abstract

Epicardial course of the septopulmonary bundle: Anatomical considerations and clinical implications for roof line completion.

Pambrun T, Duchateau J, Delgove A, Denis A, ... Walton RD, Derval N
Background
Gaps in the roof line have been ascribed to epicardial conduction using the septopulmonary bundle.
Objectives
We sought to evaluate the frequency of septopulmonary bundle bypass during roof line ablation, to describe anatomical conditions favoring this epicardial gap, and to propose an alternative strategy when present.
Methods
One hundred consecutive patients underwent atrial fibrillation ablation. A de novo roof line was created between the superior pulmonary veins. In cases of residual gaps, a floor line was created between the inferior pulmonary veins. Microtomography imaging and histological analyses of 5 human donor hearts were performed: a specific focus was made on the dome and the posterior wall.
Results
Residual gaps were more frequent in roof lines than floor lines (33% vs 15%; P = .049). Electrogram morphologies, activation sequences, and pacing maneuvers indicated an epicardial bypass of the roof line in all cases. Conduction block was obtained in 67 roof lines and 28 floor lines, resulting in a 95% success rate of linear block, without \"box\" isolation. Between the superior pulmonary veins, the atrial myocardium was thicker and consistently displayed adipose tissue separating the septopulmonary bundle from the septoatrial bundle.
Conclusion
Epicardial conduction across the roof line is common and requires careful electrogram analysis to detect. In such cases, a floor line can be an effective alternative strategy, with clear validation criteria. Myocardial thickness and fat interposition may explain difficulties in achieving lesion transmurality during roof line ablation.

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

Heart Rhythm: 27 Feb 2021; 18:349-357
Pambrun T, Duchateau J, Delgove A, Denis A, ... Walton RD, Derval N
Heart Rhythm: 27 Feb 2021; 18:349-357 | PMID: 33188900
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Abstract

Percutaneous management of superior vena cava syndrome in patients with cardiovascular implantable electronic devices.

Gabriels J, Chang D, Maytin M, Tadros T, ... Eisenhauer A, Epstein LM
Background
There is no consensus regarding the optimal management of cardiovascular implantable electronic device (CIED)-related superior vena cava (SVC) syndrome.
Objective
We report our experience with transvenous lead extractions (TLEs) in the setting of symptomatic CIED-related SVC syndrome.
Methods
We reviewed all TLEs performed at a high-volume center over a 14-year period and identified patients in which TLE was performed for symptomatic SVC syndrome. Patient characteristics, extraction details, percutaneous management of SVC occlusions, and clinical follow up data were analyzed.
Results
Over a 14-year period, more than 1600 TLEs were performed. Of these, 16 patients underwent TLE for symptomatic SVC syndrome. The mean age was 53.1 ± 12.8 years, and 9 (56.3%) were men. Thirty-seven leads, with a mean dwell time of 5.8 years (range 2-12 years), were extracted. After extraction, 6 patients (37.5%) received an SVC stent. Balloon angioplasty was performed before stenting in 5 cases (31.3%). There was 1 major complication (6.3%) due to an SVC tear that was managed surgically with a favorable outcome. Eleven patients underwent reimplantation of a CIED. Over a median follow-up of 5.5 years (interquartile range 2.0-8.5 years), 12 patients (75%) remained free of symptoms.
Conclusion
Combining TLE with the percutaneous treatment of symptomatic SVC syndrome is a safe and viable treatment strategy.

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

Heart Rhythm: 27 Feb 2021; 18:392-398
Gabriels J, Chang D, Maytin M, Tadros T, ... Eisenhauer A, Epstein LM
Heart Rhythm: 27 Feb 2021; 18:392-398 | PMID: 33212249
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Abstract

Reassessing the role of antitachycardia pacing in fast ventricular arrhythmias in primary prevention implantable cardioverter-defibrillator recipients: Results from MADIT-RIT.

Schuger C, Daubert JP, Zareba W, Rosero S, ... McNitt S, Kutyifa V
Background
In Multicenter Automatic Defibrillator Implantation Trial - Reduce Inappropriate Therapy (MADIT-RIT), high-rate cutoff (arm B) and delayed therapy (arm C) reduced the risk of inappropriate implantable cardioverter-defibrillator (ICD) interventions when compared with conventional programming (arm A); however, appropriate but unnecessary therapies were not evaluated.
Objective
The purpose of this study was to assess the value of antitachycardia pacing (ATP) for fast ventricular arrhythmias (VAs) ≥ 200 beats/min in patients with primary prevention ICD.
Methods
We compared ATP only, ATP and shock, and shock only rates in patients in MADIT-RIT treated for VAs ≥ 200 beats/min. The only difference between these randomized groups was the time delay between ventricular tachycardia detection and therapy (3.4 seconds vs 4.9 seconds vs 14.4 seconds).
Results
In arm A, 11.5% patients had events, the initial therapy was ATP in 10.5% and shock in 1%, and the final therapy was ATP in 8% and shock in 3.5%. In arm B, 6.6% had events, 4.2% were initially treated with ATP and 2.4% with shock, and the final therapy was ATP in 2.8% and shock in 3.8%. In arm C, 4.7% had events, 2.5% were initially treated with ATP and 2.3% with shock, and the final therapy was ATP in 1.4% and shock in 3.3%. The final shock rate was similar in arm A vs arm B (3.5% vs 3.8%; P = .800) and in arm A vs arm C (3.5% vs 3.3%; P = .855) despite the marked discrepancy in initial ATP therapy utilization.
Conclusion
In MADIT-RIT, there was a significant reduction in ATP interventions with therapy delays due to spontaneous termination, with no difference in shock therapies, suggesting that earlier interventions for VAs ≥ 200 beats/min are likely unnecessary, leading to an overestimation of the value of ATP in primary prevention ICD recipients.

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

Heart Rhythm: 27 Feb 2021; 18:399-403
Schuger C, Daubert JP, Zareba W, Rosero S, ... McNitt S, Kutyifa V
Heart Rhythm: 27 Feb 2021; 18:399-403 | PMID: 33232811
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Abstract

Predictive value of atrial fibrillation during the postradiofrequency ablation blanking period.

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

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

Heart Rhythm: 27 Feb 2021; 18:366-373
Calkins H, Gache L, Frame D, Boo LM, ... Duytschaever M, Packer DL
Heart Rhythm: 27 Feb 2021; 18:366-373 | PMID: 33242668
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Abstract

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

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

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

Heart Rhythm: 27 Feb 2021; 18:465-472
Liu X, Yuan Y, Wong J, Meng G, ... Everett TH, Chen PS
Heart Rhythm: 27 Feb 2021; 18:465-472 | PMID: 33246037
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Abstract

Sex differences in arrhythmic burden with the wearable cardioverter-defibrillator.

Goldenberg I, Erath JW, Russo AM, Burch AE, ... McNitt S, Kutyifa V
Background
Data on the arrhythmic burden of women at risk for sudden cardiac death are limited, especially in patients using the wearable cardioverter-defibrillator (WCD).
Objective
We aimed to characterize WCD compliance, atrial and ventricular arrhythmic burden, and WCD outcomes by sex in patients enrolled in the Prospective Registry of Patients Using the Wearable Cardioverter Defibrillator (WEARIT-II U.S. Registry).
Methods
In the WEARIT-II Registry, we stratified 2000 patients by sex into women (n = 598) and men (n = 1402). WCD wear time, ventricular and atrial arrhythmic events during WCD use, and implantable cardioverter-defibrillator (ICD) implantation rates at the end of WCD use were evaluated.
Results
The mean WCD wear time was similar in women and men (94 days vs 90 days; P = .145), with longer daily use in women (21.4 h/d vs 20.7 h/d; P = .001). Burden of ventricular tachycardia or ventricular fibrillation was higher in women, with 30 events per 100 patient-years compared with 18 events per 100 patient-years in men (P = .017), with similar findings for treated and non-treated ventricular tachycardia/ventricular fibrillation. Recurrent atrial arrhythmias/sustained ventricular tachycardia was also more frequent in women than in men (167 events per 100 patient-years vs 73 events per 100 patient-years; P = .042). However, ICD implantation rate at the end of WCD use was similar in both women and men (41% vs 39%; P = .448).
Conclusion
In the WEARIT-II Registry, we have shown a higher burden of ventricular and atrial arrhythmic events in women than in men. ICD implantation rates at the end of WCD use were similar. Our findings warrant monitoring women at risk for sudden cardiac death who have a high burden of atrial and ventricular arrhythmias while using the WCD.

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

Heart Rhythm: 27 Feb 2021; 18:404-410
Goldenberg I, Erath JW, Russo AM, Burch AE, ... McNitt S, Kutyifa V
Heart Rhythm: 27 Feb 2021; 18:404-410 | PMID: 33248269
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Abstract

Mortality after cardioverter-defibrillator replacement: Results of the DECODE survival score index.

Zoni-Berisso M, Martignani C, Ammendola E, Narducci ML, ... Malacrida M, Biffi M
Background
Device replacement is the ideal time to reassess health care goals regarding continuing implantable cardioverter-defibrillator (ICD) therapy. Only few data are available on the decision making at this time.
Objectives
The goals of this study were to identify factors associated with poor prognosis at the time of ICD replacement and to develop a prognostic index able to stratify those patients at risk of dying early.
Methods
DEtect long-term COmplications after implantable cardioverter-DEfibrillator replacement (DECODE) was a prospective, single-arm, multicenter cohort study aimed at estimating long-term complications in a large population of patients who underwent ICD/cardiac resynchronization therapy - defibrillator replacement. Potential predictors of death were investigated, and all these factors were gathered into a survival score index (SUSCI).
Results
We included 983 consecutive patients (median age 71 years (63-78)); 750 (76%) were men, 537 (55%) had ischemic cardiomyopathy; 460 (47%) were implanted with cardiac resynchronization therapy - defibrillator. During a median follow-up period of 761 days (interquartile range 628-904 days), 114 patients (12%) died. In multivariate Cox regression analysis, New York Heart Association class III/IV, ischemic cardiomyopathy, body mass index < 26 kg/m2, insulin administration, age ≥ 75 years, history of atrial fibrillation, and hospitalization within 30 days before ICD replacement remained associated with death. The survival score index showed a good discriminatory power with a hazard ratio of 2.6 (95% confidence interval 2.2-3.1; P < .0001). The risk of death increased according to the severity of the risk profile ranging from 0% (low risk) to 47% (high risk).
Conclusion
A simple score that includes a limited set of variables appears to be predictive of total mortality in an unselected real-world population undergoing ICD replacement. Evaluation of the patient\'s profile may assist in predicting vulnerability and should prompt individualized options, especially for high-risk patients.

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

Heart Rhythm: 27 Feb 2021; 18:411-418
Zoni-Berisso M, Martignani C, Ammendola E, Narducci ML, ... Malacrida M, Biffi M
Heart Rhythm: 27 Feb 2021; 18:411-418 | PMID: 33249200
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Abstract

Influence of Chronic Obstructive Pulmonary Disease on Atrial Mechanics by Speckle Tracking Echocardiography in Patients With Atrial Fibrillation.

Goedemans L, Leung M, van der Bijl P, Abou R, ... Delgado V, Bax JJ
The present study aimed to examine differences in left- and right atrial characteristics between atrial fibrillation (AF) patients with and without chronic obstructive pulmonary disease (COPD). For this, 420 patients (mean age 68 ± 10 years, 73% female) with first diagnosis of AF and baseline echocardiography were included. Of these, 143 COPD patients were compared with 277 patients without COPD matched by age, gender and body surface area. Additionally 38 healthy controls without cardiovascular risk factors, matched for age, were included. For all 3 groups, left atrial (LA) volumes and diameter, LA reservoir strain (LASr), left ventricular ejection fraction (LVEF), right atrial (RA) area and diameter, RA reservoir strain (RASr) and tricuspid annular plane systolic excursion were evaluated on transthoracic echocardiography. Baseline characteristics were similar in patients with and without COPD except for smoking and a history of heart failure (42% vs 11%, p < 0.001 and 48% vs 37%, p = 0.036 for COPD and non-COPD patients, respectively). Also, COPD patients less often used β-blockers (63% vs 75%, p = 0.017). There were no significant differences in LVEF, LA volume and RA area between COPD and non-COPD patients. Compared to the controls, AF patients had impaired LVEF, LASr and RASr. Only RASr was significantly worse in COPD patients as compared to non-COPD patients (15.3% [9.0 to 25.1] vs 19.6% [11.8 to 28.5], p = 0.013). Additionally, a trend towards worse RASr was observed with increasing COPD severity. In conclusion, AF patients with concomitant COPD have more impaired RA function compared to patients without COPD but with similar atrial size and LA function.

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

Am J Cardiol: 14 Mar 2021; 143:60-66
Goedemans L, Leung M, van der Bijl P, Abou R, ... Delgado V, Bax JJ
Am J Cardiol: 14 Mar 2021; 143:60-66 | PMID: 33359195
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Impact:
Abstract

Relation of Left Atrial Enlargement to Subsequent Thromboembolic Events in Nonvalvular Atrial Fibrillation Patients With Low to Borderline Embolic Risk.

Cho MS, Choi KJ, Kim M, Do U, Kim J, Nam GB
The current thromboembolic risk stratification of non-valvular atrial fibrillation (NVAF) does not include parameters from transthoracic echocardiography (TTE). We hypothesized that left atrial enlargement (LAE) on TTE could discriminate who require anticoagulation therapy among NVAF patients with low/borderline clinical embolic risk. This single-center cohort study included 6,602 patients with NVAF (median age, 56 years, 70.0% male) with a low to borderline clinical embolic risk (CHA2DS2-VASc score: 0 to 1 in males, 1 to 2 in females). LAE was classified as mild (≥41 mm in males; ≥39 mm in females) or moderate-severe (≥47 mm in males; ≥43 mm in females). The main study outcome was thromboembolic event (ischemic stroke and systemic embolism). Mild and moderate-severe LAE was diagnosed in 26.1% and 32.9% of the cohort, respectively. The patients with moderate-severe LAE showed a higher prevalence of baseline comorbidities and valvular heart disease and had a higher incidence of thromboembolic events than patients with mild or no LAE at 2 years of follow-up (2.5% vs 1.3% vs 1.1%, respectively, p < 0.001). After multivariable adjustment, patients with moderate-severe LAE were at a higher risk of thromboembolic event (hazard ratio, 2.54; 95% CI, 1.65 to 3.90; p < 0.001) compared to those with no LAE. This result persisted in a subgroup analysis of anticoagulant-naïve patients. The rate of thromboembolic events in patients with low clinical embolic risk and moderate-severe LAE was not different to those with high clinical embolic risk without LAE. In conclusion, Moderate-severe LAE on TTE was a significant predictor of thromboembolic events in NVAF patients at low/borderline clinical embolic risk.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:67-73
Cho MS, Choi KJ, Kim M, Do U, Kim J, Nam GB
Am J Cardiol: 14 Mar 2021; 143:67-73 | PMID: 33359192
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Impact:
Abstract

Rivaroxaban Monotherapy versus Combination Therapy According to Patient Risk of Stroke and Bleeding in Atrial Fibrillation and Stable Coronary Disease: AFIRE trial sub-analysis.

Akao M, Yasuda S, Kaikita K, Ako J, ... Matsui K, Ogawa H
Background
In the AFIRE trial, rivaroxaban monotherapy was non-inferior to combination therapy with rivaroxaban and an antiplatelet agent for thromboembolic events or death, and superior for major bleeding in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). Little is known about impacts of stroke and bleeding risks on the efficacy and safety of rivaroxaban monotherapy.
Methods
In this sub-analysis of the AFIRE trial, we assessed the risk of stroke and bleeding by the CHADS2, CHA2DS2-VASc, and HAS-BLED scores. The primary efficacy endpoint was the composite of stroke, systemic embolism, myocardial infarction (MI), unstable angina requiring revascularization, or death from any cause. The primary safety endpoint was major bleeding defined by the International Society on Thrombosis and Haemostasis.
Results
Rivaroxaban monotherapy significantly reduced the primary efficacy and safety endpoints with no evidence of differential effects by stroke risk (CHADS2, p for interaction=0.727 for efficacy, 0.395 for safety; CHA2DS2-VASc, p for interaction=0.740 for efficacy, 0.265 for safety) or bleeding risk (HAS-BLED, p for interaction=0.581 for efficacy, 0.225 for safety). There was also no evidence of statistical heterogeneity across patient risk categories for other endpoints; stroke or systemic embolism, ischemic stroke, hemorrhagic stroke, MI, MI or unstable angina, death from any cause, any bleeding, or net adverse clinical events.
Conclusions
The advantages of rivaroxaban monotherapy compared with those of combination therapy with respect to all pre-specified endpoints, including thromboembolism, bleeding, and mortality were similar across patients with AF and stable CAD, irrespective of their risk for stroke and bleeding.
Clinical trial registration
UMIN Clinical Trials Registry number, UMIN000016612, and ClinicalTrials.gov number, NCT02642419.

Copyright © 2021. Published by Elsevier Inc.

Am Heart J: 27 Feb 2021; epub ahead of print
Akao M, Yasuda S, Kaikita K, Ako J, ... Matsui K, Ogawa H
Am Heart J: 27 Feb 2021; epub ahead of print | PMID: 33657403
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Impact:
Abstract

Left ventricular systolic dysfunction identification using artificial intelligence-augmented electrocardiogram in cardiac intensive care unit patients.

Jentzer JC, Kashou AH, Attia ZI, Lopez-Jimenez F, ... Friedman PA, Noseworthy PA
Background
An artificial intelligence-augmented electrocardiogram (AI-ECG) can identify left ventricular systolic dysfunction (LVSD). We examined the accuracy of AI ECG for identification of LVSD (defined as LVEF ≤40% by transthoracic echocardiogram [TTE]) in cardiac intensive care unit (CICU) patients.
Method
We included unique Mayo Clinic CICU patients admitted from 2007 to 2018 who underwent AI-ECG and TTE within 7 days, at least one of which was during hospitalization. Discrimination of the AI-ECG for LVSD was determined using receiver-operator characteristic curve (AUC) values.
Results
We included 5680 patients with a mean age of 68 ± 15 years (37% females). Acute coronary syndrome (ACS) was present in 55%. LVSD was present in 34% of patients (mean LVEF 48 ± 16%). The AI-ECG had an AUC of 0.83 (95% confidence interval 0.82-0.84) for discrimination of LVSD. Using the optimal cut-off, the AI-ECG had 73%, specificity 78%, negative predictive value 85% and overall accuracy 76% for LVSD. AUC values were higher for patients aged <70 years (0.85 versus 0.80), males (0.84 versus 0.79), patients without ACS (0.86 versus 0.80), and patients who did not undergo revascularization (0.84 versus 0.80).
Conclusions
The AI-ECG algorithm had very good discrimination for LVSD in this critically-ill CICU cohort with a high prevalence of LVSD. Performance was better in younger male patients and those without ACS, highlighting those CICU patients in whom screening for LVSD using AI ECG may be more effective. The AI-ECG might potentially be useful for identification of LVSD in resource-limited settings when TTE is unavailable.

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

Int J Cardiol: 28 Feb 2021; 326:114-123
Jentzer JC, Kashou AH, Attia ZI, Lopez-Jimenez F, ... Friedman PA, Noseworthy PA
Int J Cardiol: 28 Feb 2021; 326:114-123 | PMID: 33152415
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Impact:
Abstract

Arrhythmic burden in patients with new-onset persistent left bundle branch block after transcatheter aortic valve replacement: 2-year results of the MARE study.

Muntané-Carol G, Urena M, Nombela-Franco L, Amat-Santos I, ... Philippon F, Rodés-Cabau J
Aims
We determined the incidence and type of arrhythmias at 2-year follow-up in patients with new-onset persistent left bundle branch block (LBBB) following transcatheter aortic valve replacement (TAVR).
Methods and results
Multicentre prospective study including 103 consecutive patients with new-onset persistent LBBB post-TAVR (SAPIEN XT/3: 53; CoreValve/Evolut R: 50). An implantable cardiac monitor (Reveal XT, Reveal Linq) was implanted before hospital discharge and patients had continuous monitoring for up to 2 years. Arrhythmic events were adjudicated in a central core lab. 1836 new arrhythmic events (tachyarrhythmias: 1655 and bradyarrhythmias: 181) occurred at 2 years. Of these, 283 (15%) occurred beyond 1 year (tachyarrhythmias 212, bradyarrhythmias 71) in 33 (36%) patients, without differences between valve type. Most late (>1 year) arrhythmic events were asymptomatic (94%) and led to a treatment change in 17 (19%) patients. A total of 71 late bradyarrhythmias [high-degree atrioventricular block (HAVB): 3, severe bradycardia: 68] were detected in 17 (21%) patients. At 2 years, 18 (17%) patients had received a permanent pacemaker (PPM) or implantable cardiac-defibrillator. PPM implantation due to HAVB predominated in the early phase post-TAVR, with only 1 HAVB event requiring PPM implantation after 1 year.
Conclusion
Patients with new-onset LBBB post-TAVR exhibited a very high burden of arrhythmic events within the 2 years post-procedure. While new tachyarrhythmic events were homogeneously distributed over time, the vast majority of new HAVB episodes leading to PPM implantation occurred early after the procedure. These results should help to guide the management of this challenging group of patients. (clinicaltrials.gov: NCT02153307).

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

Europace: 04 Feb 2021; 23:254-263
Muntané-Carol G, Urena M, Nombela-Franco L, Amat-Santos I, ... Philippon F, Rodés-Cabau J
Europace: 04 Feb 2021; 23:254-263 | PMID: 33083813
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Impact:
Abstract

Age threshold for anticoagulation in patients with atrial fibrillation: A Swedish nationwide observational study.

Andersson T, Aspberg S
Background
There is controversy as to whether patients with atrial fibrillation (AF) and perceived low risk of cerebral infarction should be treated with anticoagulants, especially at what age a cut-off treatment might be indicated.
Method
We performed a retrospective, nationwide cohort study based on the Swedish National Patient Register and the Prescribed Drugs Register. Patients with a diagnosis of AF between July 1, 2005, and December 31, 2014, were included and divided into age categories (<55, 55-59, 60-64 and 65-74 years) and CHA2DS2-VA score of 0 and 1. Incidence rates (IR) of cerebral infarction and cerebral bleeding were calculated. Associations between outcomes from anticoagulant therapy and no therapy were calculated with Cox regression and given as hazard ratios (HR) with 95% confidence intervals (CI).
Results
The analyzed cohort consisted of 294,470 patients. All age categories older than 55 years on anticoagulants had lower IR and HR for cerebral infarction compared to patients off anticoagulants, from HR 0.72, 95% CI (0.54-0.96) for patients 55-59 years with 0 points according to the CHA2DS2-VA score, to HR 0.37, 95% CI (0.33-0.42) for patients 65-74 years with 1 point. Anticoagulant therapy was associated to an increased risk of cerebral bleeding in three of seven categories, <55 years with 0 point, 55-59 years with 1 point, and 65-74 years with 1 point.
Conclusion
Anticoagulant therapy in patients with AF and age 55 years and older may be considered even if the patient has no other known risk factors for cerebral infarction.

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

Int J Cardiol: 28 Feb 2021; 326:92-97
Andersson T, Aspberg S
Int J Cardiol: 28 Feb 2021; 326:92-97 | PMID: 33152417
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Impact:
Abstract

Additional posterior wall isolation is associated with gastric hypomotility in catheter ablation of atrial fibrillation.

Oikawa J, Fukaya H, Wada T, Horiguchi A, ... Niwano S, Ako J
Background
Gastric hypomotility (GH) is a possible complication of catheter ablation (CA) for atrial fibrillation (AF). However, it is unclear which factors are associated with GH. We sought to elucidate the relationship between the CA procedure and GH.
Methods
The study population consisted of 254 patients who underwent CA for AF from November 2017 to October 2018. Finally, 119 patients were enrolled and divided into two groups: with or without GH (GH or non-GH groups). To evaluate the association with GH, the clinical backgrounds and procedure characteristics of the radiofrequency CA (RFCA) were compared between the two groups.
Results
The median age was 69 years old with 34% of female. GH were observed in 27.7% of patients who underwent RFCA, which was significantly higher than that in the cohort of patients who underwent esophago-gastro-duodenoscopy during the same time period (1.9%: 151 in 8063 patients, p < 0.0001). According to the detailed RFCA procedure, additional posterior wall isolation with pulmonary vein isolation (PVI) had a higher prevalence of GH than that with only PVI (54.8% vs. 18.2%; odds ratio 5.46, 95%CI 2.24-13.32, p = 0.0002). After an adjustment using a multivariate logistic analysis, a posterior wall isolation with the PVI was identified as the only independent predictor for GH (odds ratio 5.01, 95%CI 1.94-13.43, p = 0.0009).
Conclusions
Additional posterior wall isolation with PVI was associated with gastric hypomotility.

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

Int J Cardiol: 28 Feb 2021; 326:103-108
Oikawa J, Fukaya H, Wada T, Horiguchi A, ... Niwano S, Ako J
Int J Cardiol: 28 Feb 2021; 326:103-108 | PMID: 33130261
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Impact:
Abstract

Defining the normal QT interval in newborns: the natural history and reference values for the first 4 weeks of life.

Pærregaard MM, Hvidemose SO, Pihl C, Sillesen AS, ... Bundgaard H, Christensen AH
Aims
Evaluation of the neonatal QT interval is important to diagnose arrhythmia syndromes and evaluate side effects of drugs. We aimed at describing the natural history of the QT interval duration during the first 4 weeks of life and to provide reference values from a large general population sample.
Methods and results
The Copenhagen Baby Heart Study is a prospective general population study that offered cardiac evaluation of newborns. Eight-lead electrocardiograms were obtained and analysed with a computerized algorithm with manual validation. We included 14 164 newborns (52% boys), aged 0-28 days, with normal echocardiograms. The median values (ms, 2-98%ile) for the corrected intervals QTc (Bazett), QTc (Hodges), QTc (Fridericia), and QTc (Framingham) were 419 (373-474), 419 (373-472), 364 (320-414), and 363 (327-405). During the 4 weeks, we observed a small decrease of QTcFramingham, and an increase of QTcHodges (both P < 0.01), while QTcBazett and QTcFridericia did not change (P > 0.05). Applying published QT interval cut-off values resulted in 5-25% of the newborns having QT prolongation. Uncorrected QT intervals decreased linearly with increasing heart rate (HR). Sex and infant size did not affect the QT interval and the gestational age (GA) only showed an effect when comparing the extreme low- vs. high GA groups (≤34 vs. ≥42 weeks, P = 0.021).
Conclusion
During the 4 weeks QTcFramingham and QTcHodges showed minor changes, whereas QTcBazett and QTcFridericia were stable. The QT interval was unaffected by sex and infant size and GA only showed an effect in very premature newborns. Reference values for HR-specific uncorrected QT intervals may facilitate a more accurate diagnosis of newborns with abnormal QT intervals.

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

Europace: 04 Feb 2021; 23:278-286
Pærregaard MM, Hvidemose SO, Pihl C, Sillesen AS, ... Bundgaard H, Christensen AH
Europace: 04 Feb 2021; 23:278-286 | PMID: 32940668
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Impact:
Abstract

Long-term impact of the burden of new-onset atrial fibrillation in patients with acute myocardial infarction: results from the NOAFCAMI-SH registry.

Luo J, Xu S, Li H, Gong M, ... Shi B, Wei Y
Aims 
We aimed to investigate the prognostic impact of the burden of new-onset atrial fibrillation (NOAF) on long-term cardiovascular outcomes in patients with acute myocardial infarction (AMI).
Methods and results 
This retrospective analysis consecutively included patients without a documented atrial fibrillation (AF) history who admitted for AMI at Shanghai Tenth People\'s Hospital between February 2014 and March 2018. Atrial fibrillation burden was measured as the percentage of time spent in AF, and its optimal cut-off value of 10.87% was identified by X-tile software. Of 2399 patients (mean age: 65.8 years, 76.6% of men), 278 (11.6%) developed NOAF during hospitalization. During a median follow-up of 2.7 years, the incidence of all-cause death was 3.19, 9.00, and 17.41 per 100 person-years in the sinus rhythm (SR), low-burden (AF burden ≤ 10.87%), and high-burden (AF burden > 10.87%) groups, respectively. After adjustment for confounders, it was the high-burden NOAF [hazard ratio (HR): 1.94, 95% confidence interval (CI): 1.28-2.95] rather than the low-burden one (HR: 1.47, 95% CI: 0.97-2.21) that was significantly associated with increased mortality compared with SR. Concordant results were obtained in our propensity score-matched analyses [2.55 (1.57-4.16) and 1.32 (0.85-2.05) for high- and low-burden NOAF, respectively). In addition, post-myocardial infarction NOAF was associated with an increased risk of heart failure irrespective of its burden. Only those high-burden individuals were at heightened risk of ischaemic stroke. The restricted cubic spline curves illustrated a dose-response relationship of NOAF burden with outcomes.
Conclusion
In patients with NOAF complicating AMI, high AF burden was strongly associated with long-term outcomes.

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

Europace: 04 Feb 2021; 23:196-204
Luo J, Xu S, Li H, Gong M, ... Shi B, Wei Y
Europace: 04 Feb 2021; 23:196-204 | PMID: 32929491
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Impact:
Abstract

Utilization and procedural adverse outcomes associated with Watchman device implantation.

Khalil F, Arora S, Killu AM, Tripathi B, ... Holmes D, Deshmukh AJ
Aims 
The Food and Drug Administration (FDA) approval of the Watchman device [percutaneous left atrial appendage occlusion (LAAO)] has resulted in the widespread use of this procedure in many centres across the USA. We sought to estimate the nationwide utilization and frequency of adverse outcomes associated with Watchman device implantation. The objective of this study was to evaluate the Watchman device implantation peri-procedural complications and comparison of the results with the previous studies.
Methods and results 
The National Inpatient Sample (NIS) was queried for all hospitalizations with a primary diagnosis of atrial fibrillation or atrial flutter during the year 2016 with percutaneous LAAO during the same admission (ICD-10 code-02L73DK). The frequency of peri-procedural complications, including mortality, procedure-related stroke, major bleeding requiring blood transfusion, and pericardial effusion, was assessed. We compared the complication rates with the published randomized controlled trials and the European Watchman registry. An estimated 5175 LAAO procedures were performed in 2016. The majority of procedures was performed in males (59.1%), age ≥75 years (58.7%), and White (83.1%). The overall complication rate was 1.9%. The in-hospital mortality was 0.29%. Pericardial effusion requiring pericardiocentesis was the most frequent complication (0.68%). Bleeding requiring transfusion was noted in 0.1% of device implants. The rates of post-procedure stroke and systemic embolism were 0% and 0.29%, respectively.
Conclusion 
Percutaneous LAAO with the Watchman device in the USA is associated with low in-hospital complications and a similar safety profile to a recently published EWOLUTION cohort. The complication rates were lower than those reported in the major randomized clinical trials (RCTs). We report the frequency of peri-procedural complications of the LAAO using the Watchman device from the NIS database. We also compare the frequency of peri-procedural complications with the previously published RCTs and EWOLUTION cohort. Our findings are in concordance with findings from EWOLUTION cohort and compare favourably with RCTs.

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

Europace: 04 Feb 2021; 23:247-253
Khalil F, Arora S, Killu AM, Tripathi B, ... Holmes D, Deshmukh AJ
Europace: 04 Feb 2021; 23:247-253 | PMID: 32929501
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Impact:
Abstract

Relation of outcomes to ABC (Atrial Fibrillation Better Care) pathway adherent care in European patients with atrial fibrillation: an analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry.

Proietti M, Lip GYH, Laroche C, Fauchier L, ... Boriani G, ESC-EORP Atrial Fibrillation General Long-Term Registry Investigators Group
Aims
There has been an increasing focus on integrated, multidisciplinary, and holistic care in the treatment of atrial fibrillation (AF). The \'Atrial Fibrillation Better Care\' (ABC) pathway has been proposed to streamline integrated care in AF. We evaluated the impact on outcomes of an ABC adherent management in a contemporary real-life European-wide AF cohort.
Methods and results
Patients enrolled in the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry with baseline data to evaluate ABC criteria and available follow-up data were considered for this analysis. Among the original 11 096 AF patients enrolled, 6646 (59.9%) were included in this analysis, of which 1996 (30.0%) managed as ABC adherent. Patients adherent to ABC care had lower CHA2DS2-VASc and HAS-BLED scores (mean ± SD, 2.68 ± 1.57 vs. 3.07 ± 1.90 and 1.26 ± 0.93 vs. 1.58 ± 1.12, respectively; P < 0.001). At 1-year follow-up, patients managed adherent to ABC pathway compared to non-adherent ones had a lower rate of any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death (3.8% vs. 7.6%), CV death (1.9% vs. 4.8%), and all-cause death (3.0% vs. 6.4%) (all P < 0.0001). On Cox multivariable regression analysis, ABC adherent care showed an association with a lower risk of any TE/ACS/CV death [hazard ratio (HR): 0.59, 95% confidence interval (CI): 0.44-0.79], CV death (HR: 0.52, 95% CI: 0.35-0.78), and all-cause death (HR: 0.57, 95% CI: 0.43-0.78).
Conclusion
In a large contemporary cohort of European AF patients, a clinical management adherent to ABC pathway for integrated care is associated with a significant lower risk for cardiovascular events, CV death, and all-cause death.

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

Europace: 04 Feb 2021; 23:174-183
Proietti M, Lip GYH, Laroche C, Fauchier L, ... Boriani G, ESC-EORP Atrial Fibrillation General Long-Term Registry Investigators Group
Europace: 04 Feb 2021; 23:174-183 | PMID: 33006613
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Impact:
Abstract

Low-voltage bridge strategy to guide cryoablation of typical and atypical atrioventricular nodal re-entry tachycardia in children: mid-term outcomes in a large cohort of patients.

Drago F, Calvieri C, Russo MS, Remoli R, ... Allegretti G, Silvetti MS
Aims
In the current literature, results of the low-voltage bridge (LVB) ablation strategy for the definitive treatment of atrioventricular nodal re-entry tachycardia (AVNRT) seem to be encouraging also in children. The aims of this study were (i) to prospectively evaluate the mid-term efficacy of LVB ablation in a very large cohort of children with AVNRT, and (ii) to identify electrophysiological factors associated with recurrence.
Methods and results
One hundred and eighty-four children (42% male, mean age 13 ± 4 years) with AVNRT underwent transcatheter cryoablation guided by voltage mapping of the Koch\'s triangle. Acute procedural success was 99.2% in children showing AVNRT inducibility at the electrophysiological study. The overall recurrence rate was 2.7%. The presence of two LVBs, a longer fluoroscopy time and the presence of both typical and atypical AVNRT, were found to be significantly associated with an increased recurrence rate during mid-term follow-up. Conversely, there was no significant association between recurrences and patient\'s age, type of LVB, lesion length, number of cryolesions or catheter tip size.
Conclusion
The LVB ablation strategy is very effective in AVNRT treatment in children. Recurrences are related to the complexity of the arrhythmogenic substrate.

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

Europace: 04 Feb 2021; 23:271-277
Drago F, Calvieri C, Russo MS, Remoli R, ... Allegretti G, Silvetti MS
Europace: 04 Feb 2021; 23:271-277 | PMID: 33038208
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Impact:
Abstract

Association of anticoagulant therapy with risk of dementia among patients with atrial fibrillation.

Kim D, Yang PS, Jang E, Yu HT, ... Lip GYH, Joung B
Aims
To investigate the risk of dementia in atrial fibrillation (AF) patients treated with different oral anticoagulants (OACs).
Methods and results
This observational, population-based cohort study enrolled 53 236 dementia-free individuals with non-valvular AF who were aged ≥50 years and newly prescribed OACs from 1 January 2013 to 31 December 2016 from the Korean National Health Insurance Service database. Propensity score matching was used to compare the rates of dementia between users of non-vitamin K antagonist oral anticoagulant (NOAC) (dabigatran, rivaroxaban, and apixaban) and warfarin and to compare each individual NOAC with warfarin. Propensity score weighting analyses were also performed. In the study population (41.3% women; mean age: 70.7 years), 2194 had a diagnosis of incident dementia during a mean follow-up of 20.2 months. Relative to propensity-matched warfarin users, NOAC users tended to be at lower risk of dementia [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.69-0.90]. When comparing individual NOACs with warfarin, all the three NOACs were associated with lower dementia risk. In pairwise comparisons among NOACs, rivaroxaban was associated with decreased dementia risk, compared with dabigatran (HR 0.83, 95% CI 0.74-0.92). Supplemental propensity-weighted analyses showed consistent protective associations of NOACs with dementia relative to warfarin. The associations were consistent irrespectively of age, sex, stroke, and vascular disease and more prominent in standard dose users of NOAC.
Conclusion
In this propensity-matched and -weighted analysis using a real-world population-based cohort, use of NOACs was associated with lower dementia risk than use of warfarin among non-valvular AF patients initiating OAC treatment.

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

Europace: 04 Feb 2021; 23:184-195
Kim D, Yang PS, Jang E, Yu HT, ... Lip GYH, Joung B
Europace: 04 Feb 2021; 23:184-195 | PMID: 33063123
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Impact:
Abstract

Avoiding implant complications in cardiac implantable electronic devices: what works?

Frausing MHJP, Kronborg MB, Johansen JB, Nielsen JC
Nearly one in ten patients experience complications in relation to cardiac implantable electronic device (CIED) implantations. CIED complications have serious implications for the patients and for the healthcare system. In light of the rising rates of new implants and consistent rate of complications, primary prevention remains a major concern. To guide future efforts, we sought to review the evidence base underlying common preventive actions made during a primary CIED implantation.

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

Europace: 04 Feb 2021; 23:163-173
Frausing MHJP, Kronborg MB, Johansen JB, Nielsen JC
Europace: 04 Feb 2021; 23:163-173 | PMID: 33063088
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Impact:
Abstract

Myocardial calcification is associated with endocardial ablation failure of post-myocardial infarction ventricular tachycardia.

de Riva M, Naruse Y, Ebert M, Watanabe M, ... Montero-Cabezas JM, Zeppenfeld K
Aims
In patients with post-myocardial infarction (post-MI) ventricular tachycardia (VT), the presence of myocardial calcification (MC) may prevent heating of a subepicardial VT substrate contributing to endocardial ablation failure. The aims of this study were to assess the prevalence of MC in patients with post-MI VT and evaluate the impact of MC on outcome after endocardial ablation.
Methods and results
In 158 patients, the presence of MC was retrospectively assessed on fluoroscopy recordings in seven standard projections obtained during pre-procedural coronary angiograms. Myocardial calcification, defined as a distinct radiopaque area that moved synchronously with the cardiac contraction, was detected in 30 patients (19%). After endocardial ablation, only 6 patients (20%) with MC were rendered non-inducible compared with 56 (44%) without MC (P = 0.033) and of importance, 8 (27%) remained inducible for the clinical VT [compared with 9 (6%) patients without MC; P = 0.003] requiring therapy escalation. After a median follow-up of 31 months, 61 patients (39%) had VT recurrence and 47 (30%) died. Patients with MC had a lower survival free from the composite endpoint of VT recurrence or therapy escalation at 24-month follow-up (26% vs. 59%; P = 0.003). Presence of MC (HR 1.69; P = 0.046), a lower LV ejection fraction (HR 1.03 per 1% decrease; P = 0.017), and non-complete procedural success (HR 2.42; P = 0.002) were independently associated with a higher incidence of VT recurrence or therapy escalation.
Conclusion
Myocardial calcification was present in 19% of post-MI patients referred for VT ablation and was associated with a high incidence of endocardial ablation failure.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 06 Feb 2021; epub ahead of print
de Riva M, Naruse Y, Ebert M, Watanabe M, ... Montero-Cabezas JM, Zeppenfeld K
Europace: 06 Feb 2021; epub ahead of print | PMID: 33550383
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Impact:
Abstract

Non-invasive detection of exercise-induced cardiac conduction abnormalities in sudden cardiac death survivors in the inherited cardiac conditions.

Leong KMW, Ng FS, Shun-Shin MJ, Koa-Wing M, ... Varnava A, Kanagaratnam P
Aims 
Rate adaptation of the action potential ensures spatial heterogeneities in conduction across the myocardium are minimized at different heart rates providing a protective mechanism against ventricular fibrillation (VF) and sudden cardiac death (SCD), which can be quantified by the ventricular conduction stability (V-CoS) test previously described. We tested the hypothesis that patients with a history of aborted SCD due to an underlying channelopathy or cardiomyopathy have a reduced capacity to maintain uniform activation following exercise.
Methods and results 
Sixty individuals, with (n = 28) and without (n = 32) previous aborted-SCD event underwent electro-cardiographic imaging recordings following exercise treadmill test. These included 25 Brugada syndrome, 13 hypertrophic cardiomyopathy, 12 idiopathic VF, and 10 healthy controls. Data were inputted into the V-CoS programme to calculate a V-CoS score that indicate the percentage of ventricle that showed no significant change in ventricular activation, with a lower score indicating the development of greater conduction heterogeneity. The SCD group, compared to those without, had a lower median (interquartile range) V-CoS score at peak exertion [92.8% (89.8-96.3%) vs. 97.3% (94.9-99.1%); P < 0.01] and 2 min into recovery [95.2% (91.1-97.2%) vs. 98.9% (96.9-99.5%); P < 0.01]. No significant difference was observable later into recovery at 5 or 10 min. Using the lowest median V-CoS scores obtained during the entire recovery period post-exertion, SCD survivors had a significantly lower score than those without for each of the different underlying aetiologies.
Conclusion 
Data from this pilot study demonstrate the potential use of this technique in risk stratification for the inherited cardiac conditions.

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

Europace: 04 Feb 2021; 23:305-312
Leong KMW, Ng FS, Shun-Shin MJ, Koa-Wing M, ... Varnava A, Kanagaratnam P
Europace: 04 Feb 2021; 23:305-312 | PMID: 33083839
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Impact:
Abstract

Complications in pulmonary vein isolation in the Netherlands Heart Registration differ with sex and ablation technique.

Mol D, Houterman S, Balt JC, Bhagwandien RE, ... de Groot JR, Netherlands Heart Registration Ablation Registration Committee
Aims 
Pulmonary vein isolation (PVI) has become a cornerstone of the invasive treatment of atrial fibrillation. Severe complications are reported in 1-3% of patients. This study aims to compare complications and follow-up outcome of PVI in patients with atrial fibrillation.
Methods and results 
The data were extracted from the Netherlands Heart Registration. Procedural and follow-up outcomes in patients treated with conventional radiofrequency (C-RF), multielectrode phased RF (Ph-RF), or cryoballoon (CB) ablation from 2012 to 2017 were compared. Subgroup analysis was performed to identify variables associated with complications and repeat ablations. In total, 13 823 patients (69% male) were included. The reported complication incidence was 3.6%. Patients treated with C-RF developed more cardiac tamponades (C-RF 0.8% vs. Ph-RF 0.3% vs. CB 0.3%, P ≤ 0.001) and vascular complications (C-RF 1.7% vs. Ph-RF 1.2% vs. CB 1.3%, P ≤ 0.001). Ph-RF was associated with fewer bleeding complications (C-RF: 1.0% vs. Ph-RF: 0.4% vs. CB: 0.7%, P = 0.020). Phrenic nerve palsy mainly occurred in patients treated with CB (C-RF: 0.1% vs. Ph-RF: 0.2% vs. CB: 1.5%, P ≤ 0.001). In total, 18.4% of patients were referred for repeat ablation within 1 year. Female sex, age, and CHA2DS2-VASc were independent risk factors for cardiac tamponade and bleeding complications, with an adjusted OR for female patients of 2.97 (95% CI 1.98-4.45) and 2.02 (95% CI 1.03-4.00) respectively.
Conclusion 
The reported complication rate during PVI was low. Patients treated with C-RF ablation were more likely to develop cardiac tamponades and vascular complications. Female sex was associated with more cardiac tamponade and bleeding complications.

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

Europace: 04 Feb 2021; 23:216-225
Mol D, Houterman S, Balt JC, Bhagwandien RE, ... de Groot JR, Netherlands Heart Registration Ablation Registration Committee
Europace: 04 Feb 2021; 23:216-225 | PMID: 33141152
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Impact:
Abstract

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

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

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

Europace: 04 Feb 2021; 23:298-304
Joosten IBT, van Lohuizen R, den Uijl DW, Evertz R, ... Faber CG, Vernooy K
Europace: 04 Feb 2021; 23:298-304 | PMID: 33150426
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Impact:
Abstract

Prediction of current and new development of atrial fibrillation on electrocardiogram with sinus rhythm in patients without structural heart disease.

Hirota N, Suzuki S, Arita T, Yagi N, ... Yajima J, Yamashita T
Background
Diagnosis of atrial fibrillation (AF) based on electrocardiogram (ECG) with sinus rhythm remains a major challenge. Obtaining a panoramic view with hundreds of automatically measured ECG parameters at sinus rhythm on the predictive capability for AF would be informative.
Methods
We used a single-center database of a specialist cardiovascular hospital (Shinken Database 2010-2017; n = 19,170). We analyzed 12,863 index ECGs with sinus rhythm after excluding those showing AF rhythm, other atrial tachyarrhythmia, pacing beat, or indeterminate axis, and those of patients with structural heart diseases. We used 438 automatically measured ECG parameters in the MUSE data management system. The predictive models were developed using random forest algorithm with the 10-fold cross-validation method.
Results
In 12,863 index ECGs with sinus rhythm, a predictive capability for current paroxysmal AF (n = 1131) by c-statistics was 0.99981 ± 0.00037 for training dataset and 0.91337 ± 0.00087 for testing dataset, respectively. Excluding AF at baseline (n = 11,732), a predictive capability for newly developed AF (n = 98) by c-statistics was 0.99973 ± 0.00086 for training dataset and 0.99160 ± 0.00038 for testing dataset, respectively. The distribution of parameter importance was mostly similar among P, QRS, and ST-T segment for both current and newly developed AF.
Conclusions
This study intended to provide panoramic information in relation between ECG parameters and AF. The parameter importance of ECG parameters for predicting AF was mostly similar in P, QRS, and ST-T segment in models for both current and future AF.

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

Int J Cardiol: 14 Mar 2021; 327:93-99
Hirota N, Suzuki S, Arita T, Yagi N, ... Yajima J, Yamashita T
Int J Cardiol: 14 Mar 2021; 327:93-99 | PMID: 33188796
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Impact:
Abstract

Real-world experience with implantable loop recorder monitoring to detect subclinical atrial fibrillation in patients with cryptogenic stroke: The value of p wave dispersion in predicting arrhythmia occurrence.

Marks D, Ho R, Then R, Weinstock JL, ... Ortman M, Russo AM
Purpose
We hypothesized patients implanted with ILRs for cryptogenic stroke in \"real life\" clinical practice will show an AF detection rate comparable to prior clinical studies, and that clinical or imaging features may help to identify those at higher risk of AF detection.
Methods
A retrospective chart review was conducted of all patients who presented with cryptogenic stroke and received an ILR at an academic medical center from 2015 to 2017 with an active inpatient stroke service. The electronic health record and remote monitoring were used to identify occurrence of AF.
Results
A total of 178 patients who received ILRs for cryptogenic stroke were included. Overall, after a thorough evaluation for other etiologies of stroke, 35 (19.6%) were found to have AF detected. Mean follow-up was 365 days with a median time to detection of 131 days. Advanced age (p = 0.001), diastolic dysfunction on echo (p = 0.03), as well as ECG findings of premature atrial contractions (PACs) and p wave dispersion (PWD) > 40 ms were found to be predictive of AF detection (p = 0.04, p < 0.001, respectively). On multiple regression analysis, the only independent predictor of AF detection was PWD > 40 ms.
Conclusion
After a thorough evaluation to exclude other etiologies for stroke, approximately 20% of patients of our cryptogenic stroke population were found to have AF with ILR surveillance. Advanced age, diastolic dysfunction, as well as ECG findings of PACs and increased PWD may help to predict those at higher risk of AF detection, while PWD was the only independent predictor. This has important clinical implications, as better prediction of AF may help identify those at highest risk and might subsequently aid in guiding therapy.

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

Int J Cardiol: 14 Mar 2021; 327:86-92
Marks D, Ho R, Then R, Weinstock JL, ... Ortman M, Russo AM
Int J Cardiol: 14 Mar 2021; 327:86-92 | PMID: 33186666
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Impact:
Abstract

Incidence, predictors of bleeding and prognosis of bleeding in anticoagulated nonagenarian patients with atrial fibrillation.

Domínguez-Erquicia P, Raposeiras-Roubín S, Abbu-Assi E, Cespón-Fernández M, ... Melendo-Viu M, Íñiguez-Romo A
Background
The prevalence of atrial fibrillation (AF) increases with age. The prescription of anticoagulation in very elderly patients is controversial and sometimes underused. Our objective is to report the incidence and predictors of major bleeding in anticoagulated nonagenarian patients with non valvular atrial fibrillation (NVAF).
Methods
We analyzed a large multicentre registry of anticoagulated nonagenarian patients diagnosed with NVAF from three health areas of Spain, between 2013 and 2017. Predictors of major bleeding were studied with a competing risk analysis and the impact of major bleeding with a time-dependent mortality analysis.
Results
The incidence rate of major bleeding was 5 per100 person-year (95% Confidence Interval [CI]: 4.59-6.35), similar in the group of patients with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOAC). In the VKAs group we found as predictors of major bleeding: previous admission for bleeding (sub-distribution hazard ratio [sHR] 3.25, 95% CI: 1.48-7.13), creatinine (sHR 1.38, 95% CI: 1.16-1.64,) and control out-of-range INR (sHR 1.90, 95% CI: 1.02-3.55). In DOAC group, male sex (sHR 1.92, 95% CI: 1.18-3.13) and the history of previous admission for bleeding (sHR 2.60, 95% CI 1.33-5.06) were found as a predictor. The HAS-BLED was not associated with major bleeding. Major bleeding was associated with increased mortality in both VKAs and DOAC groups without significant differences.
Conclusions
We found an incidence rate of major bleeding with relative low values, similar in those treated with VKAs and those treated with DOAC, with different predictors of major bleeding in each group. Major bleeding was associated with increased mortality, with no significant difference by oral anticoagulation therapy (OAT).

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 14 Mar 2021; 327:217-222
Domínguez-Erquicia P, Raposeiras-Roubín S, Abbu-Assi E, Cespón-Fernández M, ... Melendo-Viu M, Íñiguez-Romo A
Int J Cardiol: 14 Mar 2021; 327:217-222 | PMID: 33220362
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Impact:
Abstract

Quality indicators in the management of atrial fibrillation: the BALKAN-AF survey.

Kozieł M, Mihajlovic M, Nedeljkovic M, Pavlovic N, ... Potpara TS, BALKAN-AF Investigators
Background
The implementation of quality indicators in the atrial fibrillation (AF) care should be considered to improve quality of management and patient outcome.
Methods
In the post-hoc analysis of the BALKAN-AF dataset, we assessed concordance with quality indicators for AF management. Available domains for AF management [patient assessment (baseline), anticoagulation, rate control strategy, rhythm control strategy and risk factor management] were identified and assessed at baseline visit.
Results
Among 132 patients with a CHA2DS2-VASc score of 0 (men) or 1 (women), 75 (56.8%) were prescribed oral anticoagulation (OAC). Of 2539 patients with a CHA2DS2-VASc score ≥ 1 for men and ≥ 2 for women, 1890 (74.4%) were prescribed OAC. Among 1088 patients with permanent AF, 110 (10.1%) individuals were prescribed antiarrhythmic drugs (AADs). Of 1616 patients with structural heart disease, 37 (2.2%) were prescribed class IC AADs. Of 1624 patients with paroxysmal or persistent AF, 59 (3.6%) were offered catheter ablation. Among 2712 AF patients, 2121 (78.2%) had hypertension, 671 (24.7%) were obese, 53 (2.0%) had obstructive sleep apnoea, 110 (4.0%) had alcohol abuse and 340 (12.5%) were smokers.
Conclusions
In the BALKAN-AF cohort, the use of OAC for stroke prevention was poorly associated with patients stroke risk. The use of AADs in patients with permanent AF was low. The prescription of class IC AADs to patients with structural heart disease was infrequent. A large proportion of AF patients had their modifiable risk factors identified.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 19 Feb 2021; epub ahead of print
Kozieł M, Mihajlovic M, Nedeljkovic M, Pavlovic N, ... Potpara TS, BALKAN-AF Investigators
Int J Cardiol: 19 Feb 2021; epub ahead of print | PMID: 33621622
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Impact:
Abstract

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

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

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

Europace: 04 Feb 2021; 23:287-297
Marume K, Noguchi T, Kamakura T, Tateishi E, ... Ogawa H, Yasuda S
Europace: 04 Feb 2021; 23:287-297 | PMID: 33212485
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Impact:
Abstract

Randomized comparison of oesophageal protection with a temperature control device: results of the IMPACT study.

Leung LWM, Bajpai A, Zuberi Z, Li A, ... Hayat J, Gallagher MM
Aims 
Thermal injury to the oesophagus is an important cause of life-threatening complication after ablation for atrial fibrillation (AF). Thermal protection of the oesophageal lumen by infusing cold liquid reduces thermal injury to a limited extent. We tested the ability of a more powerful method of oesophageal temperature control to reduce the incidence of thermal injury.
Methods and results 
A single-centre, prospective, double-blinded randomized trial was used to investigate the ability of the ensoETM device to protect the oesophagus from thermal injury. This device was compared in a 1:1 randomization with a control group of standard practice utilizing a single-point temperature probe. In the protected group, the device maintained the luminal temperature at 4°C during radiofrequency (RF) ablation for AF under general anaesthesia. Endoscopic examination was performed at 7 days post-ablation and oesophageal injury was scored. The patient and the endoscopist were blinded to the randomization. We recruited 188 patients, of whom 120 underwent endoscopy. Thermal injury to the mucosa was significantly more common in the control group than in those receiving oesophageal protection (12/60 vs. 2/60; P = 0.008), with a trend toward reduction in gastroparesis (6/60 vs. 2/60, P = 0.27). There was no difference between groups in the duration of RF or in the force applied (P value range= 0.2-0.9). Procedure duration and fluoroscopy duration were similar (P = 0.97, P = 0.91, respectively).
Conclusion 
Thermal protection of the oesophagus significantly reduces ablation-related thermal injury compared with standard care. This method of oesophageal protection is safe and does not compromise the efficacy or efficiency of the ablation procedure.

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

Europace: 04 Feb 2021; 23:205-215
Leung LWM, Bajpai A, Zuberi Z, Li A, ... Hayat J, Gallagher MM
Europace: 04 Feb 2021; 23:205-215 | PMID: 33205201
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Impact:
Abstract

Left atrial appendage occlusion in atrial fibrillation patients with previous intracranial bleeding: A national multicenter study.

Casu G, D\'Angelo G, Ugo F, Ronco F, ... Montorfano M, Merella P
Background
Intracranial hemorrhage (ICH) represents the most serious complication of oral anticoagulant therapy (OAT) in patients with atrial fibrillation (AF), and AF patients with previous ICH are a challenge for clinicians. Left atrial appendage (LAA) occlusion has emerged as an alternative option for AF patients not suitable for OAT. Currently, few data are available on long term outcomes after LAA occlusion in this population. We evaluated the safety and efficacy of LAA occlusion in a cohort of patients with AF and previous ICH.
Methods
This is a multicenter, observational, retrospective study involving 5 LAA occlusion centers in Italy. It includes all consecutive patients (n = 120) with previous ICH who underwent LAA occlusion for nonvalvular AF and high thromboembolic risk. Procedural outcomes, post-procedural therapies and 12-months follow-up data were analyzed.
Results
The device was successfully implanted in 100% of cases, with a 6% of major peri-procedural complications. 59% had a prior ICH during OAT. The sample had a high risk of stroke (5.18%/year) and bleeding (6.62%/year). 30% were discharged on single and 54.2% on dual antiplatelet therapy. The expected annual risk for thromboembolism was 5.1%. Excluding periprocedural ischemic complications, the stroke annual rate was 1.8%. The expected annual risk of bleeding was 6.7%. The observed annual bleeding rate was 5.45%.
Conclusions
Percutaneous LAA occlusion is an effective option for AF patients and previous intracranial hemorrhage. After LAA occlusion, a single antiplatelet therapy strategy could be considered for patients with the highest risk of recurrent bleeding.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 31 Mar 2021; 328:75-80
Casu G, D'Angelo G, Ugo F, Ronco F, ... Montorfano M, Merella P
Int J Cardiol: 31 Mar 2021; 328:75-80 | PMID: 33245957
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Impact:
Abstract

Explainable artificial intelligence to detect atrial fibrillation using electrocardiogram.

Jo YY, Cho Y, Lee SY, Kwon JM, ... Park J, Oh BH
Introduction
Early detection and intervention of atrial fibrillation (AF) is a cornerstone for effective treatment and prevention of mortality. Diverse deep learning models (DLMs) have been developed, but they could not be applied in clinical practice owing to their lack of interpretability. We developed an explainable DLM to detect AF using ECG and validated its performance using diverse formats of ECG.
Methods
We conducted a retrospective study. The Sejong ECG dataset comprising 128,399 ECGs was used to develop and internally validated the explainable DLM. DLM was developed with two feature modules, which could describe the reason for DLM decisions. DLM was external validated using data from 21,837, 10,605, and 8528 ECGs from PTB-XL, Chapman, and PhysioNet non-restricted datasets, respectively. The predictor variables were digitally stored ECGs, and the endpoints were AFs.
Results
During internal and external validation of the DLM, the area under the receiver operating characteristic curves (AUCs) of the DLM using a 12‑lead ECG in detecting AF were 0.997-0.999. The AUCs of the DLM with VAE using a 6‑lead and single‑lead ECG were 0.990-0.999. The AUCs of explainability about features such as rhythm irregularity and absence of P-wave were 0.961-0.993 and 0.983-0.993, respectively.
Conclusions
Our DLM successfully detected AF using diverse ECGs and described the reason for this decision. The results indicated that an explainable artificial intelligence methodology could be adopted to the DLM using ECG and enhance the transparency of the DLM for its application in clinical practice.

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

Int J Cardiol: 31 Mar 2021; 328:104-110
Jo YY, Cho Y, Lee SY, Kwon JM, ... Park J, Oh BH
Int J Cardiol: 31 Mar 2021; 328:104-110 | PMID: 33271204
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Impact:
Abstract

Comparative data on left atrial appendage occlusion efficacy and clinical outcomes by age group in the Amplatzer™ Amulet™ Occluder Observational Study.

Freixa X, Schmidt B, Mazzone P, Berti S, ... Aminian A, Nielsen-Kudsk JE
Aims
Left atrial appendage occlusion (LAAO) may be considered for patients with non-valvular atrial fibrillation (NVAF) and a relative/formal contraindication to anticoagulation. This study aimed to summarize the impact of aging on LAAO outcomes at short and long-term follow-up.
Methods and results
We compared subjects aged <70, ≥70 and <80, and ≥80 years old in the prospective, multicentre Amplatzer™ Amulet™ Occluder Observational Study (Abbott, Plymouth, MN, USA). Serious adverse events (SAEs) were reported from implant through a 2-year post-LAAO visit and adjudicated by an independent clinical events committee. Overall, 1088 subjects were prospectively enrolled. There were 265 subjects (24.4%) <70 years old, 491 subjects (45.1%) ≥70 and <80 years old, and 332 subjects (30.5%) ≥80 years old, with the majority (≥80%) being contraindicated to anticoagulation. As expected, CHA2DS2-VASc and HAS-BLED Scores increased with age. Implant success was high (≥98.5%) across all groups, and the proportion of subjects with a procedure- or device-related SAE was similar between groups. At follow-up, the observed ischaemic stroke rate was not significantly different between groups, and corresponding risk reductions were 62, 56, and 85% when compared with predicted rates for subjects <70, ≥70 and <80, and ≥80 years old, respectively. Major bleeding and mortality rates increased with age, while the incidence of device-related thrombus tended to increase with age.
Conclusions
Despite the increased risk for ischaemic stroke with increasing age in AF patients, LAAO reduced the risk for ischaemic stroke compared with the predicted rate across all age groups without differences in procedural SAEs.

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

Europace: 04 Feb 2021; 23:238-246
Freixa X, Schmidt B, Mazzone P, Berti S, ... Aminian A, Nielsen-Kudsk JE
Europace: 04 Feb 2021; 23:238-246 | PMID: 33279979
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Impact:
Abstract

Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation according to the drug labelling and the EHRA Practical Guide.

Capiau A, De Backer T, Grymonprez M, Lahousse L, ... Mehuys E, Boussery K
Background
This study aimed to evaluate the prevalence of potential drug-drug interactions (DDIs) and the appropriateness of direct oral anticoagulant (DOAC) dosing according to both the Summary of Product Characteristics (SmPC) and the European Heart Rhythm Association (EHRA) Practical Guide in a \'real-world\' sample of non-valvular atrial fibrillation (NVAF) patients.
Methods and results
Data of a cross-sectional observational study in a primary care sample of 654 long-term DOAC users were used for this sub-analysis. A total of 262 potential DDIs were identified in 220 patients (33.6%). Pharmacodynamic DDIs were present in 163 patients (24.9%) and pharmacokinetic DDIs in 82 patients (12.5%). One-third of patients (33.8%) received reduced DOAC dose. According to the dosing recommendations in the SmPC, 81.7% of DOACs were dosed appropriately. According to the EHRA recommendations, 76.6% of DOACs were dosed appropriately. Dosing recommendations were consistent for 90.7% of patients, with both the SmPC and EHRA Practical Guide considering DOACs dosed appropriately in 74.5% of patients, overdosed in 7.8%, underdosed in 7.6% and contraindicated in 0.8%. However, for the remaining 9.3% dosing recommendations differed between SmPC and EHRA.
Conclusions
This \'real-world\' analysis of DOAC dosing demonstrated that in about one-third of NVAF patients potential DDIs were present. In 18.3% and 23.4% of patients, DOACs were dosed inappropriately according to the SmPC and EHRA Practical Guide respectively. In almost 10% of the study population dosing advice was inconsistent between both references. More research is needed to ensure appropriate DOAC dosing in this \'grey zone\' population.

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

Int J Cardiol: 31 Mar 2021; 328:97-103
Capiau A, De Backer T, Grymonprez M, Lahousse L, ... Mehuys E, Boussery K
Int J Cardiol: 31 Mar 2021; 328:97-103 | PMID: 33279589
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Impact:
Abstract

Efficacy and safety of left atrial appendage electrical isolation during catheter ablation of atrial fibrillation: an updated meta-analysis.

Romero J, Gabr M, Patel K, Briceno D, ... Natale A, Di Biase L
Aims
Left atrial appendage electrical isolation (LAAEI) has been shown to improve freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal atrial fibrillation (AF). The aim of this study is to investigate the long-term efficacy and safety outcomes of LAAEI in patients with non-paroxysmal AF undergoing catheter ablation.
Methods and results
A systematic review of Medline, Cochrane, and Embase was performed for clinical studies evaluating the benefit of LAAEI in non-paroxysmal AF. Nine studies with a total of 2336 patients were included (mean age: 65 ± 9 years, 63% male). All studies included patients with persistent AF, long-standing persistent AF, or both. At a mean follow-up of 40.5 months, patients who underwent LAAEI had significantly higher freedom from all-atrial arrhythmia recurrence than patients who underwent standard ablation alone [69.3% vs. 46.4%; risk ratio (RR) 0.54; 95% confidence interval (CI) 0.42-0.69; P < 0.0001]. A 46% relative risk reduction and 22.9% absolute risk reduction in atrial-arrhythmia recurrence was noted with LAAEI. Rates of cerebral thromboembolism were not significantly different between the two groups (LAAEI 3% vs. standard ablation 1.6%, respectively; RR 1.76; 95% CI 0.61-5.04; P = 0.29). Furthermore, there was no significant difference in the acute procedural complication rates between the two groups (LAAEI 4% vs. standard ablation 3%, respectively; RR 1.29; 95% CI 0.83-2.02; P = 0.26).
Conclusion
At long-term follow-up, LAAEI led to a significantly higher improvement in freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal AF, when compared to standard ablation alone. Importantly, this benefit was achieved without an increased risk of acute procedural complications or cerebral thromboembolic events.

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

Europace: 04 Feb 2021; 23:226-237
Romero J, Gabr M, Patel K, Briceno D, ... Natale A, Di Biase L
Europace: 04 Feb 2021; 23:226-237 | PMID: 33324978
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Impact:
Abstract

Optimized Implementation of cardiac resynchronization therapy - a call for action for referral and optimization of care.

Mullens W, Auricchio A, Martens P, Witte K, ... Ruschitzka F, Leclercq C
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heartfailure hospitalization rates and reduces all-cause mortality. Nevertheless, up to two-thirds ofeligible patients are not referred for CRT. Furthermore, post implantation follow-up is oftenfragmented and suboptimal, hampering the potential maximal treatment effect. This jointposition statement from three ESC Associations, HFA, EHRA and EACVI focuses onoptimized implementation of CRT. We offer theoretical and practical strategies to achievemore comprehensive CRT referral and post-procedural care by focusing on four actionabledomains; (I) overcoming CRT under-utilization, (II) better understanding of pre-implantcharacteristics, (III) abandoning the term \'non-response\' and replacing this by the concept ofdisease modification, and (IV) implementing a dedicated post-implant CRT care pathway.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 04 Feb 2021; epub ahead of print
Mullens W, Auricchio A, Martens P, Witte K, ... Ruschitzka F, Leclercq C
Europace: 04 Feb 2021; epub ahead of print | PMID: 33544835
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Impact:
Abstract

The interpretation of CHA2DS2-VASc score components in clinical practice: a joint survey by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, the EHRA Young Electrophysiologists, the Association of Cardiovascular Nursing and Allied Professionals, and the European Society of Cardiology Council on Stroke.

Zhang J, Lenarczyk R, Marin F, Malaczynska-Rajpold K, ... Lip GYH, Potpara TS
This European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, EHRA Young Electrophysiologists, Association of Cardiovascular Nursing and Allied Professionals, and European Society of Cardiology (ESC) Council on Stroke joint survey aimed to assess the interpretation of the CHA2DS2-VASc score components and preferred resources for calculating the score. Of 439 respondents, most were general cardiologists (46.7%) or electrophysiologists (EPs) (42.1%). The overall adherence to the ESC-defined scoring criteria was good. Most variation was observed in the interpretation of the significance of left ventricular ejection fraction and brain natriuretic peptide in the scoring for the \'C\' component, as well as the \'one-off high reading of blood pressure\' to score on the \'H\' component. Greater confidence was expressed in scoring the \'H\' component (72.3%) compared with the \'C\' (46.2%) and \'V\' (45.9%) components. Respondents mainly relied on their recall for the scoring of CHA2DS2-VASc score (64.2%). The three most favoured referencing resources varied among different professionals, with pharmacists and physicians relying mainly on memory or web/mobile app, whereas nurses favoured using a web/mobile app followed by memory or guidelines/protocol. In conclusion, this survey revealed overall good adherence to the correct definition of each component in scoring of the \'C\', \'H\', and \'V\' elements of the CHA2DS2-VASc score, although the variation in their interpretations warrants further clarifications. The preferred referencing resources to calculate the score varied among different healthcare professionals. Guideline education to healthcare professionals and updated and unified online/mobile scoring tools are suggested to improve the accuracy in scoring the CHA2DS2-VASc score.

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

Europace: 04 Feb 2021; 23:314-322
Zhang J, Lenarczyk R, Marin F, Malaczynska-Rajpold K, ... Lip GYH, Potpara TS
Europace: 04 Feb 2021; 23:314-322 | PMID: 33554259
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Impact:
Abstract

Local catheter impedance drop during pulmonary vein isolation predicts acute conduction block in patients with paroxysmal atrial fibrillation: initial results of the LOCALIZE clinical trial.

Das M, Luik A, Shepherd E, Sulkin M, ... Ramos P, García-Bolao I
Aims
Radiofrequency ablation creates irreversible cardiac damage through resistive heating and this temperature change results in a generator impedance drop. Evaluation of a novel local impedance (LI) technology measured exclusively at the tip of the ablation catheter found that larger LI drops were indicative of more effective lesion formation. We aimed to evaluate whether LI drop is associated with conduction block in patients with paroxysmal atrial fibrillation (AF) undergoing pulmonary vein isolation (PVI).
Methods and results
Sixty patients underwent LI-blinded de novo PVI using a point-by-point ablation workflow. Pulmonary vein rings were divided into 16 anatomical segments. After a 20-min waiting period, gaps were identified on electroanatomic maps. Median LI drop within segments with inter-lesion distance ≤6 mm was calculated offline. The diagnostic accuracy of LI drop for predicting segment block was assessed using receiver operating characteristic analysis. For segments with inter-lesion distance ≤6 mm, acutely blocked segments had a significantly larger LI drop [19.8 (14.1-27.1) Ω] compared with segments with gaps [10.6 (7.8-14.7) Ω, P < 0.001). In view of left atrial wall thickness differences, the association between LI drop and block was further evaluated for anterior/roof and posterior/inferior segments. The optimal LI cut-off value for anterior/roof segments was 16.1 Ω (positive predictive value for block: 96.3%) and for posterior/inferior segments was 12.3 Ω (positive predictive value for block: 98.1%) where inter-lesion distances were ≤6 mm.
Conclusion
The magnitude of LI drop was predictive of acute PVI segment conduction block in patients with paroxysmal AF. The thinner posterior wall required smaller LI drops for block compared with the thicker anterior wall.

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

Europace: 06 Feb 2021; epub ahead of print
Das M, Luik A, Shepherd E, Sulkin M, ... Ramos P, García-Bolao I
Europace: 06 Feb 2021; epub ahead of print | PMID: 33550380
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Abstract

Late-gadolinium enhancement properties associated with atrial fibrillation rotors in patients with persistent atrial fibrillation.

Nakamura T, Kiuchi K, Fukuzawa K, Takami M, ... Ashihara T, Hirata KI
Background
A computational model demonstrated that atrial fibrillation (AF) rotors could be distributed in patchy late-gadolinium enhancement (LGE) areas and play an important role in AF drivers. However, this was not validated in humans.
Objective
The purpose of this study was to evaluate the LGE properties of AF rotors in patients with persistent AF.
Methods
A total of 287 segments in 15 patients with persistent AF (long-standing persistent AF in 9 patients) that underwent AF ablation were assessed. Non-passively activated areas (NPAs), where rotational activation (AF rotor) was frequently observed, were detected by the novel real-time phase mapping (ExTRa Mapping). The properties of the LGE areas were assessed using the LGE heterogeneity and the density which was evaluated by the entropy (LGE-entropy) and the volume ratio of the enhancement voxel (LGE-volume ratio), respectively.
Results
NPAs were found in 61 (21%) of 287 segments and were mostly found around the pulmonary vein antrum. A receiver operating characteristic curve analysis yielded an optimal cutoff value of 5.7% and 10% for the LGE-entropy and LGE-volume ratio, respectively. The incidence of NPAs was significantly higher at segments with an LGE-entropy of >5.7 and LGE-volume ratio of >10% than at the other segments (38 [30%] of 126 vs. 23 [14%] of 161 segments; p = .001). No NPAs were found at segments with an LGE-volume ratio of >50% regardless of the LGE-entropy. Of five patients with AF recurrence, NPAs outside the PV antrum were not ablated in three patients and the remaining NPAs were ablated, but their LGE-entropy and LGE-volume ratio were low.
Conclusion
AF rotors are mostly distributed in relatively weak and much more heterogenous LGE areas.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 07 Feb 2021; epub ahead of print
Nakamura T, Kiuchi K, Fukuzawa K, Takami M, ... Ashihara T, Hirata KI
J Cardiovasc Electrophysiol: 07 Feb 2021; epub ahead of print | PMID: 33556994
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Abstract

Protection of the esophagus during catheter ablation of atrial fibrillation.

Houmsse M, Daoud EG
Esophageal injury still occurs with high frequency during ablation of atrial fibrillation (AF). The purpose of this study is to provide a review of methods to protect the esophagus from injury during AF ablation. Despite advances in imaging and ablation, the potential risk of esophageal injury during AF ablation remains an important concern with a high occurrence of esophageal injury (≈15%). There have been numerous studies evaluating varied techniques for esophageal protection including active cooling and displacement of the esophagus. These techniques are reviewed in this manuscript as well as the role of esophageal protection in managing patients undergoing AF ablation procedure.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 07 Feb 2021; epub ahead of print
Houmsse M, Daoud EG
J Cardiovasc Electrophysiol: 07 Feb 2021; epub ahead of print | PMID: 33556991
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Abstract

Deep learning and the electrocardiogram: review of the current state-of-the-art.

Somani S, Russak AJ, Richter F, Zhao S, ... Argulian E, Glicksberg BS
In the recent decade, deep learning, a subset of artificial intelligence and machine learning, has been used to identify patterns in big healthcare datasets for disease phenotyping, event predictions, and complex decision making. Public datasets for electrocardiograms (ECGs) have existed since the 1980s and have been used for very specific tasks in cardiology, such as arrhythmia, ischemia, and cardiomyopathy detection. Recently, private institutions have begun curating large ECG databases that are orders of magnitude larger than the public databases for ingestion by deep learning models. These efforts have demonstrated not only improved performance and generalizability in these aforementioned tasks but also application to novel clinical scenarios. This review focuses on orienting the clinician towards fundamental tenets of deep learning, state-of-the-art prior to its use for ECG analysis, and current applications of deep learning on ECGs, as well as their limitations and future areas of improvement.

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

Europace: 09 Feb 2021; epub ahead of print
Somani S, Russak AJ, Richter F, Zhao S, ... Argulian E, Glicksberg BS
Europace: 09 Feb 2021; epub ahead of print | PMID: 33564873
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Abstract

Age-related tilt test responses in patients with suspected reflex syncope.

Rivasi G, Torabi P, Secco G, Ungar A, ... Brignole M, Fedorowski A
Aims
Tilt testing (TT) is recognized to be a valuable contribution to the diagnosis and the pathophysiology of vasovagal syncope (VVS). This study aimed to assess the influence of age on TT responses by examination of a large patient cohort.
Methods and results
Retrospective data from three experienced European Syncope Units were merged to include 5236 patients investigated for suspected VVS by the Italian TT protocol. Tilt testing-positivity rates and haemodynamics were analysed across age-decade subgroups. Of 5236 investigated patients, 3129 (60%) had a positive TT. Cardioinhibitory responses accounted for 16.5% of positive tests and were more common in younger patients, decreasing from the age of 50-59 years. Vasodepressor (VD) responses accounted for 24.4% of positive tests and prevailed in older patients, starting from the age of 50-59. Mixed responses (59.1% of cases) declined slightly with increasing age. Overall, TT positivity showed a similar age-related trend (P = 0.0001) and was significantly related to baseline systolic blood pressure (P < 0.001). Tilt testing was positive during passive phase in 18% and during nitroglycerine (TNG)-potentiated phase in 82% of cases. Positivity rate of passive phase declined with age (P = 0.001), whereas positivity rate during TNG remained quite stable. The prevalence of cardioinhibitory and VD responses was similar during passive and TNG-potentiated TT, when age-adjusted.
Conclusions
Age significantly impacts the haemodynamic pattern of TT responses, starting from the age of 50. Conversely, TT phase-passive or TNG-potentiated-does not significantly influence the type of response, when age-adjusted. Vagal hyperactivity dominates in younger patients, older patients show tendency to vasodepression.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Europace: 09 Feb 2021; epub ahead of print
Rivasi G, Torabi P, Secco G, Ungar A, ... Brignole M, Fedorowski A
Europace: 09 Feb 2021; epub ahead of print | PMID: 33564843
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