Topic: Electrophysiology

Abstract

Mortality in Patients With Atrial Fibrillation Receiving Nonrecommended Doses of Direct Oral Anticoagulants.

Camm AJ, Cools F, Virdone S, Bassand JP, ... Kakkar AK,
Background
The recommended doses for direct oral anticoagulants (DOACs) to prevent stroke and systemic embolism (SE) in patients with atrial fibrillation (AF) are described in specific regulatory authority approvals.
Objectives
The impact of DOAC dosing, according to the recommended guidance on all-cause mortality, stroke/SE, and major bleeding, was assessed at 2-year follow-up in patients with newly diagnosed AF.
Methods
Of a total of 34,926 patients enrolled (2013 to 2016) in the prospective GARFIELD-AF (Global Anticoagulant Registry in the FIELD-AF), 10,426 patients received a DOAC.
Results
The majority of patients (72.9%) received recommended dosing, 23.2% were underdosed, and 3.8% were overdosed. Nonrecommended dosing (underdosage and overdosage combined) compared with recommended dosing was associated with a higher risk of all-cause mortality (hazard ratio [HR]: 1.24; 95% confidence interval [CI]: 1.04 to 1.48); HR: 1.25 (95% CI: 1.04 to 1.50) for underdosing, and HR: 1.19 (95% CI: 0.83 to 1.71) for overdosing. The excess deaths were cardiovascular including heart failure and myocardial infarction. The risks of stroke/SE and major bleeding were not significantly different irrespective of the level of dosing, although underdosed patients had a significantly lower risk of bleeding. A nonsignificant trend to higher risks of stroke/SE (HR: 1.51; 95% CI: 0.79 to 2.91) and major bleeding (HR: 1.29; 95% CI: 0.59 to 2.78) was observed in patients with overdosing.
Conclusions
In GARFIELD-AF, most patients received the recommended DOAC doses according to country-specific guidelines. Prescription of nonrecommended doses was associated with an increased risk of death, mostly cardiovascular death, compared with patients on recommended doses, after adjusting for baseline factors. (Global Anticoagulant Registry in the Field-AF [GARFIELD-AF]; NCT01090362).

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

J Am Coll Cardiol: 21 Sep 2020; 76:1425-1436
Camm AJ, Cools F, Virdone S, Bassand JP, ... Kakkar AK,
J Am Coll Cardiol: 21 Sep 2020; 76:1425-1436 | PMID: 32943160
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Abstract

Angiotensin-converting enzyme 2 (ACE2) levels in relation to risk factors for COVID-19 in two large cohorts of patients with atrial fibrillation.

Wallentin L, Lindbäck J, Eriksson N, Hijazi Z, ... Oldgren J, Siegbahn A
Aims
The global COVID-19 pandemic is caused by the SARS-CoV-2 virus entering human cells using angiotensin-converting enzyme 2 (ACE2) as a cell surface receptor. ACE2 is shed to the circulation, and a higher plasma level of soluble ACE2 (sACE2) might reflect a higher cellular expression of ACE2. The present study explored the associations between sACE2 and clinical factors, cardiovascular biomarkers, and genetic variability.
Methods and results
Plasma and DNA samples were obtained from two international cohorts of elderly patients with atrial fibrillation (n = 3999 and n = 1088). The sACE2 protein level was measured by the Olink Proteomics® Multiplex CVD II96 × 96 panel. Levels of the biomarkers high-sensitive cardiac troponin T (hs-cTnT), N-terminal probrain natriuretic peptide (NT-proBNP), growth differentiation factor 15 (GDF-15), C-reactive protein, interleukin-6, D-dimer, and cystatin-C were determined by immunoassays. Genome-wide association studies were performed by Illumina chips. Higher levels of sACE2 were statistically significantly associated with male sex, cardiovascular disease, diabetes, and older age. The sACE2 level was most strongly associated with the levels of GDF-15, NT-proBNP, and hs-cTnT. When adjusting for these biomarkers, only male sex remained associated with sACE2. We found no statistically significant genetic regulation of the sACE2 level.
Conclusions
Male sex and clinical or biomarker indicators of biological ageing, cardiovascular disease, and diabetes are associated with higher sACE2 levels. The levels of GDF-15 and NT-proBNP, which are associated both with the sACE2 level and a higher risk for mortality and cardiovascular disease, might contribute to better identification of risk for severe COVID-19 infection.

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

Eur Heart J: 26 Sep 2020; epub ahead of print
Wallentin L, Lindbäck J, Eriksson N, Hijazi Z, ... Oldgren J, Siegbahn A
Eur Heart J: 26 Sep 2020; epub ahead of print | PMID: 32984892
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Abstract

Less dementia after catheter ablation for atrial fibrillation: a nationwide cohort study.

Kim D, Yang PS, Sung JH, Jang E, ... Lip GYH, Joung B
Aims
Accumulating evidence shows that atrial fibrillation (AF) is associated with an increased risk of dementia. Catheter ablation for AF prolongs the duration of sinus rhythm, thereby improving the quality of life. We investigated the association of catheter ablation for AF with the occurrence of dementia.
Methods and results
Using the Korean National Health Insurance Service database, among 194 928 adults with AF treated with ablation or medical therapy (antiarrhythmic or rate control drugs) between 1 January 2005 and 31 December 2015, we studied 9119 patients undergoing ablation and 17 978 patients managed with medical therapy. The time-at-risk was counted from the first medical therapy, and ablation was analysed as a time-varying exposure. Propensity score-matching was used to correct for differences between the groups. During a median follow-up of 52 months, compared with patients with medical therapy, ablated patients showed lower incidence and risk of overall dementia (8.1 and 5.6 per 1000 person-years, respectively; hazard ratio 0.73, 95% confidence interval 0.58-0.93). The associations between ablation and dementia risk were consistently observed after additionally censoring for incident stroke (hazard ratio 0.76, 95% confidence interval 0.61-0.95) and more pronounced in cases of ablation success whereas no significant differences observed in cases of ablation failure. Ablation was associated with lower risks of dementia subtypes including Alzheimer\'s disease and vascular dementia.
Conclusion
In this nationwide cohort of AF patients treated with catheter ablation or medical therapy, ablation was associated with decreased dementia risk. This relationship was evident after censoring for stroke and adjusting for clinical confounders.

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

Eur Heart J: 05 Oct 2020; epub ahead of print
Kim D, Yang PS, Sung JH, Jang E, ... Lip GYH, Joung B
Eur Heart J: 05 Oct 2020; epub ahead of print | PMID: 33022705
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Abstract

Heart Failure and Atrial Fibrillation Modify the Associations of Nocturnal Blood Pressure Dipping Pattern With Mortality in Hemodialysis Patients.

Mayer CC, Schmaderer C, Loutradis C, Matschkal J, ... Wassertheurer S, Sarafidis PA

Heart failure (HF), hypertension, and abnormal nocturnal blood pressure dipping are highly prevalent in hemodialysis patients. Atrial fibrillation (AF) and HF might be important mediators for the association of abnormal dipping patterns with worse prognosis. Thus, the aim of this study is to investigate the association of dipping with mortality in hemodialysis patients and to assess the influence of AF and HF. In total, 525 hemodialysis patients underwent 24-hour ambulatory blood pressure monitoring. All-cause and cardiovascular mortality served as end points. Patients were categorized according to their systolic dipping pattern (dipper, nondipper, and reverse dipper). Cox regression analysis was performed to determine the association between dipping pattern and study end points with dipping as reference. Subgroup analysis was performed for patients with and without AF or HF. In total, 185 patients with AF or HF and 340 patients without AF or HF were included. During a median follow-up of 37.8 months, 177 patients died; 81 from cardiovascular causes. Nondipping and reverse dipping were significantly associated with all-cause mortality in the whole cohort (nondipper: hazard ratio, 1.95 [1.22-3.14]; =0.006; reverse dipper: hazard ratio, 2.31 [1.42-3.76]; <0.001) and in patients without AF or HF (nondipper: hazard ratio, 2.78 [1.16-6.66]; =0.02; reverse dipper: hazard ratio, 4.48 [1.87-10.71]; <0.001) but not in patients with AF or HF. For cardiovascular mortality, associations were again significant in patients without AF or HF and in the whole cohort. The observed associations remained significant after adjustment for possible confounders. This study provides well-powered evidence for the association between abnormal dipping patterns and mortality in hemodialysis patients and suggests that HF or AF modifies this association.



Hypertension: 29 Sep 2020; 76:1231-1239
Mayer CC, Schmaderer C, Loutradis C, Matschkal J, ... Wassertheurer S, Sarafidis PA
Hypertension: 29 Sep 2020; 76:1231-1239 | PMID: 32862707
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Abstract

Genetics of height and risk of atrial fibrillation: A Mendelian randomization study.

Levin MG, Judy R, Gill D, Vujkovic M, ... Voight BF, Damrauer SM
Background
Observational studies have identified height as a strong risk factor for atrial fibrillation, but this finding may be limited by residual confounding. We aimed to examine genetic variation in height within the Mendelian randomization (MR) framework to determine whether height has a causal effect on risk of atrial fibrillation.
Methods and findings
In summary-level analyses, MR was performed using summary statistics from genome-wide association studies of height (GIANT/UK Biobank; 693,529 individuals) and atrial fibrillation (AFGen; 65,446 cases and 522,744 controls), finding that each 1-SD increase in genetically predicted height increased the odds of atrial fibrillation (odds ratio [OR] 1.34; 95% CI 1.29 to 1.40; p = 5 × 10-42). This result remained consistent in sensitivity analyses with MR methods that make different assumptions about the presence of pleiotropy, and when accounting for the effects of traditional cardiovascular risk factors on atrial fibrillation. Individual-level phenome-wide association studies of height and a height genetic risk score were performed among 6,567 European-ancestry participants of the Penn Medicine Biobank (median age at enrollment 63 years, interquartile range 55-72; 38% female; recruitment 2008-2015), confirming prior observational associations between height and atrial fibrillation. Individual-level MR confirmed that each 1-SD increase in height increased the odds of atrial fibrillation, including adjustment for clinical and echocardiographic confounders (OR 1.89; 95% CI 1.50 to 2.40; p = 0.007). The main limitations of this study include potential bias from pleiotropic effects of genetic variants, and lack of generalizability of individual-level findings to non-European populations.
Conclusions
In this study, we observed evidence that height is likely a positive causal risk factor for atrial fibrillation. Further study is needed to determine whether risk prediction tools including height or anthropometric risk factors can be used to improve screening and primary prevention of atrial fibrillation, and whether biological pathways involved in height may offer new targets for treatment of atrial fibrillation.



PLoS Med: 29 Sep 2020; 17:e1003288
Levin MG, Judy R, Gill D, Vujkovic M, ... Voight BF, Damrauer SM
PLoS Med: 29 Sep 2020; 17:e1003288 | PMID: 33031386
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Abstract

Atrial fibrillation and the prothrombotic state: revisiting Virchow\'s triad in 2020.

Ding WY, Gupta D, Lip GYH

Atrial fibrillation (AF) is characterised by an increased risk of pathological thrombus formation due to a disruption of physiological haemostatic mechanisms that are better understood by reference to Virchow\'s triad of \'abnormal blood constituents\', \'vessel wall abnormalities\' and \'abnormal blood flow\'. First, there is increased activation of the coagulation cascade, platelet reactivity and impaired fibrinolysis as a result of AF per se, and these processes are amplified with pre-existing comorbidities. Several prothrombotic biomarkers including platelet factor 4, von Willebrand factor, fibrinogen, β-thromboglobulin and D-dimer have been implicated in this process. Second, structural changes such as atrial fibrosis and endothelial dysfunction are linked to the development of AF which promote further atrial remodelling, thereby providing a suitable platform for clot formation and subsequent embolisation. Third, these factors are compounded by the presence of reduced blood flow secondary to dilatation of cardiac chambers and loss of atrial systole which have been confirmed using various imaging techniques. Overall, an improved understanding of the various factors involved in thrombus formation will allow better clinical risk stratification and targeted therapies in AF.

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

Heart: 29 Sep 2020; 106:1463-1468
Ding WY, Gupta D, Lip GYH
Heart: 29 Sep 2020; 106:1463-1468 | PMID: 32675218
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Abstract

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

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



Stroke: 07 Oct 2020:STROKEAHA120029959; epub ahead of print
Zhou E, Lord A, Boehme A, Henninger N, ... Elkind MSV, Yaghi S
Stroke: 07 Oct 2020:STROKEAHA120029959; epub ahead of print | PMID: 33028172
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Abstract

Association of household income and adverse outcomes in patients with atrial fibrillation.

LaRosa AR, Claxton J, O\'Neal WT, Lutsey PL, ... Alonso A, Magnani JW
Background
Social determinants of health are relevant to cardiovascular outcomes but have had limited examination in atrial fibrillation (AF).
Objectives
The purpose of this study was to examine the association of annual household income and cardiovascular outcomes in individuals with AF.
Methods
We analysed administrative claims for individuals with AF from 2009 to 2015 captured by a health claims database. We categorised estimates of annual household income as <$40 000; $40-$59 999; $60-$74 999; $75-$99 999; and ≥$100 000. Covariates included demographics, education, cardiovascular disease risk factors, comorbid conditions and anticoagulation. We examined event rates by income category and in multivariable-adjusted models in reference to the highest income category (≥$100 000).
Results
Our analysis included 336 736 individuals (age 72.7±11.9 years; 44.5% women; 82.6% white, 8.4% black, 7.0% Hispanic and 2.1% Asian) with AF followed for median (25th and 75th percentile) of 1.5 (95% CI 0.6 to 3.0) years. We observed an inverse association between income and heart failure and myocardial infarction (MI) with evidence of progressive risk across decreased income categories. Individuals with household income <$40 000 had the greatest risk for heart failure (HR 1.17; 95% CI 1.05 to 1.30) and MI (HR 1.18; 95% CI 0.98 to 1.41) compared with those with income ≥$100 000.
Conclusions
We identified an association between lower household income and adverse outcomes in a large cohort of individuals with AF. Our findings support consideration of income in the evaluation of cardiovascular risk in individuals with AF.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Oct 2020; 106:1679-1685
LaRosa AR, Claxton J, O'Neal WT, Lutsey PL, ... Alonso A, Magnani JW
Heart: 30 Oct 2020; 106:1679-1685 | PMID: 32144188
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Abstract

Changes in quality of life, cognition and functional status following catheter ablation of atrial fibrillation.

Piccini JP, Todd DM, Massaro T, Lougee A, ... Di Biase L, Kirchhof P
Objective
To investigate changes in quality of life (QoL), cognition and functional status according to arrhythmia recurrence after atrial fibrillation (AF) ablation.
Methods
We compared QoL, cognition and functional status in patients with recurrent atrial tachycardia (AT)/AF versus those without recurrent AT/AF in the AXAFA-AFNET 5 clinical trial. We also sought to identify factors associated with improvement in QoL and functional status following AF ablation by overall change scores with and without analysis of covariance (ANCOVA).
Results
Among 518 patients who underwent AF ablation, 154 (29.7%) experienced recurrent AT/AF at 3 months. Patients with recurrent AT/AF had higher mean CHADS-VASc scores (2.8 vs 2.3, p<0.001) and more persistent forms of AF (51 vs 39%, p=0.012). Median changes in the SF-12 physical (3 (25th, 75th: -1, 8) vs 1 (-5, 8), p=0.026) and mental scores (2 (-3, 9) vs 0 (-4, 5), p=0.004), EQ-5D (0 (0,2) vs 0 (-0.1, 0.1), p=0.027) and Karnofsky functional status scores (10 (0, 10) vs 0 (0, 10), p=0.001) were more favourable in patients without recurrent AT/AF. In the overall cohort, the proportion with at least mild cognitive impairment (Montreal Cognitive Assessment <26) declined from 30.3% (n=157) at baseline to 21.8% (n=113) at follow-up. ANCOVA identified greater improvement in Karnofsky functional status (p<0.001) but not SF-12 physical (p=0.238) or mental scores (p=0.065) in those without recurrent AT/AF compared with patients with recurrent AT/AF.
Conclusions
Patients without recurrent AT/AF appear to experience greater improvement in functional status but similar QoL as those with recurrent AT/AF after AF ablation.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

Heart: 11 Oct 2020; epub ahead of print
Piccini JP, Todd DM, Massaro T, Lougee A, ... Di Biase L, Kirchhof P
Heart: 11 Oct 2020; epub ahead of print | PMID: 33046527
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Abstract

Cessation of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation.

Middeldorp ME, Gupta A, Elliott A, Kadhim K, ... Lau D, Sanders P
Objective
To characterise the rate, causes and predictors of cessation of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF).
Patients and methods
Consecutive patients with AF with a long-term anticoagulation indication treated with NOACs (dabigatran, apixaban and rivaroxaban) in our centre from September 2010 through December 2016 were included. Prospectively collected data with baseline characteristics, causes of cessation, mean duration-to-cessation and predictors of cessation were analysed.
Results
The study comprised 1415 consecutive patients with AF, of whom 439 had a CHADS-VASc≥1 and were on a NOAC. Mean age was 71.9±8.7 years and 37% were females. Over a median follow-up of 3.6 years (IQR=2.7-5.3), 147 (33.5%) patients ceased their index-NOAC (113 switched to a different form of OAC), at a rate of 8.8 per 100 patient-years. Serious adverse events warranting NOAC cessation occurred in 28 patients (6.4%) at a rate of 1.6 events per 100 patient-years. The mean duration-to-cessation was 4.9 years (95% CI 4.6 to 5.1) and apixaban had the longest duration-to-cessation with (5.1, 95% CI 4.8 to 5.4) years, compared with dabigatran (4.6, 95% CI 4.2 to 4.9) and rivaroxaban (4.5, 95% CI 3.9 to 5.1), pairwise log-rank p=0.002 and 0.025, respectively. In multivariable analyses, age was an independent predictor of index-NOAC cessation (HR 1.03, 95% CI 1.01 to 1.05; p=0.006). Female gender (HR 2.2, 95% CI 1.04 to 4.64; p=0.04) independently predicted serious adverse events.
Conclusion
In this \'real world\' cohort, NOAC use is safe and well-tolerated when prescribed in an integrated care clinic. Whether apixaban is better tolerated compared with other NOACs warrants further study.

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

Heart: 15 Oct 2020; epub ahead of print
Middeldorp ME, Gupta A, Elliott A, Kadhim K, ... Lau D, Sanders P
Heart: 15 Oct 2020; epub ahead of print | PMID: 33067328
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Abstract

Atrial Myocyte NLRP3/CaMKII Nexus Forms a Substrate for Postoperative Atrial Fibrillation.

Heijman J, Muna AP, Veleva T, Molina CE, ... Wehrens XHT, Dobrev D
Rationale
Postoperative atrial fibrillation (POAF) is a common and troublesome complication of cardiac surgery. POAF is generally believed to occur when postoperative triggers act on a preexisting vulnerable substrate, but the underlying cellular and molecular mechanisms are largely unknown.
Objective
To identify cellular POAF mechanisms in right atrial samples from patients without a history of atrial fibrillation undergoing open-heart surgery.
Methods and results
Multicellular action potentials, membrane ion-currents (perforated patch-clamp), or simultaneous membrane-current (ruptured patch-clamp) and [Ca]-recordings in atrial cardiomyocytes, along with protein-expression levels in tissue homogenates or cardiomyocytes, were assessed in 265 atrial samples from patients without or with POAF. No indices of electrical, profibrotic, or connexin remodeling were noted in POAF, but Ca-transient amplitude was smaller, although spontaneous sarcoplasmic reticulum (SR) Ca-release events and L-type Ca-current alternans occurred more frequently. CaMKII (Ca/calmodulin-dependent protein kinase-II) protein-expression, CaMKII-dependent phosphorylation of the cardiac RyR2 (ryanodine-receptor channel type-2), and RyR2 single-channel open-probability were significantly increased in POAF. SR Ca-content was unchanged in POAF despite greater SR Ca-leak, with a trend towards increased SR Ca-ATPase activity. Patients with POAF also showed stronger expression of activated components of the NLRP3 (NACHT, LRR, and PYD domains-containing protein-3)-inflammasome system in atrial whole-tissue homogenates and cardiomyocytes. Acute application of interleukin-1β caused NLRP3-signaling activation and CaMKII-dependent RyR2/phospholamban hyperphosphorylation in an immortalized mouse atrial cardiomyocyte cell-line (HL-1-cardiomyocytes) and enhanced spontaneous SR Ca-release events in both POAF cardiomyocytes and HL-1-cardiomyocytes. Computational modeling showed that RyR2 dysfunction and increased SR Ca-uptake are sufficient to reproduce the Ca-handling phenotype and indicated an increased risk of proarrhythmic delayed afterdepolarizations in POAF subjects in response to interleukin-1β.
Conclusions
Preexisting Ca-handling abnormalities and activation of NLRP3-inflammasome/CaMKII signaling are evident in atrial cardiomyocytes from patients who subsequently develop POAF. These molecular substrates sensitize cardiomyocytes to spontaneous Ca-releases and arrhythmogenic afterdepolarizations, particularly upon exposure to inflammatory mediators. Our data reveal a potential cellular and molecular substrate for this important clinical problem.



Circ Res: 24 Sep 2020; 127:1036-1055
Heijman J, Muna AP, Veleva T, Molina CE, ... Wehrens XHT, Dobrev D
Circ Res: 24 Sep 2020; 127:1036-1055 | PMID: 32762493
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Abstract

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

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



J Hypertens: 05 Oct 2020; epub ahead of print
Matsumoto K, Jin Z, Homma S, Elkind MSV, ... Sacco RL, Di Tullio MR
J Hypertens: 05 Oct 2020; epub ahead of print | PMID: 33031165
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Abstract

A Superior-type Fast-slow Atrioventricular Nodal Reentrant Tachycardia Phenotype Mimicking the Slow-fast Type.

Kaneko Y, Nakajima T, Tamura S, Hasegawa H, ... Iizuka T, Kurabayashi M

- Superior-type fast-slow (sup-F/S-) atrioventricular nodal reentrant tachycardia (AVNRT) is a rare AVNRT variant using a superior (sup-) slow pathway (SP) as the retrograde limb. Its intracardiac appearance, characterized by a short atrio-His (AH) interval and the earliest site of atrial activation in the His-bundle (HB; EAA-HB), is an initial indicator for making a diagnosis.- Among 22 consecutive patients with sup-F/S-AVNRT, three (age, 68-81 years) patients had an apparent but not typical slow-fast (S/F) AVNRT characterized by a long AH interval and EAA-HB (tachy-long-AH).- The diagnosis of sup-F/S-AVNRT was based on the standard criteria in two patients and on the occurrence of Wenckebach-type AV block during tachycardia, which was attributable to a block at the lower common pathway (LCP) below the circuit of the AVNRT, detected owing to the LCP potentials, in one patient. As with the typical S/F-AVNRT, tachy-long-AH was induced after a jump in the AH interval. In contrast to typical S/F-AVNRT, fluctuation in the ventriculoatrial interval was observed during the tachy-long-AH. Ventricular overdrive pacing was unable to entrain or terminate the tachy-long-AH. Moreover, the tachy-long-AH reciprocally transited to/from sup-F/S-AVNRT spontaneously or was triggered by ventricular contractions while the atrial cycle length and EAA remained unchanged. Both tachycardias were cured by ablation at a single site in the right-side parahisian region of two patients and the non-coronary aortic cusp of one patient. Collectively, the essential circuit of both tachycardias was identical, and the tachy-long-AH was diagnosed as another phenotype of sup-F/S-AVNRT accompanied by sustained antegrade conduction via another bystander SP breaking through the HB owing to the repetitive antegrade block at the LCP, thus representing a long AH interval during the ongoing sup-F/S-AVNRT.- An unknown sup-F/S-AVNRT phenotype exists that apparently mimics the typical S/F-AVNRT and is also an unknown subtype of apparent S/F-AVNRT.



Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print
Kaneko Y, Nakajima T, Tamura S, Hasegawa H, ... Iizuka T, Kurabayashi M
Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print | PMID: 33000970
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Abstract

Long-term Outcome of the Randomized Defibrillator After Primary Angioplasty (DAPA) Trial.

Haanschoten DM, Elvan A, Ramdat Misier AR, Delnoy PPHM, ... Verheugt FWA, Ottervanger JP

- The randomized Defibrillator After Primary Angioplasty (DAPA) trial aimed to evaluate the survival benefit of prophylactic implantable cardioverter defibrillator (ICD) implantation in early selected high-risk patients after primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI).- A randomized, multicenter, controlled trial compared ICD versus conventional medical therapy in high risk primary PCI patients, based on one of the following factors: left ventricular ejection fraction (LVEF) < 30% within 4 days after STEMI, primary ventricular fibrillation, Killip class ≥2 and/or TIMI flow < 3 after PCI. ICD was implanted 30-60 days after MI. Primary endpoint was all-cause mortality at 3 years follow-up. The trial prematurely ended after inclusion of 266 patients (38% of the calculated sample size). Additional survival assessment was performed in February 2019 for the primary endpoint.- A total of 266 patients, 78.2% males, with a mean age of 60.8 ± 11.3 years, were enrolled. 131 patients were randomized to the ICD arm and 135 patients to the control arm. All-cause mortality was significant lower in the ICD group (5% vs 13%, HR 0.37; 95% CI 0.15-0.95) after 3 years follow-up. Appropriate ICD therapy occurred in 9 patients at 3 years follow-up (5 within the first 8 months after implantation). After median long-term follow-up of 9 years (IQR, 3-11), total mortality (18% vs 38%, HR 0.58; 95% CI 0.37-0.91) and cardiac mortality (HR 0.52; 95% CI 0.28-0.99) was significant lower in the ICD group. Non-cardiac death was not significantly different between groups. LVEF increased ≥10% in 46.5% of the patients during follow up and the extent of improvement was similar in both study groups.- In this prematurely terminated and thus underpowered randomized trial, early prophylactic ICD implantation demonstrated lower total and cardiac mortality in high-risk STEMI patients treated with primary PCI.



Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print
Haanschoten DM, Elvan A, Ramdat Misier AR, Delnoy PPHM, ... Verheugt FWA, Ottervanger JP
Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print | PMID: 33003972
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Impact:
Abstract

Safely Administering Potential QTc Prolonging Therapy Across a Large Healthcare System in the COVID-19 Era.

Saleh M, Gabriels J, Chang D, Fishbein J, ... Mountantonakis SE, Epstein LM

- The SARs-CoV-2 coronavirus has resulted in a global pandemic. Hydroxychloroquine ± azithromycin have been widely used to treat COVID-19 despite a paucity of evidence regarding efficacy. The incidence of torsade de pointes (TdP) remains unknown. Widespread use of these medications forced overwhelmed healthcare systems to search for ways to effectively monitor these patients while simultaneously trying to minimize healthcare provider (HCP) exposure and use of personal protective equipment (PPE).- COVID-19 positive patients that received hydroxychloroquine ± azithromycin across 13 hospitals between March 1 and April 15 were included in this study. A comprehensive search of the electronic medical records was performed using a proprietary python script to identify any mention of QT prolongation, ventricular tachy-arrhythmias and cardiac arrest.- The primary outcome of TdP was observed in 1 (0.015%) out of 6,476 hospitalized COVID-19 patients receiving hydroxychloroquine ± azithromycin. Sixty-seven (1.03%) had hydroxychloroquine ± azithromycin held or discontinued due to an average QT prolongation of 60.5±40.5ms from a baseline QTc of 473.7±35.9ms to a peak QTc of 532.6±31.6ms. Of these patients, hydroxychloroquine ± azithromycin were discontinued in 58 patients (86.6%), while one or more doses of therapy were held in the remaining nine (13.4%). A simplified approach to monitoring for QT prolongation and arrythmia was implemented on April 5. There were no deaths related to the medications with the simplified monitoring approach and HCP exposure was reduced.- The risk of torsade de pointes is low in hospitalized COVID-19 patients receiving hydroxychloroquine ± azithromycin therapy.



Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print
Saleh M, Gabriels J, Chang D, Fishbein J, ... Mountantonakis SE, Epstein LM
Circ Arrhythm Electrophysiol: 30 Sep 2020; epub ahead of print | PMID: 33003964
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Abstract

Cardiac Inflammation Impedes Response to Cardiac Resynchronization Therapy in Patients with Idiopathic Dilated Cardiomyopathy.

Verdonschot JAJ, Merken JJ, van Stipdonk AMW, Pliger P, ... Heymans SRB, Hazebroek MR

- Cardiac resynchronization therapy (CRT) is an established therapy in patients with dilated cardiomyopathy (DCM) and conduction disorders. Still, one-third of the patients with DCM do not respond to CRT. This study aims to depict the underlying cardiac pathophysiological processes of non-response to CRT in DCM patients using endomyocardial biopsies (EMB).- Within the Maastricht and Innsbruck registries of DCM patients, 99 patients underwent EMB before CRT implantation, with histological quantification of fibrosis and inflammation, where inflammation was defined as >14 infiltrating cells/mm2. Echocardiographic left ventricular end-systolic volume (LVESV) reduction ≥15% after 6 months was defined as response to CRT. RNA was isolated from cardiac biopsies of a representative subset of responders and non-responders.- Sixty-seven patients responded (68%), whereas 32 (32%) did not respond to CRT. Cardiac inflammation prior to implantation was negatively associated with response to CRT (25% of responders, 47% of non-responders; odds ratio 0.3 [0.12-0.76]; p=0.01). EMB fibrosis did not relate to CRT response. Cardiac inflammation improved the robustness of prediction beyond well-known clinical predictors of CRT response (likelihood ratio test p<0.001). Cardiac transcriptomic profiling of EMB reveals a strong pro-inflammatory and pro-fibrotic signature in the hearts of non-responders compared to responders. In particular, , , , , , , , , , ,andwere significantly higher expressed in the hearts of non-responders.- Cardiac inflammation along with a transcriptomic profile of high expression of combined pro-inflammatory and pro-fibrotic genes are associated with a poor response to CRT in DCM patients.



Circ Arrhythm Electrophysiol: 29 Sep 2020; epub ahead of print
Verdonschot JAJ, Merken JJ, van Stipdonk AMW, Pliger P, ... Heymans SRB, Hazebroek MR
Circ Arrhythm Electrophysiol: 29 Sep 2020; epub ahead of print | PMID: 32997547
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Abstract

Risk Factors for Early Recurrence following Ablation for Accessory Pathways: The Role of Consolidation Lesions.

Dionne A, Gauvreau K, O\'Leary E, Mah DY, ... Triedman JK, Walsh EP

- Atrioventricular reentrant tachycardia is common in children. Catheter ablation is increasingly used as a first line therapy with a high acute success rate, but recurrence during follow-up remains a concern. The aim of this study was to identify risk factors for recurrence after accessory pathway (AP) ablation.- Retrospective cohort study including patients who underwent AP ablation between 2013-2018. Cox proportional hazards model were used to examine the association between patient and procedural characteristics and recurrence during follow-up.- From 558 AP ablation procedure, 542 (97%) were acutely successful. During a median follow-up of 0.4 [IQR 0.1, 1.4] years, there were 42 (8%) patients with documented recurrence. On univariate analysis, early recurrence was associated with younger age, congenital heart disease, multiple AP, AP location (right sided and postero-septal versus left sided), cryoablation (versus RF), empiric ablation, the lack of full power RF lesions (<50W), RF consolidation time < 90 seconds and the use of fluoroscopy without a 3-dimensional electroanatomic mapping system. On multivariable analysis, only multiple AP (HR 2.78 [95% CI 1.063, 4.74]) and RF consolidation time < 90 seconds (HR 4.38 [95% CI 1.92, 9.51]) remained significantly associated with early recurrence; this association remained true when analyzed in subgroups by pathway location for right and left free wall AP.- In our institutional experience, RF consolidation time < 90 seconds after ablation of AP was associated with an increased risk of early recurrence.



Circ Arrhythm Electrophysiol: 04 Oct 2020; epub ahead of print
Dionne A, Gauvreau K, O'Leary E, Mah DY, ... Triedman JK, Walsh EP
Circ Arrhythm Electrophysiol: 04 Oct 2020; epub ahead of print | PMID: 33017181
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Abstract

3D Late Gadolinium Enhancement Cardiovascular Magnetic Resonance Predicts Inducibility of Ventricular Tachycardia in Adults with Repaired Tetralogy of Fallot.

Ghonim S, Ernst S, Keegan J, Giannakidis A, ... Gatzoulis MA, Babu-Narayan SV

- Adults with repaired tetralogy of Fallot (rTOF) die prematurely from ventricular tachycardia (VT) and sudden cardiac death. Inducible VT predicts mortality. Ventricular scar, the key substrate for VT, can be non-invasively defined with late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) but whether this relates to inducible VT is unknown.- Sixty-nine consecutive rTOF patients (43 male, mean 40{plus minus}15 years) clinically scheduled for invasive programmed VT-stimulation were prospectively recruited for prior 3D LGE CMR. Ventricular LGE was segmented and merged with reconstructed cardiac chambers and LGE volume measured.- VT was induced in 22(31%) patients. Univariable predictors of inducible VT included increased RV LGE (OR 1.15;p=0.001 per cm), increased non-apical vent LV LGE (OR 1.09;p=0.008 per cm), older age (OR 1.6;p=0.01 per decile), QRS duration ≥180ms (OR 3.5;p=0.02), history of non-sustained VT (OR 3.5; p=0.02) and previous clinical sustained VT (OR 12.8;p=0.003); only prior sustained VT (OR 8.02;p=0.02) remained independent in bivariable analyses after controlling for RV LGE volume (OR 1.14;p=0.003). An RV LGE volume of 25cm had 72% sensitivity and 81% specificity for predicting inducible VT (AUC 0.81;p<0.001). At the extreme cutoffs for \'ruling-out\' and \'ruling-in\' inducible VT, RV LGE >10cm was 100% sensitive and >36cm was 100% specific for predicting inducible VT.- 3D LGE CMR-defined scar burden is independently associated with inducible VT and may help refine patient selection for programmed VT-stimulation when applied to an at least intermediate clinical risk cohort.



Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print
Ghonim S, Ernst S, Keegan J, Giannakidis A, ... Gatzoulis MA, Babu-Narayan SV
Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022183
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Abstract

Digital Health and the Care of the Arrhythmia Patient; What Every Electrophysiologist Needs to Know.

Tarakji KG, Silva JNA, Chen LY, Turakhia MP, ... Wan EY, Chung MK

The field of cardiac electrophysiology has been on the cutting edge of advanced digital technologies for many years. More recently, medical device development through traditional clinical trials has been supplemented by direct to consumer products with advancement of wearables and healthcare apps. The rapid growth of innovation along with the mega-data generated has created challenges and opportunities. This review summarizes the regulatory landscape, applications to clinical practice, opportunities for virtual clinical trials, the use of artificial intelligence to streamline and interpret data, and integration into the electronic medical records and medical practice. Preparation of the new generation of physicians, guidance and promotion by professional societies, and advancement of research in the interpretation and application of big data and the impact of digital technologies on health outcomes will help to advance the adoption and the future of digital health care.



Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print
Tarakji KG, Silva JNA, Chen LY, Turakhia MP, ... Wan EY, Chung MK
Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33021815
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Abstract

The Clinical Application of the Deep Learning Technique for Predicting Trigger Origins in Paroxysmal Atrial Fibrillation Patients with Catheter Ablation.

Liu CM, Chang SL, Chen HH, Chen WS, ... Lu HH, Chen SA

- Non-pulmonary vein (NPV) trigger has been reported as an important predictor of recurrence post-atrial fibrillation (AF) ablation. Elimination of NPV triggers can reduce the recurrence of post-ablation AF. Deep learning was applied to pre-ablation pulmonary vein computed tomography (PVCT) geometric slices to create a prediction model for NPV triggers in patients with paroxysmal atrial fibrillation (PAF).- We retrospectively analyzed 521 PAF patients who underwent catheter ablation of PAF. Among them, PVCT geometric slices from 358 non-recurrent AF patients (1-3 mm interspace per slice, 20-200 slices for each patient, ranging from the upper border of the left atrium to the bottom of the heart, for a total of 23683 images of slices) were used in the deep learning process, the ResNet34 of the neural network, to create the prediction model of the NPV trigger. There were 298 (83.2%) patients with only pulmonary vein (PV) triggers and 60 (16.8%) patients with NPV triggers +/- PV triggers. The patients were randomly assigned to either training, validation or test groups and their data was allocated according to those sets. The image datasets were split into training (n=17340), validation (n=3491), and testing (n=2852) groups, which had completely independent sets of patients.- The accuracy of prediction in each PVCT image for NPV trigger was up to 82.4±2.0%. The sensitivity and specificity were 64.3±5.4% and 88.4±1.9%, respectively. For each patient, the accuracy of prediction for a NPV trigger was 88.6±2.3%. The sensitivity and specificity were 75.0±5.8% and 95.7±1.8%, respectively. The area under the curve (AUC) for each image and patient were 0.82±0.01 and 0.88±0.07, respectively.- The deep learning model using pre-ablation PVCT can be applied to predict the trigger origins in PAF patients receiving catheter ablation. The application of this model may identify patients with a high risk of NPV trigger before ablation.



Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print
Liu CM, Chang SL, Chen HH, Chen WS, ... Lu HH, Chen SA
Circ Arrhythm Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33021404
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Abstract

Long-term Outcomes of Left Atrial Appendage Electrical Isolation in Patients with Non-Paroxysmal Atrial Fibrillation: A Propensity Score-Matched Analysis.

Romero J, Di Biase L, Mohanty S, Trivedi C, ... Lakkireddy D, Natale A

- Left atrial appendage electrical isolation (LAAEI) has been proposed for the treatment of non-paroxysmal atrial fibrillation (AF). The long-term clinical outcomes and safety of this approach remain unclear. The objective of our study was to investigate the incremental benefit of LAAEI in patients undergoing catheter ablation (CA) for non-paroxysmal AF.- Propensity score-matched analysis was performed using a prospective registry database from 2010-2014. All patients in the LAAEI group were matched based on baseline characteristics, echocardiographic parameters, and procedural ablation techniques.- We identified 1842 patients who underwent CA for non-paroxysmal AF. Propensity score matching yielded 1092 patients, 546 patients with LAAEI and 546 patients without LAAEI. At 5-year follow-up, overall freedom from all-atrial arrhythmia recurrence, off-anti-arrhythmic drugs, in patients who underwent LAAEI was 68.9% vs. 50.2% in those who underwent standard ablation alone (p <0.001). Acute complication rates were similar between groups (LAAEI 1.3% vs. non-LAAEI 0.73%, p=0.36). At 5-year follow-up, 382 (70%) patients in the LAAEI group remained on oral anticoagulation (OAC) vs. 217 (39.7%) in the non-LAAEI group. No thromboembolic events occurred in either group on-OAC. In patients that were off-OAC, at 5-year follow-up, thromboembolic events occurred in 15/164 (9.1%) in the LAAEI group, and 4/329 (1.2%) in the non-LAAEI group (p < 0.001).- At 5-year follow-up, LAAEI was associated with significantly higher freedom from all-atrial arrhythmia recurrence in patients with persistent and long-standing persistent AF without increasing acute procedural complication rate. In patients off-OAC, there appears to be a higher risk of thromboembolic events in the LAAEI group.



Circ Arrhythm Electrophysiol: 29 Sep 2020; epub ahead of print
Romero J, Di Biase L, Mohanty S, Trivedi C, ... Lakkireddy D, Natale A
Circ Arrhythm Electrophysiol: 29 Sep 2020; epub ahead of print | PMID: 32998529
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Abstract

Magnetic Resonance Imaging-Guided Fibrosis Ablation for the Treatment of Atrial Fibrillation: The ALICIA Trial.

Bisbal F, Benito E, Teis A, Alarcón F, ... Bayés-Genis A, Mont L

Myocardial fibrosis is key for atrial fibrillation (AF) maintenance. We aimed to test the efficacy of ablating cardiac magnetic resonance (CMR)-detected atrial fibrosis plus pulmonary vein isolation (PVI).- This was an open label, parallel-group, randomized, controlled trial. Patients with symptomatic drug-refractory AF (paroxysmal and persistent) undergoing first or repeat ablation were randomized in a 1:1 basis to receive PVI plus CMR-guided fibrosis ablation (CMR group) or PVI alone (PVI-alone group). The primary endpoint was the rate of recurrence (>30 seconds) at 12 months of follow-up using a 12-lead ECG and Holter monitoring at 3, 6, and 12 months. The analysis was conducted by intention-to-treat.- In total, 155 patients (71% male, age 59±10, CHA2DS2-VASc 1.3±1.1, 54% Paroxysmal AF) were allocated to the PVI-alone group (N=76) or CMR group (N=79). First ablation was performed in 80% and 71% of patients in the PVI-alone and CMR groups, respectively. The mean atrial fibrosis burden was 12% (only 〜50% of patients had fibrosis outside the pulmonary vein area). 100% and 99% of patients received the assigned intervention in the PVI-alone and CMR group, respectively. The primary outcome was achieved in 21 patients (27.6%) in the PVI-alone group and 22 patients (27.8%) in the CMR group (odds ratio[OR]: 1.01, 95% confidence interval [CI] 0.50-2.04; p=0.976). There were no differences in the rate of adverse events (3 in the CMR group and 2 in the PVI-alone group; p=0.68).- A pragmatic ablation approach targeting CMR-detected atrial fibrosis plus PVI was not more effective than PVI alone in an unselected population undergoing AF ablation with low fibrosis burden.



Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print
Bisbal F, Benito E, Teis A, Alarcón F, ... Bayés-Genis A, Mont L
Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print | PMID: 33031713
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Impact:
Abstract

A Cross-Center Virtual Education Fellowship Program for Early-Career Researchers in Atrial Fibrillation.

Ajayi TB, Remein CD, Stafford RS, Fagerlin A, ... Childs E, Benjamin EJ

- It is estimated that over 46 million individuals have atrial fibrillation (AF) worldwide, and the incidence and prevalence of AF are increasing globally. There is an urgent need to accelerate the academic development of scientists possessing the skills to conduct innovative, collaborative AF research.- We designed and implemented a virtual AF Strategically Focused Research Network (SFRN) Cross-Center Fellowship program to enhance the competencies of early-stage AF basic, clinical, and population health researchers through experiential education and mentorship. The pedagogical model involves significant cross-Center collaboration to produce a curriculum focused on enhancing AF scientific competencies, fostering career/professional development, and cultivating grant writing skills. Outcomes for success involve clear expectations for fellows to produce manuscripts, presentations, and-for those at the appropriate career stage-grant applications. We evaluated the effectiveness of the fellowship model via mixed methods formative and summative surveys.- In two years of the fellowship, fellows generally achieved the productivity metrics sought by our pedagogical model, with outcomes for the twelve fellows including 50 AF-related manuscripts, 7 publications, 28 presentations, and 3 grant awards applications. Participant evaluations reported that the fellowship effectively met its educational objectives. All fellows reported medium to high satisfaction with the overall fellowship, webinar content and facilitation, staff communication and support, and program organization.- The fellowship model represents an innovative educational strategy by providing a virtual AF training and mentoring curriculum for early-career basic, clinical, and population health scientists working across multiple institutions, which is particularly valuable in the pandemic era.



Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print
Ajayi TB, Remein CD, Stafford RS, Fagerlin A, ... Childs E, Benjamin EJ
Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print | PMID: 33031707
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Abstract

Histopathologic and Ultrastructural Findings in Human Myocardium after Stereotactic Body Radiation Therapy for Recalcitrant Ventricular Tachycardia.

Kiani S, Kutob L, Schneider F, Higgins KA, Lloyd MS

- Stereotactic body radiation therapy (SBRT) is a novel treatment for refractory ventricular tachycardia (VT). While outcomes have been described in small studies, histological findings after SBRT for VT are unknown.- We identified four explanted hearts in the context of transplant who received prior SBRT as part of an 11-patient compassionate use series at our institution. Clinical VTs and CT-defined target volume areas of SBRT were correlated to the anatomic specimens. Gross pathologic, histologic and ultrastructural examination of tissue in the target area of SBRT were performed.- All four patients had NICM, and three had left ventricular assist devices. In all cases, patients had recurrent sustained VT and had failed multiple antiarrhythmics and radiofrequency ablations. Four patients underwent 5 total SBRT therapy session with 25 Gy single fraction dose delivered to the area of culprit scar. The time from SBRT to explant ranged from 12-250 days. Histopathologic features following radiation were comparable in all patients and were characterized by areas of subendocardial necrosis surrounded by a rim of fibrosis. In one patient, the surrounding myocardium showed cytoplasmic vacuolization in myocytes and in another patchy interstitial fibrosis. Vascular changes consisted of myointimal thickening with prominence of endothelial cells. Electron microscopy (EM) of myocardium showed irregular, convoluted intercalated disc regions, loss of contractile elements with disrupted and haphazardly arranged myofibrils and edematous mitochondria with loss of cisternae.- Here, we report the first series of findings in human tissue in four patients after SBRT. Histopathologic features were consistent across all four patients, and were indicative of cell injury, death, and to a lesser extent, fibrosis. EM demonstrated features consistent with acute injury. These specimens provide radiobiological mechanisms of acute cellular injury during SBRT for VT which may have an antiarrhythmic effect prior to the onset of fibrosis.



Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print
Kiani S, Kutob L, Schneider F, Higgins KA, Lloyd MS
Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print | PMID: 33031001
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Abstract

Social Media Influence Does Not Reflect Scholarly or Clinical Activity in Real Life.

Zenger B, Swink JM, Turner JL, Bunch TJ, ... Piccini JP, Steinberg BA

- Social media has become a major source of communication in medicine. We aimed to understand the relationship between physicians\' social media influence and their scholarly and clinical activity.- We identified attending, US electrophysiologists on Twitter. We compared physician Twitter activity to (a) scholarly publication record (h-index) and (b) clinical volume according to CMS. The ratio of observed vs. expected Twitter followers (obs/exp) was calculated based on each scholarly (K-index) and clinical activity.- We identified 284 physicians, with mean Twitter age of 5.0 (SD 3.1) years and median 568 followers (25, 75: 195, 1146). They had a median 34.5 peer-reviewed papers (25, 75: 14, 105), 401 citations (25, 75: 102, 1677), and h-index 9 (25, 75: 4, 19.8). The median K-index was 0.4 (25, 75: 0.15, 1.0), ranging 0.0008 - 29.2. The median EP procedures was 77 (25, 75: 0, 160) and E&M visits 264 (25, 75: 59, 516) in 2017. The top 1% electrophysiologists for followers accounted for 20% of all followers, 17% of status updates, had a mean h-index of 6 (vs. 15 for others, p=0.3), and accounted for 1% of procedural and E&M volumes. They had a mean K-index of 21 (vs. 0.77 for others, p<0.0001), and clinical obs/exp follower ratio of 17.9 and 18.1 for procedures and E&M (p<0.001 each, vs. others [0.81 for each]).- Electrophysiologists are active on Twitter, with modest influence often representative of scholarly and clinical activity. However, the most influential physicians appear to have relatively modest scholarly and clinical activity.



Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print
Zenger B, Swink JM, Turner JL, Bunch TJ, ... Piccini JP, Steinberg BA
Circ Arrhythm Electrophysiol: 07 Oct 2020; epub ahead of print | PMID: 33030380
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Abstract

Left Ventricular Enlargement, CRT Response and Impact of MultiPoint Pacing.

Varma N, Baker Ii J, Tomassoni G, Love CJ, ... Lee K, Corbisiero R

- Left ventricular (LV) epicardial pacing results in slowly propagating paced wavefronts. We postulated that this effect might limit cardiac resynchronization therapy (CRT) efficacy in patients with LV enlargement using conventional biventricular (BiV) pacing with single-site LV pacing, but be mitigated by LV stimulation from 2 widely spaced sites using MultiPoint™ Pacing (MPP-AS: anatomical separation ≥ 30mm). We tested this hypothesis in the multicenter randomized MPP IDE trial.- Following implant, quadripolar BiV pacing was activated in all patients (n=506). From 3 to 9 months postimplant, among patients with available baseline LV end-diastolic volume (LVEDV) measures, 188 received BiV pacing, and 43 received MPP-AS. Patients were dichotomized by median baseline LVEDV indexed to height (LVEDVI). Outcomes were measured by the clinical composite score (CCS, primary efficacy endpoint), quality of life (QOL), LV structural remodeling (↑EF>5% and ↓ESV 10%) and heart failure (HF) event/ cardiovascular death.- LVEDVI was 1.1 mL/cm. Baseline characteristics differed in patients with LVEDVI vs. LVEDVI. Among patients with LVEDVI, BiV was less efficacious compared to patients with LVEDVI (CCS 65% vs. 79%). In contrast, MPP-AS programming generated greater CCS response (92% vs. 65%, p=0.023) and improved QOL (-31.0±29.7 vs. -15.7±22.1, p=0.038) vs. BiV in patients with LVEDVI. Reverse remodeling trended better with MPP-AS programming. When LVEDVI, HF event rate increased following the 3-month randomization point (0.0150±0.1725 in LVEDVI vs. -0.0190±0.0808 in LVEDVI, p=0.012) in BiV, but no heart failure event occurred in patients with MPP-AS programming between 3 and 9 months in LVEDVI. All measured outcomes did not differ in patients receiving MPP-AS and BiV pacing with LVEDVI.- Conventional BiV pacing, even with a quadripolar lead, has reduced efficacy in patients with LV enlargement. However, in patients with larger hearts and programmed to MPP-AS the greatest response rate was observed.



Circ Arrhythm Electrophysiol: 06 Oct 2020; epub ahead of print
Varma N, Baker Ii J, Tomassoni G, Love CJ, ... Lee K, Corbisiero R
Circ Arrhythm Electrophysiol: 06 Oct 2020; epub ahead of print | PMID: 33028082
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Abstract

Malignant Arrhythmias in Patients with COVID-19: Incidence, Mechanisms and Outcomes.

Turagam MK, Musikantow D, Goldman ME, Bassily-Marcus A, ... Kohli-Seth R, Reddy VY

- Patients with coronavirus disease 2019 (COVID-19) who develop cardiac injury are reported to experience higher rates of malignant cardiac arrhythmias. However, little is known about these arrhythmias - their frequency, the underlying mechanisms, and their impact on mortality.- We extracted data from a registry (NCT04358029) regarding consecutive inpatients with confirmed COVID-19, were receiving continuous telemetric ECG monitoring, and had a definitive disposition of hospital discharge or death. Between patients who died versus discharged, we compared a primary composite endpoint of cardiac arrest from ventricular tachycardia/fibrillation or bradyarrhythmias such as atrio-ventricular block.- Among 800 COVID-19 patients at Mount Sinai Hospital with definitive dispositions, 140 patients had telemetric monitoring and either died (52) or were discharged (88). The median (IQR) age was 61 years (48 - 74); 73% men; and ethnicity was Caucasian in 34%. Comorbidities included hypertension in 61%, coronary artery disease in 25%, ventricular arrhythmia history in 1.4%, and no significant comorbidities in 16%. Compared to discharged patients, those who died had elevated peak troponin I levels (0.27 vs 0.02 ng/mL), and more primary endpoint events (17% vs 4%, p = 0.01), a difference driven by tachyarrhythmias. Fatal tachyarrhythmias invariably occurred in the presence of severe metabolic imbalance, while atrioventricular block was largely an independent primary event.- Hospitalized COVID-19 patients who die experience malignant cardiac arrhythmias more often than those surviving to discharge. However, these events represent a minority of cardiovascular deaths, and ventricular tachyarrhythmias are mainly associated with severe metabolic derangement.



Circ Arrhythm Electrophysiol: 06 Oct 2020; epub ahead of print
Turagam MK, Musikantow D, Goldman ME, Bassily-Marcus A, ... Kohli-Seth R, Reddy VY
Circ Arrhythm Electrophysiol: 06 Oct 2020; epub ahead of print | PMID: 33026892
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Abstract

Automated blood pressure measurement in atrial fibrillation: validation process modification and evaluation of a novel professional device which detects atrial fibrillation and adapts its blood pressure measurement algorithm.

Stergiou GS, Kyriakoulis KG, Bountzona I, Menti A, ... Kalogeropoulos P, Kollias A
Objectives
Blood pressure (BP) measurement in atrial fibrillation (AF) patients is problematic and automated monitors are regarded as inaccurate. The optimal procedure for validating BP monitors in AF is questionable. This study evaluated the accuracy of a novel professional oscillometric upper-arm cuff device (Microlife WatchBP Office), which has an algorithm for detecting AF and then applies an AF-specific BP measurement algorithm. BP variability, which is inherently increased in AF patients, was considered in the analysis.
Methods
Subjects with sustained AF were included in a validation study using the same arm sequential measurement method of the Universal Standard (ISO 81060-2:2018) for special populations. Analysis was performed in all subjects and separately in those with and without high reference BP variability (>12/8 mmHg SBP/DBP).
Results
Thirty-five subjects with 105 paired test/reference BP measurements were included (mean age 76.3 ± 8.4 years, reference SBP/DBP 128.2 ± 19.5/72.5 ± 12.1 mmHg, pulse rate 68.3 ± 14.9 bpm). Validation Criterion 1 (mean difference ± SD) was 0.0 ± 7.7/0.2 ± 7.0 mmHg in all 105 BP pairs (threshold ≤5 ± 8 mmHg). Criterion 1 was 0.5 ± 6.1/-0.2 ± 6.8 mmHg in 18 subjects (54 BP pairs) with low reference BP variability and -0.6 ± 9.2/0.6 ± 7.3 mmHg in 17 (51 pairs) with high variability. Criterion 1 did not differ in pulse rate < 70 vs. ≥ 70 bpm Validation Criterion 2 (SD of differences for 35 individuals) was 5.38/6.20 mmHg (SBP/DBP; threshold ≤6.95/6.95).
Conclusion
A technology which detects AF and activates an AF-specific BP measurement algorithm introduces a challenging solution for clinical practice. Validation of BP monitors in AF patients should not ignore their inherently high BP variability.



J Hypertens: 15 Oct 2020; epub ahead of print
Stergiou GS, Kyriakoulis KG, Bountzona I, Menti A, ... Kalogeropoulos P, Kollias A
J Hypertens: 15 Oct 2020; epub ahead of print | PMID: 33060450
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Abstract

A novel 9-partition method using fluoroscopic images for guiding left bundle branch pacing.

Jiang H, Hou X, Qian Z, Wang Y, ... Li K, Zou J
Background
Left bundle branch (LBB) pacing is a novel pacing modality, but there is no standard fluoroscopic methodology.
Objectives
This study aimed to analyze the characteristics of His bundle (HB) and LBB pacing lead locations and establish a method to guide LBB pacing using fluoroscopic images.
Methods
Seventy patients who underwent HB or LBB pacing were enrolled. The fluoroscopic image was recorded, and ventricular contraction ring in the right anterior oblique 30° projection was determined. The region between the apex and the ventricular contraction ring was divided into 9 partitions. All patients underwent postoperative computed tomography to confirm components of the ventricular contraction ring and to measure the distance from the lead tip to the junction of the noncoronary aortic cusp and right coronary cusp.
Results
HB and LBB pacing leads were successfully implanted in 11 and 35 patients, respectively. All HB pacing leads were distributed in the second partition, and 94.3% (33/35) of LBB pacing leads were in the junctional area of second and fifth partitions. The computed tomography image confirmed that the ventricular contraction ring was composed of cardiac valves. The distance from the lead tip to the junction of the noncoronary cusp and right coronary cusp of LBB and HB pacing leads was 3.8 ± 0.6 and 1.9 ± 0.2 cm, respectively. Under the guidance of the 9-partition method, the success rate of LBB pacing in 30 prospective patients increased from 58.3% (35/60) to 83.3% (25/30) (P = .03). The fluoroscopy time and the number of screwing sites also significantly decreased.
Conclusion
The distributions of HB and LBB pacing leads exhibited unique imaging characteristics. A new 9-partition method is useful to guide successful LBB pacing.

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

Heart Rhythm: 29 Sep 2020; 17:1759-1767
Jiang H, Hou X, Qian Z, Wang Y, ... Li K, Zou J
Heart Rhythm: 29 Sep 2020; 17:1759-1767 | PMID: 32417259
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Abstract

Sudden cardiac arrest with shockable rhythm in patients with heart failure.

Woolcott OO, Reinier K, Uy-Evanado A, Nichols GA, ... Jui J, Chugh SS
Background
Patients with shockable sudden cardiac arrest (SCA; ventricular fibrillation/tachycardia) have significantly better resuscitation outcomes than do those with nonshockable rhythm (pulseless electrical activity/asystole). Heart failure (HF) increases the risk of SCA, but presenting rhythms have not been previously evaluated.
Objective
We hypothesized that based on unique characteristics, HFpEF (HF with preserved ejection fraction; left ventricular ejection fraction [LVEF] ≥50%), bHFpEF (HF with borderline preserved ejection fraction; LVEF >40% and <50%), and HFrEF (HF with reduced ejection fraction; LVEF ≤40%) manifest differences in presenting rhythm during SCA.
Methods
Consecutive cases of SCA with HF (age ≥18 years) were ascertained in the Oregon Sudden Unexpected Death Study (2002-2019). LVEF was obtained from echocardiograms performed before and unrelated to the SCA event. Presenting rhythms were identified from first responder reports. Logistic regression was used to evaluate the independent association of presenting rhythm with HF subtype.
Results
Of 648 subjects with HF and SCA (median age 72 years; interquartile range 62-81 years), 274 had HFrEF (23.4% female), 92 had bHFpEF (35.9% female), and 282 had HFpEF (42.5% female). The rates of shockable rhythms were 44.5% (n = 122), 48.9% (n = 45), and 27.0% (n = 76) for HFrEF, bHFpEF, and HFpEF, respectively (P < .001). Compared with HFpEF, the adjusted odds ratios for shockable rhythm were 1.86 (95% confidence interval 1.27-2.74; P = .002) in HFrEF and 2.26 (95% CI 1.35-3.77; P = .002) in bHFpEF. The rates of survival to hospital discharge were 10.6% (n = 29) in HFrEF, 22.8% (n = 21) in bHFpEF, and 9.9% (n = 28) in HFpEF (P = .003).
Conclusion
The rates of shockable rhythm during SCA depend on the HF clinical subtype. Patients with bHFpEF had the highest likelihood of shockable rhythm, correlating with the highest rates of survival.

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

Heart Rhythm: 29 Sep 2020; 17:1672-1678
Woolcott OO, Reinier K, Uy-Evanado A, Nichols GA, ... Jui J, Chugh SS
Heart Rhythm: 29 Sep 2020; 17:1672-1678 | PMID: 32504821
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Abstract

New Predictor of Very Late Recurrence After Catheter Ablation of Atrial Fibrillation Using Holter Electrocardiogram Parameters.

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

This study aimed to evaluate the predictors of very late recurrence of atrial fibrillation (VLRAF) after an initial AF catheter ablation (CA) by analyzing the follow-up Holter electrocardiogram. We retrospectively studied patients (n = 253, mean age: 66 years, woman: 30%, paroxysmal AF: 73%) without recurrence of AF within 12 months and the use of antiarrhythmic drugs. In the Holter electrocardiogram analysis, the atrial premature complexes (APCs) burden, the profile of the APCs run and prematurity index of the APCs were evaluated. Fifty-one patients (20%) had VLRAF during the follow-up period (mean follow up: 46 months). Patients with VLRAF had a significantly greater APCs burden (0.318% [0.084 to 1.405] vs 0.132% [0.051 to 0.461], p = 0.022), longer number of APCs run (5 [3 to 11] vs 4 [0 to 7], p = 0.019), and shorter minimum prematurity index of the APCs (47 ± 7 vs 51 ± 6, p = 0.001) than those without VLRAF. The optimal cutoff value for the APCs burden, maximum number of APCs run, and minimum prematurity index of the APCs to predict VLRAF was 0.159%, 10, and 48%, respectively. The minimum prematurity index of the APCs (≤48%) was significantly associated with VLRAF in the multivariate analysis. In conclusion, the minimum prematurity index of the APCs (≤48%) at 12 months after CA was shown to be an independent predictor of VLRAF in patients without antiarrhythmic drugs. Although the index is a very simple parameter automatically calculated by analysis software, it can be an important index for following patients after CA over the long-term.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Oct 2020; 133:71-76
Egami Y, Ukita K, Kawamura A, Nakamura H, ... Nishino M, Tanouchi J
Am J Cardiol: 14 Oct 2020; 133:71-76 | PMID: 32811653
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Abstract

Differentiating Hereditary Arrhythmogenic Right Ventricular Cardiomyopathy from Cardiac Sarcoidosis Fulfilling 2010 ARVC Task Force Criteria.

Gasperetti A, Rossi V, Chiodini A, Casella M, ... Duru F, Saguner AM
Background
Cardiac sarcoidosis (CS) may resemble the clinical presentation of arrhythmogenic right ventricular cardiomyopathy (ARVC).
Objective
goal of our study was identification of clinical variables to better discriminate between patients with genetically-determined ARVC and CS fulfilling definite ARVC 2010 TFC.
Methods
In this multicenter study, 10 patients with CS fulfilling definite 2010 ARVC TFC were age-and gender matched with 10 genetically-proven ARVC patients. A cardiac 18F-FDG PET-scan was required to be included in this study.
Results
The 2010 ARVC TFC did not reliably differentiate between the two diseases. CS patients presented with longer PR-intervals, advanced AVB, and a longer QRS-duration (p <0.001; and p=0.009, respectively), while T wave inversions (TWI) in peripheral leads were more common in ARVC (p=0.009). CS patients presented with more extensive LV involvement and a lower LVEF, while ARVC patients had a larger RVOT (p=0.044). PET scan positivity was only present in CS patients (90% vs 0%).
Conclusion
The 2010 TFC do not reliably differentiate between CS patients fulfilling 2010 TFC and hereditary ARVC. A prolonged PR interval, advanced AVB, longer QRS duration, RV apical involvement, a reduced LVEF, and a positive 18F-FDG PET scan should raise the suspicion of CS, whereas larger RVOT dimensions and peripheral TWI favor the diagnosis of hereditary ARVC.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 21 Sep 2020; epub ahead of print
Gasperetti A, Rossi V, Chiodini A, Casella M, ... Duru F, Saguner AM
Heart Rhythm: 21 Sep 2020; epub ahead of print | PMID: 32976989
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Abstract

Effects of Atrial Fibrillation and Chronic Kidney Disease on Major Adverse Cardiovascular Events.

Ding WY, Lip GYH, Pastori D, Shantsila A

Atrial fibrillation (AF) is strongly linked to chronic kidney disease (CKD) and both of these conditions contribute to poor cardiovascular outcomes. We evaluated the impact of renal failure on major adverse cardiovascular events (MACE) in AF, and predictive value of the 2MACE score in this post-hoc analysis of the AMADEUS trial. The primary endpoint was MACE (composite of myocardial infarction, cardiac revascularisation and cardiovascular mortality). Secondary endpoints included the composite of stroke, major bleeding and non-cardiovascular mortality, and each of the specific outcomes separately. Of the 4,554 patients, 1,526 (33.5%) were females and the median age was 71 (IQR 64 to 77) years. There were 3,838 (84.3%) non-CKD and 716 (15.7%) CKD patients. The incidence of cardiovascular and non-cardiovascular mortality were 1.41% and 2.44% per 100 patient-years, respectively. There was no significant difference in crude study endpoints between the groups. Multivariable regression analysis found no association between CKD and MACE (HR 1.03 [95% CI, 0.45 to 2.34]). The c-index of the 2MACE score for MACE was 0.65 (95% CI, 0.59 to 0.71, p <0.001). In the presence of CKD, each additional point of the 2MACE score contributed to a greater risk of MACE (HR 3.17 [95% CI, 1.28 to 7.85] vs 1.48 [95% CI, 1.17 to 1.87] in the non-CKD group). In conclusion, the 2MACE score may be a useful tool for clinical risk stratification of high-risk AF patients with CKD and those at high MACE risk could be targeted for more intensive cardiovascular prevention strategies. The presence of CKD was not found to be independently associated with MACE in AF patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2020; 132:72-78
Ding WY, Lip GYH, Pastori D, Shantsila A
Am J Cardiol: 30 Sep 2020; 132:72-78 | PMID: 32773222
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Abstract

Risks and outcomes of gastrointestinal malignancies in anticoagulated atrial fibrillation patients experiencing gastrointestinal bleeding: A nationwide cohort study.

Chang TY, Chan YH, Chiang CE, Lin YJ, ... Chen SA, Chao TF
Background
Oral anticoagulants (OACs) may serve as a \"screening test\" for gastrointestinal (GI) tract malignancies through the clinical presentation of bleeding.
Objective
The purpose of this study was to investigate the 1-year incidence and predictors of GI cancer after GI bleeding among atrial fibrillation (AF) patients treated with warfarin or non-vitamin K antagonist oral anticoagulants (NOACs). The risks of mortality after GI cancers between patients receiving warfarin and those receiving NOACs were compared.
Methods
A total of 10,845 anticoagulated AF patients hospitalized due to GI bleeding without a previous history of GI cancer were identified from the Taiwan National Health Insurance Research Database. Patients were followed-up for incident GI cancers for up to 1 year.
Results
Within 1 year after GI bleeding, 290 patients (2.67%) were diagnosed with GI tract cancer. More patients treated with NOACs were diagnosed with GI cancer than those treated with warfarin (3.87% vs 2.44%; P <.001; odds ratio [OR] 1.606; P <.001). Age (OR 1.025 per 1-year increment) and male sex (OR 1.356) were associated with the diagnosis of GI cancer. Among patients diagnosed with GI cancer, 45.2% died within 1 year. The risk of mortality was lower in patients treated with NOACs than in those treated with warfarin (23.5% vs 51.8%; adjusted hazard ratio 0.441; P <.001).
Conclusion
Incident GI cancers were diagnosed in 1 of 37 AF patients at 1 year after OAC-related GI bleeding and were more common among patients treated with NOACs (1/26) compared to warfarin (1/41). Detailed examinations for occult GI cancers are necessary, especially among elderly males.

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

Heart Rhythm: 29 Sep 2020; 17:1745-1751
Chang TY, Chan YH, Chiang CE, Lin YJ, ... Chen SA, Chao TF
Heart Rhythm: 29 Sep 2020; 17:1745-1751 | PMID: 32470625
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Abstract

Durability of posterior wall isolation after catheter ablation among patients with recurrent atrial fibrillation.

Markman TM, Hyman MC, Kumareswaran R, Arkles JS, ... Marchlinski FE, Nazarian S
Background
Electrical posterior wall isolation (PWI) is increasingly being used for the treatment of patients with atrial fibrillation (AF). Few data exist on the durability of PWI using current technology.
Objective
The purpose of this study was to characterize the frequency and location of posterior wall reconnection at the time of repeat catheter ablation for AF.
Methods
We performed a single-center retrospective cohort study of 50 patients undergoing repeat AF ablation after previous PWI. Durability of PWI was assessed at the time of repeat ablation based on posterior wall entrance and exit block. Sites of posterior wall reconnection were characterized based on review of recorded electrical signals and electroanatomic maps.
Results
At the time of repeat ablation, mean age was 67 ± 10 years, 31 of 50 patients had persistent AF, and mean CHADS-VASc score was 3.0 ± 1.8. Of the 50 patients, 30 had durable PWI at repeat ablation, 1.4 ± 1.6 years after the index procedure. Patients with posterior wall reconnection required repeat ablation earlier (0.9 ± 0.6 years vs1.8 ± 1.9 years from index PWI; P = .048) and were more likely to have atypical atrial flutter (55% vs 27%; P = .043). Among patients with posterior wall reconnection, the roof was the most common site of reconnection (14/20), and 12 patients had multiple regions of reconnection noted.
Conclusion
Posterior wall reconnection is noted in 40% of patients undergoing repeat ablation after an index PWI. The roof of the left atrium is the most common site of posterior wall reconnection.

Copyright © 2020 Heart Rhythm Society. All rights reserved.

Heart Rhythm: 29 Sep 2020; 17:1740-1744
Markman TM, Hyman MC, Kumareswaran R, Arkles JS, ... Marchlinski FE, Nazarian S
Heart Rhythm: 29 Sep 2020; 17:1740-1744 | PMID: 32389682
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Abstract

Use of virtual visits for the care of the arrhythmia patient.

Hu PT, Hilow H, Patel D, Eppich M, ... Wazni O, Tarakji KG
Background
Virtual visits (VVs) are a modality for delivering health care services remotely through videoconferencing tools. Data about patient and physician experience in using VVs are limited.
Objective
The purpose of this study was to assess patient and physician experience with the use of VVs in cardiac electrophysiology.
Methods
We performed a prospective survey of cardiac electrophysiology patients and physicians who participated in an outpatient VV from December 2018 to July 2019.
Results
One-hundred consecutive VVs were included. Sixty-four patients elected to complete a survey. Patients rated their experience as either excellent/very good in scheduling a VV (87%), seeing their physician of choice (100%), transmitting arrhythmia data (88%), rating their physician\'s ability to communicate (98%), asking all questions (98%), rating the level of care received (98%), paying for the cost of a VV (67%), and rating their overall level of satisfaction (98%). Thirty-eight of 64 patients (59.4%) preferred a VV for their next visit, 12 of 64 (18.8%) preferred an in-office visit, 13 of 64 (20.3%) responded that their decision for a virtual or office visit depended on indication, and 1 of 64 (1.6%) had no preference. A total of 14 cardiac electrophysiologists participated in 100 VVs. Nine visits were not included due to technical difficulty. Physician responses to survey questions were rated as excellent/very good in the ability to communicate (92%), accessing monitoring data (95%), and overall level of satisfaction (98%).
Conclusion
In our small study population, most patients and physicians prefer VVs. Convenience, cost, and reason for follow-up were important determinants that affected both patient and physician preference.

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

Heart Rhythm: 29 Sep 2020; 17:1779-1783
Hu PT, Hilow H, Patel D, Eppich M, ... Wazni O, Tarakji KG
Heart Rhythm: 29 Sep 2020; 17:1779-1783 | PMID: 32438016
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Abstract

Ten-year outcomes of transcaval cardiac puncture for catheter ablation after extracardiac Fontan surgery.

Moore JP, Gallotti RG, Tran E, Perens GS, Shannon KM
Background
Although they are at lower risk, patients with previous extracardiac conduit (EC) Fontan still may require catheter ablation for supraventricular arrhythmia.
Objective
The purpose of this study was to determine the optimal approach to pulmonary venous atrium (PVA) access after EC Fontan operation.
Methods
All electrophysiological procedures requiring PVA over a 10-year period at the UCLA Medical Center were reviewed. PVA was grouped by transcaval cardiac puncture (TCP) or direct conduit puncture. Procedural characteristics and outcomes were compared.
Results
Between June 2009 and November 2019, 23 electrophysiological procedures requiring PVA access were performed in 17 EC Fontan patients (53% male; median age 25 years; interquartile range 11-34). Cavoatrial overlap was identified in 14 patients by preprocedural imaging (10 cardiac computed tomography, 4 cardiac magnetic resonance). PVA access was obtained via TCP in 11, direct conduit puncture in 6, pre-existing fenestration in 5, and pulmonary artery puncture in 1. Time to PVA was significantly shorter for TCP vs direct conduit puncture (0.2 vs 1.1 hours, respectively; P = .03). The only predictor of successful TCP was the length of cavoatrial overlap by preprocedural imaging (14 vs 3 mm; P = .02). No procedural complications occurred. No change in oxygen saturation was noted, and no evidence of residual shunting was detected by follow-up echocardiography.
Conclusion
TCP is feasible in most patients after EC Fontan surgery and can be predicted by preprocedural advanced imaging. TCP is associated with shorter time to PVA and was uncomplicated in this single-center study. Preoperative assessment of cavoatrial overlap should be considered before catheter ablation for EC Fontan.

Published by Elsevier Inc.

Heart Rhythm: 29 Sep 2020; 17:1752-1758
Moore JP, Gallotti RG, Tran E, Perens GS, Shannon KM
Heart Rhythm: 29 Sep 2020; 17:1752-1758 | PMID: 32438019
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Abstract

Long-term outcomes of ventricular tachycardia substrate ablation incorporating hidden slow conduction analysis.

Acosta J, Soto-Iglesias D, Jáuregui B, Armenta JF, ... Mont L, Berruezo A
Background
Ventricular tachycardia substrate ablation (VTSA) incorporating hidden slow conduction (HSC) analysis allows further arrhythmic substrate identification.
Objective
The purpose of this study was to analyze whether the elimination of HSC electrograms (HSC-EGMs) during VTSA results in better short- and long-term outcomes.
Methods
Consecutive patients (N = 70; 63% ischemic; mean age 64 ± 14.6 years) undergoing VTSA were prospectively included. Bipolar EGMs with >3 deflections and duration <133 ms were considered as potential HSC-EGMs. Whenever a potential HSC-EGM was identified, double or triple ventricular extrastimuli were delivered. If a local potential showed up as a delayed component, it was annotated as HSC-EGM. Ablation was delivered at conducting channel entrances and HSC-EGMs. Radiofrequency time, ventricular tachycardia (VT) inducibility after VTSA, and VT/ventricular fibrillation recurrence at 24 months after the procedure were compared with data from a historical control group.
Results
A total of 5076 EGMs were analyzed; 1029 (20.2%) qualified as potential HSC-EGMs, and 475 of them were tagged as HSC-EGMs. Scars in patients with HSC-EGMs (n = 43 [61.4%]) were smaller (32.2 [17-58] cm vs 85 [41-92.4] cm; P = .006) and more heterogeneous (core/scar area ratio 0.15 [0.05-0.44] vs 0.44 [0.33-0.57]; P = .017); 32.4% of HSC-EGMs were located in normal voltage tissue. Patients undergoing VTSA incorporating HSC analysis required less radiofrequency time (15.6 [8-23.1] vs 23.9 [14.9-30.8]; P < .001) and had a lower rate of VT inducibility after VTSA (28.6% vs 52.9%; P = .003) than did the historical controls. Patients undergoing VTSA incorporating HSC analysis showed a higher 2-year VT/ventricular fibrillation-free survival (75.7% vs 58.8%; log-rank, P = .046) after VTSA.
Conclusion
VTSA incorporating HSC analysis allowed further arrhythmic substrate identification (especially in the border zone and normal voltage areas) and was associated with increased VTSA efficiency and better short- and long-term outcomes.

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

Heart Rhythm: 29 Sep 2020; 17:1696-1703
Acosta J, Soto-Iglesias D, Jáuregui B, Armenta JF, ... Mont L, Berruezo A
Heart Rhythm: 29 Sep 2020; 17:1696-1703 | PMID: 32417258
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Abstract

Automated electrocardiographic quantification of myocardial scar in patients undergoing primary prevention implantable cardioverter-defibrillator implantation: Association with mortality and subsequent appropriate and inappropriate therapies.

Reichlin T, Asatryan B, Vos MA, Willems R, ... Sticherling C,
Background
Myocardial scarring from infarction or nonischemic fibrosis forms an arrhythmogenic substrate. The Selvester QRS score has been developed to estimate myocardial scar from the 12-lead electrocardiogram.
Objective
We aimed to assess the value of an automated version of the Selvester QRS score for the prediction of implantable cardioverter-defibrillator (ICD) therapy and death in patients undergoing primary prevention ICD implantation.
Methods
Unselected patients undergoing primary prevention ICD implantation were included in this retrospective, observational, multicenter study. The QRS score was calculated automatically from a digital standard preimplantation 12-lead electrocardiogram and was correlated to the occurrence of death and appropriate and inappropriate shocks during follow-up. Analyses were performed in groups defined by QRS duration < 130 ms vs ≥ 130 ms.
Results
Overall, 1047 patients (872 [83%] men; median age 64 years IQR [55-71]) with ischemic (648, 62%) or nonischemic (399, 38%) cardiomyopathy were included. The median QRS duration was 123 ms (interquartile range [IQR] 111-157 ms), and the median QRS score was 5 (IQR 2-8). The QRS duration was <130 ms in 59% and ≥130 ms in 41%. During a median follow-up of 45 months (IQR 24-72 months), a QRS score of ≥5 was independently associated with a significantly higher risk of mortality (hazard ratio [HR] 1.67; 95% confidence interval [CI] 1.05-2.66; P = .031) and appropriate (HR 1.83; 95% CI 1.07-3.14; P = .028) and inappropriate (HR 2.32; 95% CI 1.04-5.17; P = .039) shocks in patients with QRS duration ≥ 130 ms. No association of the QRS score and outcome was observed in patients with QRS duration < 130 ms (P > .05).
Conclusion
The automatically calculated Selvester QRS score, an indicator of myocardial scar burden, predicts mortality and appropriate and inappropriate shocks in patients undergoing primary prevention ICD implantation with a prolonged QRS duration.

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

Heart Rhythm: 29 Sep 2020; 17:1664-1671
Reichlin T, Asatryan B, Vos MA, Willems R, ... Sticherling C,
Heart Rhythm: 29 Sep 2020; 17:1664-1671 | PMID: 32428669
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Impact:
Abstract

Association of Life\'s Simple 7 with Atrial Fibrillation Burden (From the Atherosclerosis Risk in Communities [ARIC] Study).

Wang W, Norby FL, Rooney MR, Zhang M, ... Lutsey PL, Chen LY

The American Heart Association\'s Life\'s Simple 7 (LS7) metric consists of 7 modifiable risk factors. Although a more favorable LS7 risk factor profile is associated with lower AF incidence, this relationship is unknown in regard to AF burden. We assessed the prospective association of overall LS7 score and individual LS7 risk factors in midlife with AF burden in late-life in the Atherosclerosis Risk in Communities Study. LS7 components were assessed at Visit 3 (1993-95) and a composite score ranging from 0 to 14 was calculated. A higher score indicates better cardiovascular health. AF burden was measured at Visit 6 (2016-17) with a 2-week Zio® XT Patch. AF burden, defined as the percent of time a participant was in AF, was categorized as none, intermittent (>0 to <100%), or continuous (100%). Weighted multinomial logistic regression was used. Of the 2,363 participants, 58% were female and 24% were black. Participants were aged 57±5 years at Visit 3 and 79±5 years at Visit 6. From the Zio® XT Patch, 5% had continuous AF, 4% had intermittent AF, and 91% had none. After multivariable adjustment, each 1-point increase in LS7 score had 0.87 (95% CI: 0.79-0.95) higher odds of continuous AF than no AF. Individually, poor levels of physical activity, BMI, and fasting blood glucose were associated with greater AF burden. In conclusion, this population-based prospective cohort study reports that unfavorable cardiovascular health profile in midlife is associated with higher AF burden in late-life and future research to evaluate the effectiveness of optimizing physical activity, BMI, and fasting blood glucose in lowering AF burden is warranted.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 26 Sep 2020; epub ahead of print
Wang W, Norby FL, Rooney MR, Zhang M, ... Lutsey PL, Chen LY
Am J Cardiol: 26 Sep 2020; epub ahead of print | PMID: 32998009
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Impact:
Abstract

Diagnostic yield and long-term outcome of nonischemic sudden cardiac arrest survivors and their relatives: Results from a tertiary referral center.

Jacobsen EM, Hansen BL, Kjerrumgaard A, Tfelt-Hansen J, ... Bundgaard H, Winkel BG
Background
Cardiac arrest may be the first manifestation of most inherited cardiac diseases. International guidelines recommend screening of relatives of sudden cardiac arrest (SCA) survivors if an inherited cardiac disorder is suspected.
Objective
The purpose of this study was to assess the prevalence and spectrum of inherited cardiac diseases and the long-term outcome in a consecutive cohort of nonischemic SCA survivors (probands) and their relatives.
Methods
This retrospective study consecutively included probands and their relatives referred to our tertiary center for family screening between 2005 and 2018. All participants underwent a systematic workup and follow-up protocol. Data were retrieved from medical records.
Results
We included 155 probands (age 41.2 ± 15.5 years; 61% male) and 282 relatives (age 35.7 ± 18.8 years; 51% male). Mean follow-up was 7.1 years for probands and 4.4 years for relatives. We identified an inherited cardiac disease in 76 (49%) probands and 42 (15%) relatives. An implantable cardioverter-defibrillator was inserted in 147 (95%) probands and 9 (3%) relatives. During follow-up, 4 (3%) probands and 3 (1%) relatives died, and 37 probands and 2 relatives received appropriate shock therapy. All relatives received genetic counseling, and 18 (6%) relatives started pharmacologic treatment during follow-up.
Conclusion
Systematic workup of nonischemic SCA survivors and their relatives identified an inherited cardiac disease in 49% of referred probands and 15% of their relatives. The favorable long-term prognosis of diagnosed relatives probably not only reflects lower age but also the effects of early diagnosis, treatment, and follow-up. These findings support systematic workup of SCA survivors and their relatives.

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

Heart Rhythm: 29 Sep 2020; 17:1679-1686
Jacobsen EM, Hansen BL, Kjerrumgaard A, Tfelt-Hansen J, ... Bundgaard H, Winkel BG
Heart Rhythm: 29 Sep 2020; 17:1679-1686 | PMID: 32615163
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Impact:
Abstract

Outer loop and isthmus in ventricular tachycardia circuits: Characteristics and implications.

Frontera A, Pagani S, Limite LR, Hadjis A, ... Quarteroni A, Della Bella P
Background
The isthmus of ventricular tachycardia (VT) circuits has been extensively characterized. Few data exist regarding the contribution of the outer loop (OL) to the VT circuit.
Objective
The purpose of this study was to characterize the electrophysiological properties of the OL.
Methods
Complete substrate activation mapping during sinus rhythm (SR) and full activation mapping of the VT circuit with high-density mapping were performed. Maps were analyzed mathematically to reconstruct conduction velocities (CVs) within the circuit. CV >100 cm/s was defined as normal and <50 cm/s as slow. Electrograms along the entire circuit were analyzed for fractionation, duration, and amplitude.
Results
Six postmyocardial infarction patients were enrolled. The VT circuit was a figure-of-eight reentrant circuit in 4 patients and a single-loop circuit in 2 patients. The OL exhibited a mean of 1.9 ± 0.9 and 1.6 ± 0.5 corridors of slow conduction (SC) during VT and SR, respectively. SC in the OL were longer and faster than SC in the isthmus during SR. At the OL, SC sites showed local abnormal ventricular activity in 92%, and a bipolar voltage <0.5 mV was identified in 80.7%. Of the double-loop circuits, only 1 patient had fixed lines of block as isthmus boundaries, whereas in 3 patients the circuits were at least partially functional.
Conclusion
In ischemic reentrant VT circuits, the OL contributes significantly to reentry with multiple corridors of SC. These corridors can result from structural or functional phenomena. Isthmus boundaries may correspond to functional or fixed lines of block.

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

Heart Rhythm: 29 Sep 2020; 17:1719-1728
Frontera A, Pagani S, Limite LR, Hadjis A, ... Quarteroni A, Della Bella P
Heart Rhythm: 29 Sep 2020; 17:1719-1728 | PMID: 32497763
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Impact:
Abstract

Loss of ventricular preexcitation during noninvasive testing does not exclude high-risk accessory pathways: A multicenter study of WPW in children.

Escudero CA, Ceresnak SR, Collins KK, Pass RH, ... Etheridge SP, Janson CM
Background
Abrupt loss of ventricular preexcitation on noninvasive evaluation, or nonpersistent preexcitation, in Wolff-Parkinson-White syndrome (WPW) is thought to indicate a low risk of life-threatening events.
Objective
The purpose of this study was to compare accessory pathway (AP) characteristics and occurrences of sudden cardiac arrest (SCA) and rapidly conducted preexcited atrial fibrillation (RC-AF) in patients with nonpersistent and persistent preexcitation.
Methods
Patients 21 years or younger with WPW and invasive electrophysiology study (EPS) data, SCA, or RC-AF were identified from multicenter databases. Nonpersistent preexcitation was defined as absence/sudden loss of preexcitation on electrocardiogram, Holter monitoring, or exercise stress test. RC-AF was defined as clinical preexcited atrial fibrillation with shortest preexcited R-R interval (SPERRI) ≤ 250 ms. AP effective refractory period (APERP), SPERRI at EPS , and shortest preexcited paced cycle length (SPPCL) were collected. High-risk APs were defined as APERP, SPERRI, or SPPCL ≤ 250 ms.
Results
Of 1589 patients, 244 (15%) had nonpersistent preexcitation and 1345 (85%) had persistent preexcitation. There were no differences in sex (58% vs 60% male; P=.49) or age (13.3±3.6 years vs 13.1±3.9 years; P=.43) between groups. Although APERP (344±76 ms vs 312±61 ms; P<.001) and SPPCL (394±123 ms vs 317±82 ms; P<.001) were longer in nonpersistent vs persistent preexcitation, there was no difference in SPERRI at EPS (331±71 ms vs 316±73 ms; P=.15). Nonpersistent preexcitation was associated with fewer high-risk APs (13% vs 23%; P<.001) than persistent preexcitation. Of 61 patients with SCA or RC-AF, 6 (10%) had nonpersistent preexcitation (3 SCA, 3 RC-AF).
Conclusion
Nonpersistent preexcitation was associated with fewer high-risk APs, though it did not exclude the risk of SCA or RC-AF in children with WPW.

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

Heart Rhythm: 29 Sep 2020; 17:1729-1737
Escudero CA, Ceresnak SR, Collins KK, Pass RH, ... Etheridge SP, Janson CM
Heart Rhythm: 29 Sep 2020; 17:1729-1737 | PMID: 32497761
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Abstract

Purkinje system hyperexcitability and ventricular arrhythmia risk in type 3 long QT syndrome.

Barake W, Giudicessi JR, Asirvatham SJ, Ackerman MJ
Background
Gain-of-function variants in the SCN5A-encoded Na1.5 sodium channel cause type 3 long QT syndrome (LQT3) and multifocal ectopic Purkinje-related premature contractions. Although the Purkinje system is uniquely sensitive to the action potential-prolonging effects of LQT3-causative variants, the existence of additional Purkinje phenotype(s) in LQT3 is unknown.
Objective
The purpose of this study was to determine the prevalence and clinical implications of frequent fascicular/Purkinje-related premature ventricular contractions (PVCs) and short-coupled ventricular arrhythmias (VAs), suggestive of Purkinje system hyperexcitability (PSH), in a single-center LQT3 cohort.
Methods
A retrospective analysis of 177 SCN5A-positive patients was performed to identify individuals with a LQT3 phenotype. Available electrocardiographic, electrophysiology study, device, and genetic data from 91 individuals with LQT3 were reviewed for evidence of presumed fascicular PVCs and short-coupled VAs. The relationship between PSH and ventricular fibrillation events was assessed by Kaplan-Meier and Cox regression analyses.
Results
Overall, 30 of 91 patients with LQT3 (33%) exhibited evidence of presumed PSH (fascicular PVCs 30 of 30 [100%]; short-coupled VAs 17 of 30 [56%]). Kaplan-Meier and Cox regression analyses demonstrated an increased risk of ventricular fibrillation events in individuals with LQT3 and PSH (log-rank, P < .03; hazard ratio 3.95; 95% confidence interval 1.15-15.7; P = .03). Interestingly, variants in the voltage-sensing domain regions of Na1.5 were more frequently observed in patients with LQT3 and PSH than those without (19 of 30 [63%] vs 9 of 61 [15%]; P < .0001).
Conclusion
This study demonstrates that a discernible Purkinje phenotype is present in one-third of LQT3 cases and increases the risk of potentially lethal VAs. Further study is needed to determine whether a distinct cellular electrophysiology phenotype underlies this phenomenon.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 29 Sep 2020; 17:1768-1776
Barake W, Giudicessi JR, Asirvatham SJ, Ackerman MJ
Heart Rhythm: 29 Sep 2020; 17:1768-1776 | PMID: 32454217
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Abstract

QRS morphology in lead V for the rapid localization of idiopathic ventricular arrhythmias originating from the left ventricular papillary muscles: A novel electrocardiographic criterion.

Briceño DF, Santangeli P, Frankel DS, Liang JJ, ... Marchlinski FE, Schaller RD
Background
Twelve-lead electrocardiogram (ECG) criteria have been developed to identify idiopathic ventricular arrhythmias (VAs) from the left ventricular (LV) papillary muscles (PAPs), but accurate localization remains a challenge.
Objective
The purpose of this study was to develop ECG criteria for accurate localization of LV PAP VAs using lead V exclusively.
Methods
Consecutive patients undergoing mapping and ablation of VAs from the LV PAPs guided by intracardiac echocardiography from 2007 to 2018 were reviewed (study group). The QRS morphology in lead V was compared to patients with VAs with a \"right bundle branch block\" morphology from other LV locations (reference group). Patients with structural heart disease were excluded.
Results
One hundred eleven patients with LV PAP VAs (mean age 54 ± 16 years; 65% men) were identified, including 64 (55%) from the posteromedial PAP and 47 (42%) from the anterolateral PAP. The reference group included patients with VAs from the following LV locations: fascicles (n = 21), outflow tract (n = 36), ostium (n = 37), inferobasal segment (n = 12), and apex (5). PAP VAs showed 3 distinct QRS morphologies in lead V 93% of the time: Rr (53%), R with a slurred downslope (29%), and RR (11%). Sensitivity, specificity, positive predictive value, and negative predictive value for the 3 morphologies combined are 93%, 98%, 98%, and 93%, respectively. The intrinsicoid deflection of PAP VAs in lead V was shorter than that of the reference group (63 ± 13 ms vs 79 ± 24 ms; P < .001). An intrinsicoid deflection time of <74 ms best differentiated the 2 groups (sensitivity 79%; specificity 87%).
Conclusion
VAs originating from the LV PAPs manifest unique QRS morphologies in lead V, which can aid in rapid and accurate localization.

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

Heart Rhythm: 29 Sep 2020; 17:1711-1718
Briceño DF, Santangeli P, Frankel DS, Liang JJ, ... Marchlinski FE, Schaller RD
Heart Rhythm: 29 Sep 2020; 17:1711-1718 | PMID: 32454219
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Impact:
Abstract

Ventricular tachycardia in cardiolaminopathy: Characteristics and considerations for device programming.

Sidhu K, Han L, Picard KCI, Tedrow UB, Lakdawala NK
Background
Mutations in LMNA cause an arrhythmogenic cardiomyopathy (cardiolaminopathy) with high risk of ventricular tachycardia (VT). The natural history of VT among patients with cardiolaminopathy is incompletely understood.
Objective
The purpose of this study was to determine the longitudinal burden and progression of VT, including change in tachycardia cycle length (TCL), response to antitachycardia pacing (ATP), and prognostic significance of high-burden VT (>5 episodes of VT at any device interrogation) in cardiolaminopathy patients.
Methods
Patients with cardiolaminopathy and an implantable cardioverter-defibrillator (ICD) were identified from a single-center database. Serial device interrogations and medical records were used to collect data on VT burden, TCL, and response to ATP.
Results
Cardiolaminopathy patients with primary (n = 27) or secondary prevention (n = 16) ICDs were followed for 2 years (interquartile range [IQR] 1-5). VT burden was substantially higher in patients receiving secondary prevention ICDs (28 ± 40.9 vs 3.6 ± 7.3 episodes per 100 patient-years; P <.001). ATP was highly effective (94%) at terminating VT except for short TCL (<250 ms), for which ATP failed in 60%. Among patients with recurrent VT, TCL increased by 112 ± 93.6 ms during follow-up. Inappropriate shocks were rare (0.4% of all therapies). Median time to transplantation, ventricular assist device, or death was 18 months (IQR 0.7-27.1) in patients with high-burden VT.
Conclusion
In patients with cardiolaminopathy, VT is recurrent and highly responsive to ATP, which supports the use of transvenous ICDs iteratively programmed to manage VT of various TCLs. Onset of high-burden VT indicates poor prognosis and should warrant referral to a heart failure specialist.

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

Heart Rhythm: 29 Sep 2020; 17:1704-1710
Sidhu K, Han L, Picard KCI, Tedrow UB, Lakdawala NK
Heart Rhythm: 29 Sep 2020; 17:1704-1710 | PMID: 32454220
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Impact:
Abstract

Electrocardiographic interpretation of pacemaker algorithms enabling minimal ventricular pacing.

Mond HG

Cardiac pacing from the apex of the right ventricle has been shown to result in left ventricular dysfunction, atrial fibrillation, and increased mortality. To counter these effects, one of the strategies developed is avoidance of ventricular pacing when not necessary, using programmable algorithms to minimize ventricular pacing. Seven algorithms are available from 5 manufacturers. Four of the manufacturers have mode conversion algorithms that pace AAI(R) but, in the presence of failed atrioventricular (AV) conduction, demonstrate algorithm-offset and convert to DDD(R) with ventricular pacing. Three manufacturers do not have mode conversion but rather AV extension to encourage AV conduction. Each of these algorithms has a unique design and, when ventricular pacing is present, will regularly schedule conduction testing to encourage AV conduction and hence algorithm-onset. All of these algorithms seem to violate the rule of AV conduction by allowing the AV delay for sensed ventricular events to be longer than for ventricular paced events. The result is frequently bizarre electrocardiographic (ECG) appearances that often are unique to the company\'s algorithm but also suggest pacemaker malfunction. This review highlights and illustrates the features of these algorithms as they appear on ECG, and discusses other situations that result in unintended ventricular pacing.

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

Heart Rhythm: 29 Sep 2020; 17:1784-1792
Mond HG
Heart Rhythm: 29 Sep 2020; 17:1784-1792 | PMID: 32413512
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Abstract

Comparison of cardiovascular screening in college athletes by history and physical examination with and without an electrocardiogram: Efficacy and cost.

Harmon KG, Suchsland MZ, Prutkin JM, Owens DS, ... Malik A, Drezner JA
Background
Preparticipation screening for conditions associated with sudden cardiac death (SCD) is required in college athletes. Previous cost analyses used theoretical models based on variable assumptions, but no study used real-life outcomes.
Objective
The purpose of this study was to compare disease prevalence, positive findings, and costs of 2 different screening strategies: history and physical examination alone (H&P) or with an electrocardiogram (H&P+ECG).
Methods
De-identified preparticipation data (2009-2017) from Pacific-12 Conference institutions were abstracted for cardiovascular history questions, cardiovascular physical examination, and ECG result. Secondary testing, cardiac diagnoses, return to play outcomes, and complications from testing were recorded. The costs of screening and secondary testing were based on the Centers for Medicare & Medicaid Services Physician Fee Schedule.
Results
A total of 8602 records (4955 H&P, 3647 H&P+ECG) were included. Eleven conditions associated with SCD were detected (2 H&P only, 9 H&P+ECG). The prevalence of cardiovascular conditions associated with SCD discovered with H&P alone was 0.04% (1/2454) compared to 0.24% (1/410) when ECG was added (P = .01) (odds ratio 5.17; 95% confidence interval 1.28-20.85; P = .02). Cost of screening and secondary testing with H&P alone was $130 per athlete and in the ECG-added group was $152 per athlete. The cost per diagnosis was $312,407 in the H&P group and $61,712 in the ECG-added group. There were no adverse outcomes from secondary testing or treatment.
Conclusion
H&P with the addition of ECG is 6 times more likely to detect a cardiovascular condition associated with SCD than without. The addition of ECG improves the cost efficiency per diagnosis by 5-fold and should be considered at college institutions with appropriate resources.

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

Heart Rhythm: 29 Sep 2020; 17:1649-1655
Harmon KG, Suchsland MZ, Prutkin JM, Owens DS, ... Malik A, Drezner JA
Heart Rhythm: 29 Sep 2020; 17:1649-1655 | PMID: 32380289
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Abstract

Improvement in sudden cardiac death risk prediction by the enhanced American College of Cardiology/American Heart Association strategy in Chinese patients with hypertrophic cardiomyopathy.

Liu J, Wu G, Zhang C, Ruan J, ... Wang J, Song L
Background
The lack of validated and effective sudden cardiac death (SCD) risk prediction methods is the biggest barrier to perform the lifesaving treatment with a prophylactic implantable cardioverter-defibrillator in Chinese patients with hypertrophic cardiomyopathy (HCM).
Objective
This study aimed to evaluate the efficacy of 3 existing SCD risk prediction methods recommended by the 2011 American College of Cardiology Foundation and American Heart Association (ACCF/AHA) guideline, the 2014 European Society of Cardiology (ESC) guideline, and the 2019 enhanced American College of Cardiology (ACC)/AHA strategy in Chinese patients with HCM.
Methods
The present study consisted of 1369 consecutive adult patients with HCM without a history of SCD events. The primary end point was a composite of SCD and equivalent events, namely, resuscitation from cardiac arrest and appropriate implantable cardioverter-defibrillator shock therapy for ventricular tachycardia or fibrillation.
Results
During follow-up of 3.2 ± 2.4 years, 39 patients reached SCD end points, of whom 26 (66.7%) were correctly predicted as those at a high risk of SCD by using methods recommended by the 2019 enhanced ACC/AHA strategy, 20 (51.3%) by the 2011 ACCF/AHA guideline, but only 5 (12.8%) by the 2014 ESC guideline. The 2019 enhanced ACC/AHA strategy showed a higher C-statistic (0.647) for SCD prediction than did the 2011 ACCF/AHA guideline (0.598) and 2014 ESC guideline (0.605) and resulted in the correct reclassification of SCD risk when compared with the 2011 ACCF/AHA guideline (net reclassification index 0.113; P = .074) and 2014 ESC guideline (net reclassification index 0.245; P = .038).
Conclusion
The 2019 enhanced ACC/AHA strategy showed better predictive performance for SCD risk stratification in Chinese patients with HCM, with a notably high sensitivity.

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

Heart Rhythm: 29 Sep 2020; 17:1658-1663
Liu J, Wu G, Zhang C, Ruan J, ... Wang J, Song L
Heart Rhythm: 29 Sep 2020; 17:1658-1663 | PMID: 32311532
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Abstract

Left cardiac sympathetic denervation reduces skin sympathetic nerve activity in patients with long QT syndrome.

Han J, Ackerman MJ, Moir C, Cai C, ... Chen PS, Cha YM
Background
Although left cardiac sympathetic denervation (LCSD) is an effective antiarrhythmic therapy for patients with long QT syndrome (LQTS), direct evidence of reduced sympathetic activity after LCSD in humans is limited.
Objective
The purpose of this study was to assess skin sympathetic nerve activity (SKNA) in patients with LQTS undergoing LCSD.
Methods
We prospectively enrolled 17 patients with LQTS who underwent LCSD between 2017 and 2019. SKNA recordings from the left arm (L-SKNA) and chest (C-SKNA) leads were performed before and after LCSD. Mean SKNA, burst activity, and nonburst activity of L-SKNA and C-SKNA were analyzed.
Results
The mean patient age was 21 ± 9 years (8 men 47%). The longest baseline corrected QT value was 497 ± 55 ms at rest and 531 ± 38 ms on exercise stress testing. Five patients (29.4%) had previous LQTS-triggered cardiac events including syncope, documented torsades de pointes, and ventricular fibrillation. In the 24 hours after LCSD, mean L-SKNA decreased from 1.25 ± 0.64 to 0.85 ± 0.33 μV (P = .005) and mean C-SKNA from 1.36 ± 0.67 to 1.05 ± 0.49 μV (P = .11). The frequency of episodes of SKNA bursts recorded from the left-arm lead (2.87 ± 1.61 bursts per minute vs 1.13 ± 0.99 bursts per minute; P < .001) and mean L-SKNA during burst (1.82 ± 0.79 μV vs 1.15 ± 0.44 μV; P < .001) and nonburst (1.09 ± 0.60 μV vs 0.75 ± 0.32 μV; P = .03) periods significantly decreased after LCSD, while the frequency of episodes of SKNA bursts recorded from the chest lead (P = .57) and mean C-SKNA during burst (P = .44) and nonburst (P = .10) periods did not change significantly. No arrhythmic events were documented after 11.9 months (range 3.0-22.2 months) of follow-up.
Conclusion
LCSD provides an inhibitory effect on cardiac sympathetic activity by suppressing burst discharge as measured by SKNA.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 29 Sep 2020; 17:1639-1645
Han J, Ackerman MJ, Moir C, Cai C, ... Chen PS, Cha YM
Heart Rhythm: 29 Sep 2020; 17:1639-1645 | PMID: 32276050
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Impact:
Abstract

Mapping and ablation of clinical spontaneous peri-mitral atrial tachycardias using an ultra-high resolution mapping system.

Miyazaki S, Hasegawa K, Yamao K, Ishikawa E, ... Iesaka Y, Tada H
Background
Peri-mitral atrial tachycardias (PMATs) are common ATs, yet the mechanisms vary.
Objective
We sought to characterize clinical spontaneous PMATs using an ultra-high resolution mapping (UHRM) system.
Methods
This study included 32 consecutive PMATs in 31 patients who underwent AT mapping/ablation using UHRM systems.
Results
Six, 10, 11, and 5 PMATs occurred in cardiac intervention-naïve (Group-A), post- lateral/posterior mitral isthmus linear ablation (Group-B), post-atrial fibrillation ablation without mitral isthmus linear ablation (Group-C), and post-cardiac surgery (Group-D) patients, respectively. Group-A tended to be older and more likely female and had sinus node or atrioventricular conduction disturbances more frequently. A 12-lead synchronous isoelectric interval was observed in 15 (46.9%) PMATs. Coronary sinus activation was proximal-to-distal or distal-to-proximal except in 3 PMATs with straight patterns owing to epicardial gaps. LA anterior/septal wall (LAASW) low voltage areas were smallest in group-B. Slow conduction areas (SCAs) were identified in 26 (81.2%) PMATs and were on the LAASW in all group-A and group-D patients. The conduction velocity in the SCAs was slowest in group-B. In group-B, all PMATs were terminated by single applications, and the gaps were located epicardially in 5/10 (50%). Anterior (n=23) or lateral/posterior (n=9) mitral isthmus linear block was successfully created without any complications in all. Twenty-five concomitant ATs among 18 (58.1%) patients were also eliminated. During 20.0[11.0-40.0] months of follow-up, 28 (90.3%) patients were free from any atrial tachyarrhythmias.
Conclusion
A UHRM-guided approach with identification of the individual tachycardia mechanism should be the preferred strategy since arrhythmia mechanisms are distinct and complex.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 28 Sep 2020; epub ahead of print
Miyazaki S, Hasegawa K, Yamao K, Ishikawa E, ... Iesaka Y, Tada H
Heart Rhythm: 28 Sep 2020; epub ahead of print | PMID: 33007441
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Impact:
Abstract

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

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

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

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Arora S, Jaswaney R, Jani C, Zuzek Z, ... Viles-Gonzalez J, Deshmukh A
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 33002464
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Impact:
Abstract

Anticoagulation for Stroke Prevention in Patients With Hypertrophic Cardiomyopathy and Atrial Fibrillation: A Review.

Nasser MF, Gandhi S, Siegel RJ, Rader F

Atrial fibrillation is the most common arrhythmia in patients with hypertrophic cardiomyopathy with a prevalence and incidence of 23% and 3.1% respectively. The risk of thromboembolism is high in patients with hypertrophic cardiomyopathy regardless of the CHADS2VASC score. This review includes five observational studies that focused on prevention of thromboembolism in patients with hypertrophic cardiomyopathy and atrial fibrillation. These papers evaluated and compared outcomes between patients on either warfarin or direct oral anticoagulants. Data showed that direct oral anticoagulants are effective and safe in this patient population and also may have a benefit over warfarin in thromboprophylaxis in patients with hypertrophic cardiomyopathy and atrial fibrillation. In conclusion, lifelong anticoagulation with warfarin is recommended to prevent thromboembolism in patients with atrial fibrillation and hypertrophic cardiomyopathy due to high risk of thromboembolism. The available observational data reviewed here suggests that direct oral anticoagulants may be safe and effective to be used in this patient population. However, adequately powered randomized controlled trials are needed to confirm their efficacy and safety.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 02 Oct 2020; epub ahead of print
Nasser MF, Gandhi S, Siegel RJ, Rader F
Heart Rhythm: 02 Oct 2020; epub ahead of print | PMID: 33022393
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Impact:
Abstract

Critical repolarization gradients determine the induction of reentry-based Torsade de Pointes arrhythmia in models of long QT syndrome.

Rivaud MR, Bayer JD, Cluitmans M, van der Waal J, ... Meijborg VMF, Coronel R
Background
Torsade de Pointes arrhythmia is a potentially lethal polymorphic ventricular tachyarrhythmia (pVT) in the setting of long QT syndrome. Arrhythmia susceptibility is influenced by risk factors modifying repolarization.
Objective
To characterize repolarization duration and heterogeneity in relation to pVT inducibility and maintenance.
Methods
Sotalol was infused regionally or globally in isolated Langendorff blood-perfused pig hearts (N=7) to create repolarization time (RT) heterogeneities. Programmed stimulation and epicardial activation and repolarization mapping were performed. The role of RT (heterogeneities) was studied in more detail using a computer model of the human heart.
Results
pVTs (n=11) were inducible at a critical combination of RT and RT heterogeneities. The pVT cycle lengths were similar in the short and long RT regions. Short-lasting pVTs were maintained by focal activity while longer-lasting pVTs by reentry wandering along the interface between the two regions. Local restitution curves from the long and short RT regions crossed. This was associated with T-wave inversion at coupling intervals at either side of the crossing-point. These experimental observations were confirmed by the computer simulations.
Conclusions
pVTs are inducible within a critical range of RT and RT heterogeneities and are maintained by reentry wandering along the repolarization gradient. Double potentials localize at the core of the reentrant circuit and reflect phase singularities. RT gradient and T-waves invert with short coupled premature beats in the long RT region as a result of the crossing of the restitution curves allowing reentry initiation.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 04 Oct 2020; epub ahead of print
Rivaud MR, Bayer JD, Cluitmans M, van der Waal J, ... Meijborg VMF, Coronel R
Heart Rhythm: 04 Oct 2020; epub ahead of print | PMID: 33031961
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Impact:
Abstract

Blood-based 8-hydroxy-2\'-deoxyguanosine level: a potential diagnostic biomarker for Atrial Fibrillation.

Li J, Zhang D, Ramos KS, Baks L, ... de Groot NMS, Brundel BJJM
Background
Recent research findings revealed key role for oxidative DNA damage in the pathogenesis of atrial fibrillation (AF). Therefore, a circulating oxidative DNA damage marker 8-hydroxy-2\'-deoxyguanosine (8-OHdG) may represent a biomarker to stage AF and identify patients at risk for AF recurrence and POAF after treatment.
Objectives
To investigate whether serum levels of 8-OHdG correlate with the stage of AF, recurrence after AF treatment and onset of post-operative AF (POAF) after cardiac surgery.
Methods
In this prospective and observational study, 8-OHdG levels are detected by ELISA in human serum samples. Blood samples were collected from control patients without AF history, paroxysmal AF and persistent AF patients undergoing electrical cardioversion (ECV) or pulmonary vein isolation (PVI), and sinus rhythm (SR) patients undergoing cardiac surgery. AF recurrence was determined during 12 months follow-up. Univariate and multivariate analysis were used to identify changes in 8-OHdG levels between the groups.
Results
Compared to the control group, 8-OHdG levels gradually and significantly increased during progression of this arrhythmia. Also 8-OHdG levels in AF patients showing an AF recurrence after PVI treatment were significantly increased compared to patients without AF recurrence. Moreover, in SR patients undergoing cardiac surgery, 8-OHdG levels were significantly elevated in patients showing POAF compared to patients without POAF.
Conclusions
The level of 8-OHdG may represent a potential diagnostic biomarker for AF staging, as well as prediction of AF recurrence and POAF after treatment.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 04 Oct 2020; epub ahead of print
Li J, Zhang D, Ramos KS, Baks L, ... de Groot NMS, Brundel BJJM
Heart Rhythm: 04 Oct 2020; epub ahead of print | PMID: 33031960
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Impact:
Abstract

Implant, Performance, and Retrieval of an Atrial Leadless Pacemaker in Sheep.

Vatterott PJ, Eggen MD, Hilpisch KE, Drake RA, ... Mesich ML, Ramon LC
Background
Medtronic is developing an atrial Micra™ Transcatheter Pacing System and associated retrieval system.
Objective
To evaluate chronic atrial Micra retrieval, re-implant, and chronic pacing performance.
Methods
Sheep were implanted in two groups. Group 1 (G1, n=6) for six months, a second device implanted and first retrieved and studied an additional six months. Group 2 (G2, n=6) for six months, devices were retrieved, and a second device implanted and observed acutely. Both groups underwent histopathologic evaluation. Pacing capture threshold (PCT), p-waves, and pacing impedances were measured chronically. Device retrieval times recorded and intracardiac echo was used.
Results
At 24 weeks, PCTs for G1 were low and stable for both the first device (0.55±0.14V) and second device (0.57±0.09V) where average retrieval time was 17:35 minutes (min). For G2, average retrieval time was 6:12 min, chronic PCTs in the first device were (0.53±0.11V), and acute PCTs for the second device were 0.71±0.19V. Pathologic findings were within an expected range of tissue responses for similar Micra acute and chronic implants and device retrievals. P-waves and impedance were stable and within an expected range for implant site and electrode design. Complications included one early dislodgement and one death attributed to a prototype retrieval tool.
Conclusions
In an animal model an atrial Micra can be easily implanted with excellent chronic pacing performance and is easily retrievable at six months. A second device can successfully be implanted with low, chronic stable thresholds. A developed prototype retrieval tool was easy to use and, with modifications, complication free.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 05 Oct 2020; epub ahead of print
Vatterott PJ, Eggen MD, Hilpisch KE, Drake RA, ... Mesich ML, Ramon LC
Heart Rhythm: 05 Oct 2020; epub ahead of print | PMID: 33035647
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Impact:
Abstract

Effect of Temporary Interruption of Warfarin Due to an Intervention on Downstream Time in Therapeutic Range in Patients With Atrial Fibrillation (from ORBIT AF).

Madhavan M, Holmes DN, Piccini JP, Freeman JV, ... Gersh BJ,

The aim of this study was to quantify time in therapeutic range (TTR) before and after a temporary interruption of warfarin due to an intervention in the Outcomes Registry for Better Informed Treatment of atrial fibrillation (AF). AF patients on warfarin who had a temporary interruption followed by resumption were identified. A nonparametric method for estimating survival functions for interval censored data was used to examine the first therapeutic International Normalized Ratio (INR) after interruption. TTR was compared using Wilcoxon signed rank test. Cox proportional hazards model was used to investigate the association between TTR in the first 3 months after interruption and subsequent outcomes at 3 to 9 months. Of 9,749 AF patients, 71% were on warfarin. Over a median (IQR) follow-up of 2.6 (1.8 to 3.1) y, 33% of patients had a total of 3,022 temporary interruptions. The first therapeutic INR was recorded within 1 week in 35.0% (95% confidence interval 32.6% to 37.4%), 2 weeks in 54.6% (52.2% to 57.0%), 30 days in 70.0% (67.9% to 72.1%) and 90 days in 91.3% (90.0% to 92.5%) of patients. Compared with pre-interruption, TTR 3 months after interruption was significantly lower (61.1% [36.6% to 85.0%] vs 67.6% [50.0% to 81.3%], p <0.0001). A 10 unit increment in the TTR in the first 3 months after interruption was associated with a lower risk of major bleeding [Hazard ratio 0.91 (0.85 to 0.97), p = 0.005]. This association was noted in patients who received bridging anticoagulation, but not in those who did not. In conclusion, temporary interruption of warfarin is common, and nearly half of these patients had subtherapeutic INR after 2 weeks. Lower TTR in the first 3 months after interruption was associated with higher incidence of major bleeding in patients who received bridging anticoagulation.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2020; 132:66-71
Madhavan M, Holmes DN, Piccini JP, Freeman JV, ... Gersh BJ,
Am J Cardiol: 30 Sep 2020; 132:66-71 | PMID: 32826041
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Abstract

Levothyroxine dose and risk of atrial fibrillation: a nested case-control study.

Gong IY, Atzema CL, Lega IC, Austin PC, ... Rochon PA, Lipscombe LL
Background
Contemporary data on the effect of levothyroxine dose on the occurrence of atrial fibrillation (AF) are lacking, particularly in the older population. Our objective was to determine the effect of cumulative levothyroxine exposure on risk of AF and ischemic stroke in older adults.
Methods
We conducted a population-based observational study using healthcare databases from Ontario, Canada. We identified adults aged ≥66 years without a history of AF who filled at least one levothyroxine prescription between April 1 2007 and March 31 2016. Cases were defined as cohort members who had incident AF (emergency room visit or hospitalization) between the date of first levothyroxine prescription and December 31, 2017. Index date was date of AF. Cases were matched with up to five controls without AF on the same index date. Secondary outcome was ischemic stroke. Cumulative levothyroxine exposure was estimated based on total milligrams (mg) of levothyroxine dispensed in the year prior to index date. Using nested case-control approach, we compared outcomes between older adults who received high (≥0.125 mg/day), medium (0.075-0.125 mg/day), or low (0-0.075 mg/day) cumulative levothyroxine dose. We compared outcomes between current, recent past, and remote past levothyroxine use.
Results
Of 189,672 older adults treated with levothyroxine (mean age 82 years; 72% women), 30,560 (16.1%) had an episode of AF. Compared to low levothyroxine exposure, high and medium exposure was associated with significantly increased risk of AF after adjustment for covariates (adjusted odds ratio, aOR 1.29, 95% confidence interval, CI 1.23-1.35; aOR 1.08, 95% CI 1.04-1.11; respectively). No association was observed between levothyroxine exposure and ischemic stroke. Compared with current levothyroxine use, older adults with remote levothyroxine use had lower risks of AF (aOR 0.56, 95% CI 0.52-0.59) and ischemic stroke (aOR 0.61, 95% CI 0.56-0.67).
Conclusions
Among older persons treated with levothyroxine, levothyroxine at doses above 0.075 mg/day is associated with an increased risk of AF compared to lower exposure.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am Heart J: 02 Oct 2020; epub ahead of print
Gong IY, Atzema CL, Lega IC, Austin PC, ... Rochon PA, Lipscombe LL
Am Heart J: 02 Oct 2020; epub ahead of print | PMID: 33022231
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Abstract

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

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

Cessation of oral anticoagulation (OAC) is common after the first 3 months of catheter ablation of atrial fibrillation (AF); however, thromboembolic risk has not been defined in patients with and without AF recurrence (RAF vs. NRAF) post ablation. We identified 796 patients who discontinued OAC at 3 months post AF ablation from January 2015 to May 2018 in our center. Regular follow-up was performed to detect RAF, collect medication management and thromboembolic and major bleeding events. CHADS-VASc score was 1.79±1.50; 547 (68.7%) patients were at intermediate and high risk (i.e. CHADS-VASc score ≥1 in male patients, or ≥2 in female patients); 169 (21.2%) were RAF. During 29.2±12.2 months follow-up, the incidence rate of thromboembolism was 1.62 per 100 patient-year (7 in 431 years) in RAF, 0.33 per 100 patient-year (5 in 1503 years) in NRAF. After adjusting for potential confounding factors, RAF was associated with more 3.5-fold higher rate of thromboembolism compared with NRAF (adjusting HR, 4.488; 95%CI, 1.381-14.586). Rate of thromboembolism was even higher in patients with intermediate and high risk (2.16 per 100 patient-year [7 in 323 years] versus 0.38 per 100 patient-year [4 in 1043 years], aHR, 5.807; 95%CI, 1.631-20.671). In multivariate logistic regression analysis, RAF was the only independent predictor of thromboembolism (4.837 [1.498-15.621], P=0.008). In conclusion, cessation of OAC in NRAF may be reasonable, especially for patients with the contraindications for continuing OAC; however, cessation of OAC appeared unsafe in RAF with a high-risk stroke profile because of high incidence rate of thromboembolism.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 27 Sep 2020; epub ahead of print
Rong B, Han W, Lin M, Hao L, ... Wang R, Zhong J
Am J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 33002462
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Abstract

Combined Epicardial and Endocardial Ablation for Atrial Fibrillation: Best Practices and Guide to Hybrid Convergent Procedures.

Makati KJ, Sood N, Lee LS, Yang F, ... Tondo C, Steinberg JS

The absence of strategies to consistently and effectively address non-paroxysmal atrial fibrillation (AF) by nonpharmacologic interventions has represented a longstanding treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to complete isolation of the pulmonary veins and for additional ablation as needed. Experience gained with the hybrid Convergent procedure during the last decade has led to the development and adoption of strategies to optimize the technique and mitigate risks. Additionally, a surgical and electrophysiology \"team\" approach including comprehensive training is believed critical to successfully develop the hybrid Convergent program. A recently completed randomized clinical trial indicated that this ablation strategy is superior to an endocardial only approach for patients with persistent AF. In this review, we propose and describe best practice guidelines for hybrid Convergent ablation based on a combination of published data, author consensus, and expert opinion. A summary of clinical outcomes, emerging evidence, and future perspectives are also discussed.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 08 Oct 2020; epub ahead of print
Makati KJ, Sood N, Lee LS, Yang F, ... Tondo C, Steinberg JS
Heart Rhythm: 08 Oct 2020; epub ahead of print | PMID: 33045430
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Abstract

A randomized clinical trial to evaluate the efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valve and atrial fibrillation or flutter: Rationale and design of the RIVER trial.

Guimarães HP, de Barros E Silva PGM, Liporace IL, Sampaio RO, ... Berwanger O,
Background
The efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valves and atrial fibrillation or flutter remain uncertain.
Design
RIVER was an academic-led, multicenter, open-label, randomized, non-inferiority trial with blinded outcome adjudication that enrolled 1005 patients from 49 sites in Brazil. Patients with a bioprosthetic mitral valve and atrial fibrillation or flutter were randomly assigned (1:1) to rivaroxaban 20mg once daily (15mg in those with creatinine clearance <50mL/min) or dose-adjusted warfarin (target international normalized ratio 2.0-30.); the follow-up period was 12months. The primary outcome was a composite of all-cause mortality, stroke, transient ischemic attack, major bleeding, valve thrombosis, systemic embolism, or hospitalization for heart failure. Secondary outcomes included individual components of the primary composite outcome, bleeding events, and venous thromboembolism.
Summary
RIVER represents the largest trial specifically designed to assess the efficacy and safety of a direct oral anticoagulant in patients with bioprosthetic mitral valves and atrial fibrillation or flutter. The results of this trial can inform clinical practice and international guidelines.

Copyright © 2020. Published by Elsevier Inc.

Am Heart J: 08 Oct 2020; epub ahead of print
Guimarães HP, de Barros E Silva PGM, Liporace IL, Sampaio RO, ... Berwanger O,
Am Heart J: 08 Oct 2020; epub ahead of print | PMID: 33045224
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Abstract

Cardiovascular Events and Mortality in Patients With Atrial Fibrillation and Anemia (from the Fushimi AF Registry).

An Y, Ogawa H, Esato M, Ishii M, ... Akao M,

Data regarding the associations of anemia (hemoglobin level <13.0 g/dl in men and <12.0 g/dl in women) with clinical outcomes in patients with atrial fibrillation (AF) remains scarce. This study sought to investigate the associations of anemia with the incidences of stroke or systemic embolism, major bleeding, heart failure (HF) hospitalization, and all-cause mortality including its causes, using the data from a Japanese community-based survey, the Fushimi AF Registry. A total of 4,169 AF patients were divided into the 3 groups, based on the baseline hemoglobin level: no (n = 2,622), mild (11.0 to <13.0 g/dl for men and <12.0 g/dl for women; n = 880), and moderate/severe anemia (<11.0 g/dl; n = 667). During a median follow-up of 1,464 days, the incidences of major bleeding, HF hospitalization, and mortality increased with higher rates of cardiac death, in accordance with anemic severity. On multivariate analyses, the higher risk of moderate/severe anemia, relative to no anemia, for major bleeding remained statistically significant (hazard ratio [HR]: 2.00, 95% confidential interval [CI]: 1.48 to 2.72). The risks of those with anemia, relative to no anemia, for HF hospitalization (mild; HR: 1.87, 95% CI: 1.51 to 2.31, and moderate/severe; HR: 2.02, 95% CI: 1.59 to 2.57) as well as for mortality (mild; HR: 1.80, 95% CI: 1.50 to 2.16, and moderate/severe; HR: 2.95, 95% CI: 2.45 to 3.55) were also higher, but not for stroke/systemic embolism. These relations were consistent, regardless of the use of oral anticoagulants. In conclusion, anemia was associated with higher risks of HF hospitalization, mortality, and major bleeding in AF patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:74-82
An Y, Ogawa H, Esato M, Ishii M, ... Akao M,
Am J Cardiol: 31 Oct 2020; 134:74-82 | PMID: 32900468
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Abstract

Cardiac Imaging to assess Left Ventricular Systolic Function in Atrial Fibrillation.

Bunting KV, O\'Connor K, Steeds RP, Kotecha D

The validity and reproducibility of systolic function assessment in patients with atrial fibrillation (AF) using cardiac magnetic resonance (CMR), echocardiography, nuclear imaging and computed tomography (CT) is unknown. A prospectively-registered systematic review was performed, including 24 published studies with patients in AF at the time of imaging and reporting validity or reproducibility data on left ventricular systolic parameters (PROSPERO: CRD42018091674). Data extraction and risk of bias were performed by 2 investigators independently and synthesized qualitatively. In 3 CMR studies (40 AF patients), LVEF and stroke volume measurements correlated highly with catheter angiography (r≥0.85), and intra/inter-observer variability were low. From 3 nuclear studies (171 AF patients), there were no external validation assessments but intra/inter-observer and inter-session variability were low. In 18 echocardiography studies (2566 AF patients), 2 studies showed high external validity of global longitudinal strain (GLS) and tissue Doppler s\' with angiography-derived dP/dt (r≥0.88). GLS and myocardial performance index were both associated with adverse cardiovascular events. Reproducibility of echocardiography was better when selecting an index beat (where two preceding RR intervals are similar) compared to averaging of consecutive beats. There were no studies relating to CT. Most studies were small and biased by selection of patients with good quality images, limiting clinical extrapolation of results. The validity of systolic function measurements in patients with AF remains unclear due to the paucity of good-quality data.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 12 Oct 2020; epub ahead of print
Bunting KV, O'Connor K, Steeds RP, Kotecha D
Am J Cardiol: 12 Oct 2020; epub ahead of print | PMID: 33065079
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Abstract

Meta-Analysis Comparing the Frequency of Carotid Artery Stenosis in Patients with Atrial Fibrillation and Vice Versa.

Noubiap JJ, Agbaedeng TA, Tochie JN, Nkeck JR, ... Middeldorp ME, Sanders P

Atrial fibrillation (AF) and carotid stenosis (CS) can co-exist and this association has been reported to result in a higher risk of stroke than attributed to either condition alone. Here we aimed to summarize the data on the association of CS and AF. MEDLINE and Embase were searched to identify all published studies providing relevant data through 27 February 2020. Random-effects meta-analysis method was used to pool estimates of prevalence. Heterogeneity was assessed by mean I-squared statistic. Forty-eight studies were included, 20 reporting on the prevalence of carotid disease in a pooled population of 49,070 AF patients, and 28 on the prevalence of AF in a total of 2,288,265 patients with carotid disease. The pooled prevalence of CS in AF patients was 12.4% (95% CI 8.7-16.0, I 93%; n = 3919), ranging from 4.4% to 24.3%. The pooled prevalence of carotid plaque was 48.4% (95% CI 35.2-61.7, I = 99%; n = 4292). The prevalence of AF in patients with CS was 9.3% (95% CI 8.7-10.0, I 99%; n = 2,286,518), ranging from 3.6% to 10.0%. This prevalence was much higher (p < .001) in patients undergoing carotid artery stenting (12.7%, 95% CI 11.3-14.02, I 38.3%) compared to those undergoing carotid endarterectomy (6.9%, 95% CI 8.3-10.4, I 94.1%). There was no difference in AF prevalence between patients with CS, with and without previous cerebrovascular event (p >.05). In conclusion, AF and CS frequently co-exist, with about one in ten patients with AF having CS, and vice versa. In addition, non-stenotic carotid disease is present in about half of AF patients. These findings have important implications for AF screening in patients with CS, stroke prevention and the opportunities to intervene on common risk factors.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 12 Oct 2020; epub ahead of print
Noubiap JJ, Agbaedeng TA, Tochie JN, Nkeck JR, ... Middeldorp ME, Sanders P
Am J Cardiol: 12 Oct 2020; epub ahead of print | PMID: 33065087
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Abstract

Frequency, Trends and Outcomes of Cerebrovascular Events Associated with Atrial Fibrillation Hospitalizations.

Doshi R, Adalja D, Kumar A, Dave M, ... Sattar Y, Vallabhajosyula S

The main objective is to estimate the frequency, temporal trends, and outcomes of cerebrovascular events associated with AF hospitalization in the United States using the National Inpatient Sample (NIS) dataset. The NIS data was utilized to identify hospitalizations with a primary or secondary diagnosis of AF from January 1, 2005 through September 31, 2015 for the present analysis. Jonckheere-Terpstra Trend was utilized to analyze trends from 2005 to 2015. Global Wald score was used to assess relative contributions of various covariates towards stroke among AF hospitalizations. Between the years 2005 to 2015, there were 36,457,323 (95.2%) AF hospitalizations without cerebrovascular events and 1,824,608 (4.8%) with cerebrovascular events included in the final analysis. There was a statistically significant increase in the proportion of overall stroke, AIS, and AHS (P value <0.001) per 1000 AF hospitalizations. The frequency of stroke per 1000 AF hospitalizations was highest among patients with CHA2DS2VASc score≥ 3 and Charlson\'s comorbidity index≥3. The trend of in-hospital mortality decreased during the study period, however, it remained higher in those with cerebrovascular events compared to those without. Lastly, hypertension, advancing age, and chronic lung disease were major stroke predicting factors among AF hospitalizations. These cerebrovascular events were associated with longer length of stay and higher costs. In conclusion, the incidence of cerebrovascular events associated with AF hospitalizations remained significantly high and the trend continues to ascend despite technological advancements. Strategies should improve to reduce the risk of AF-related stroke in the United States.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 11 Oct 2020; epub ahead of print
Doshi R, Adalja D, Kumar A, Dave M, ... Sattar Y, Vallabhajosyula S
Am J Cardiol: 11 Oct 2020; epub ahead of print | PMID: 33058804
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Abstract

Previously Undetected Obstructive Sleep Apnea in Patients with New-Onset Atrial Fibrillation.

Bazan V, Vicente I, Lozano L, Villuendas R, ... Padilla F, Bayés-Genís A

Obstructive sleep apnea-hypopnea syndrome (OSA) compromises the efficacy of atrial fibrillation (AF) control strategies. Continuous positive airway pressure (CPAP) may ameliorate arrhythmia control especially in early AF stages (new-onset AF). We investigated a practical screening strategy to determine the likelihood of CPAP indication in new-onset AF patients. Seventy-seven consecutive patients with new-onset (< 1 month) AF were prospectively evaluated. Of them, 4 were excluded due to previously diagnosed OSA. The remaining 73 (68% persistent AF) fulfilled the Epworth, Berlin and STOP-BANG questionnaires, an ambulatory polysomnography being performed thereafter in all them in order to determine the apnea-hipopnea index (AHI). CPAP was indicated following conventional criteria. The variables associated with the diagnosis of OSA, with the AHI value and with CPAP indication were investigated by means of descriptive, univariate and multivariate analysis. The prevalence of OSA of any degree and CPAP indication was 82% and 37%, respectively. The variables associated (p < 0.05) with a higher AHI were male gender, body mass index, obesity, hypertension and high-risk scoring at the Berlin and STOP-BANG questionnaires. In the multivariate analysis, the STOP-BANG scoring proved superior to conventional risk factors and became the only variable predicting CPAP indication (OR 4.5 [1.9 - 10.6]; p = 0.01), an optimized cutoff value of ≥ 4 being newly established (sensitivity/specificity 76/65%). In conclusion, in patients referred with new-onset AF we documented a high risk of OSA and of need for CPAP. A STOP-BANG scoring of ≥ 4 in our population was a practical screening alternative to direct polysomnography in this setting.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 11 Oct 2020; epub ahead of print
Bazan V, Vicente I, Lozano L, Villuendas R, ... Padilla F, Bayés-Genís A
Am J Cardiol: 11 Oct 2020; epub ahead of print | PMID: 33058803
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Abstract

Incidence and Predictors of 30-day Acute Cerebrovascular Accidents Post Atrial Fibrillation Catheter Ablation (From the Nationwide Readmissions Database).

Patil N, Arora S, Davis L, Akoum N, Chung M, Sridhar AR

Catheter-based ablation is increasingly being used as first-line therapy for atrial fibrillation (AF). Cerebrovascular accidents (CVA) are a known complication. In this study, we investigate the 30-day incidence and predictors of acute CVA post-catheter ablation for AF. The Nationwide Readmissions Database (NRD) from 2010-September 2015 was queried for hospitalizations with an ablation procedure and a concurrent AF diagnosis. The primary endpoint was a composite endpoint of CVA during index admission or readmission for CVA within 30 days of admission for index hospitalization. The associations between the incidence of endpoints and the covariates of interest; which included age, gender, hospital characteristics (size, procedural volume, urban/rural status, teaching status), CHA2DS2-VASc comorbidity score and its components was assessed using logistic regression. Appropriate survey weighting methodology was applied to generate nationally representative estimates. Of 67,090 weighted hospitalizations for AF ablation, 566 (0.8%) had CVA within 30 days post-ablation. In multivariate regression analysis, factors associated with CVA included hypertension (OR 1.39, 95% CI 1.04, 1.85), heart failure (HF) (OR 4.97, 95% CI 3.32, 7.44), prior stroke/ transient ischemic attack (TIA) (OR 3.25, 95% CI 2.39, 4.42) and a lower procedural volume (OR for higher procedural volume: 0.6, 95% CI 0.42, 0.85). CHA2DS2-VASc score (OR 1.27, 95% CI 1.17, 1.39) was associated with CVA in univariate analysis. In conclusion, the CVA incidence within 30-days of catheter-based AF ablation therapy was 0.8%. Higher CHA2DS2-VASc score was associated with higher risk of CVA post-ablation. Hypertension, HF, prior stroke/TIA, and procedural volume were independently associated with CVA post-ablation.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 12 Oct 2020; epub ahead of print
Patil N, Arora S, Davis L, Akoum N, Chung M, Sridhar AR
Am J Cardiol: 12 Oct 2020; epub ahead of print | PMID: 33058801
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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 (RM) of Cardiac Implantable Electronic devices (CIEDs) has become routine practice owing to 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 (IoT) comes with its risks in the form of cybersecurity lapses and possible attacks. While there has not been a cyberattack leading to patient harm reported in literature 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-boxed connectivity protocols which are susceptible to hacking. In this paper, we discuss the fundamentals of the CIED ecosystem, the potential security vulnerabilities, a historical overview of such vulnerabilities reported in literature, and recommendations regarding improving the security of the CIED ecosystem and patient safety.

Copyright © 2020. Published by Elsevier Inc.

Heart Rhythm: 11 Oct 2020; epub ahead of print
Das S, Siroky GP, Lee S, Mehta D, Suri R
Heart Rhythm: 11 Oct 2020; epub ahead of print | PMID: 33059076
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Abstract

Arrhythmic safety of hydroxychloroquine in COVID-19 patients from different clinical settings.

Gasperetti A, Biffi M, Duru F, Schiavone M, ... Tondo C, Forleo GB
Aims
The aim of the study was to describe ECG modifications and arrhythmic events in COVID-19 patients undergoing hydroxychloroquine (HCQ) therapy in different clinical settings.
Methods and results
COVID-19 patients at seven institutions receiving HCQ therapy from whom a baseline and at least one ECG at 48+ h were available were enrolled in the study. QT/QTc prolongation, QT-associated and QT-independent arrhythmic events, arrhythmic mortality, and overall mortality during HCQ therapy were assessed. A total of 649 COVID-19 patients (61.9 ± 18.7 years, 46.1% males) were enrolled. HCQ therapy was administrated as a home therapy regimen in 126 (19.4%) patients, and as an in-hospital-treatment to 495 (76.3%) hospitalized and 28 (4.3%) intensive care unit (ICU) patients. At 36-72 and at 96+ h after the first HCQ dose, 358 and 404 ECGs were obtained, respectively. A significant QT/QTc interval prolongation was observed (P < 0.001), but the magnitude of the increase was modest [+13 (9-16) ms]. Baseline QT/QTc length and presence of fever (P = 0.001) at admission represented the most important determinants of QT/QTc prolongation. No arrhythmic-related deaths were reported. The overall major ventricular arrhythmia rate was low (1.1%), with all events found not to be related to QT or HCQ therapy at a centralized event evaluation. No differences in QT/QTc prolongation and QT-related arrhythmias were observed across different clinical settings, with non-QT-related arrhythmias being more common in the intensive care setting.
Conclusion
HCQ administration is safe for a short-term treatment for patients with COVID-19 infection regardless of the clinical setting of delivery, causing only modest QTc prolongation and no directly attributable arrhythmic deaths.

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

Europace: 23 Sep 2020; epub ahead of print
Gasperetti A, Biffi M, Duru F, Schiavone M, ... Tondo C, Forleo GB
Europace: 23 Sep 2020; epub ahead of print | PMID: 32971536
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Abstract

Sex-based Differences in Procedural Complications associated with Atrial Fibrillation Catheter Ablation: a Systematic Review and Meta-analysis.

Campbell ML, Larson J, Farid T, Westerman S, ... El-Chami MF, Merchant FM
Background
Women undergoing atrial fibrillation catheter ablation (AFCA) have higher rates of vascular complications and major bleeding. However, most studies have been underpowered to detect differences in rarer complications such as stroke/transient ischemic attack (TIA) and procedural mortality.
Methods
We performed a systematic review of databases (PubMed, World of Science, Embase) to identify studies published since 2010 reporting AFCA complications by sex. Six complications of interest were: 1) vascular/groin complications; 2) pericardial effusion/tamponade; 3) stroke/TIA; 4) permanent phrenic nerve injury; 5) major bleeding & 6) procedural mortality. For meta-analysis, random effects models were used when heterogeneity between studies was ≥ 50% (vascular complications, major bleeding) and fixed effects models for other endpoints.
Results
Of 5716 citations, 19 studies met inclusion criteria, comprising 244,353 patients undergoing AFCA, of whom 33% were women. Women were older (65.3 ± 11.2 vs. 60.4 ± 13.2 years), more likely hypertensive (60.6 vs. 55.5%) and diabetic (18.3 vs. 16.5%) and had higher CHA DS -VASc scores (3.0 ± 1.8 vs. 1.4 ± 1.4) (p<0.0001 for all comparisons). The rates of all 6 complications were significantly higher in women. However, despite statistically significant differences, the overall incidences of major complications were very low in both sexes: stroke/TIA (women 0.51 vs. men 0.39%) and procedural mortality (women 0.25 vs. men 0.19%).
Conclusion
Women experience significantly higher rates of AFCA complications. However, the incidence of major procedural complications is very low in both sexes. The higher rate of complications in women may be partially attributable to older age and a higher prevalence of comorbidities at the time of ablation. More detailed studies are needed to better define the mechanisms of increased risk in women and to identify strategies for closing the sex gap. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
Campbell ML, Larson J, Farid T, Westerman S, ... El-Chami MF, Merchant FM
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966681
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Abstract

Inappropriate Atrial and Ventricular Pacing During Sustained Ventricular Tachycardia.

Wu M, Sharma E, Chu A

Patient A is an 83-year-old man with a history of non-ischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 25%, sick sinus syndrome, and aortic stenosis treated with bioprosthetic aortic valve replacement, which was complicated by post-operative complete AV block requiring biventricular implantable cardioverter-defibrillator (Medtronic Viva S CRT-D) placement. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
Wu M, Sharma E, Chu A
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966671
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Abstract

V-A-A-V Response to Ventricular Entrainment: What is the Mechanism of this SVT?

Chan WK, Skanes A, Klein GJ

A 61-year-old man presented with symptomatic, paroxysmal supraventricular tachycardia (SVT) at 210 bpm. His baseline 12-lead ECG in sinus rhythm was normal. He was brought to the electrophysiology laboratory where catheters were introduced into the right ventricular (RV) apex, His bundle region (His), high right atrium (HRA), and coronary sinus (CS). This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
Chan WK, Skanes A, Klein GJ
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966670
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Abstract

Injectable conductive hydrogel restores conduction through ablated myocardium.

van Zyl M, Pedrotty DM, Karabulut E, Kuzmenko V, ... Gatenholm P, Kapa S
Introduction
Therapies for substrate-related arrhythmias include ablation or drugs targeted at altering conductive properties or disruption of slow zones in heterogeneous myocardium. Conductive compounds such as carbon nanotubes may provide a novel personalizable therapy for arrhythmia treatment by allowing tissue homogenization.
Methods
A nanocellulose-carbon nanotube conductive hydrogel was developed to have conduction properties similar to normal myocardium. Ex vivo perfused canine hearts were studied. Electroanatomic activation mapping of the epicardial surface was performed at baseline, after radiofrequency ablation, and after uniform needle injections of the conductive hydrogel through the injured tissue. Gross histology was used to assess distribution of conductive hydrogel in the tissue.
Results
The conductive hydrogel viscosity was optimized to decrease with increasing shear rate to allow expression through a syringe. The DC conductivity under aqueous conduction was 4.3·10 S/cm. In 4 canine hearts, when compared to the homogeneous baseline conduction, isochronal maps demonstrated sequential myocardial activation with a shift in direction of activation to surround the edges of the ablated region. After injection of conductive hydrogel, isochrones demonstrated conduction through the ablated tissue with activation restored through the ablated tissue. Gross specimen examination demonstrated retention of the hydrogel within the tissue.
Conclusions
This proof-of-concept study demonstrates that conductive hydrogel can be injected into acutely disrupted myocardium to restore conduction. Future experiments should focus on evaluating long-term retention and biocompatibility of the hydrogel through in vivo experimentation. Condensed Abstract A novel conductive hydrogel was developed as a method to treat substrate-based arrhythmias by homogenizing conduction through disrupted myocardium. In ex vivo canine hearts, the hydrogel was injected evenly through ablated regions of myocardium. Electroanatomic activation mapping of the epicardial surface demonstrated a shift in conduction to surrounding edges following ablation of the region. Following injection of the conductive hydrogel, conduction improved through the ablated region in all 4 hearts. This proof-of-concept study demonstrates that conductive hydrogel can be injected into acutely disrupted myocardium to restore conduction. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
van Zyl M, Pedrotty DM, Karabulut E, Kuzmenko V, ... Gatenholm P, Kapa S
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966655
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Impact:
Abstract

Phrenic nerve stimulation during right ventricular outflow tract pacing: A rare but possible complication.

Sekihara T, Miyazaki S, Ishida T, Nagao M, ... Uzui H, Tada H

Phrenic nerve stimulation (PNS) caused by a right ventricular (RV) lead is an uncommon complication of pacemaker implantations. We demonstrated a case of left PNS caused by an RV lead placed in the RV outflow tract (RVOT). The PNS was dependent on ventricular capture. This case highlighted a risk of PNS even during RVOT pacing. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
Sekihara T, Miyazaki S, Ishida T, Nagao M, ... Uzui H, Tada H
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966650
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Impact:
Abstract

Accuracy of contrast-enhanced computed tomography for thrombus detection prior to atrial fibrillation ablation and role of novel Left Atrial Appendage Enhancement Index in appendage flow assessment.

Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Aims
To evaluate diagnostic accuracy of different protocols of contrast enhanced computed tomography venogram (CTV) for LAA thrombus detection in patients undergoing AF ablation and study the correlation of the novel LAA enhancement index (LAA-EI) to LAA flow velocity obtained using transesophageal echocardiography (TEE).
Methods
Study comprised of patients undergoing CTV and TEE on the same day from October 2016 to December 2017. Three CTV scanning protocols (described in results), were evaluated wherein ECG gating was used only for those with sinus rhythm on day of CTV. LAA-EI was calculated as Hounsfield Unit (HU) in the LAA divided by the HU unit in the center of the LA. The diagnostic accuracy for CTV was calculated in comparison to TEE. The LAA-EI was compared to LAA emptying velocities as obtained from TEE.
Results
590 patients with 45.6% non-ECG-gated without delayed imaging, 26.9% non-ECG-gated with delayed imaging and 27.5% ECG-gated with delayed imaging, were included in the study. All three protocols had 100% negative predictive value with improvement in specificity from 61.8% to 98.1% upon adding delayed imaging. The LAA-EI correlated significantly with reduced LAA flow velocities (r = 0.45, p < .0001). The mean LAA emptying velocity in patients with LAA-EI of ≤ 0.6 was significantly lower than in those with LAA-EI of >0.6 (36.2 cm/s [95% CI: 32.6-39.7] vs, (58 cm/s [95% CI 55.3-60.8]), respectively (p < .0001).
Conclusion
CTV with delayed imaging (with or without ECG gating) is highly specific in ruling out LAA thrombus. The novel LAA-EI can detect low LAA flow velocities.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 31 Oct 2020; 318:147-152
Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Int J Cardiol: 31 Oct 2020; 318:147-152 | PMID: 32629004
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Impact:
Abstract

A new clinical risk score for predicting the prevalence of low-voltage areas in patients undergoing atrial fibrillation ablation.

Matsuda Y, Masuda M, Asai M, Iida O, ... Uematsu H, Mano T
Introduction
Although the presence of left atrial low-voltage areas (LVAs) is strongly associated with the recurrence of atrial fibrillation (AF) after ablation, few methods are available to classify the prevalence of LVAs. The purpose of this study was to establish a risk score for predicting the prevalence of LVAs in patients undergoing ablation for AF.
Methods
We enrolled 1004 consecutive patients who underwent initial ablation for AF (age, 68 ± 10 years old; female, 346 (34%); persistent atrial fibrillation, 513 (51%)). LVAs were deemed present when the voltage map after pulmonary vein isolation demonstrated low-voltage areas with a peak-to-peak bipolar voltage of <0.5 mV covering ≥5 cm of the left atrium.
Results
LVAs were present in 206 (21%) patients. The SPEED score was obtained as the total number of independent predictors as identified on multivariate analysis, namely female sex (odds ratio (OR) 3.4 [95% confidence interval (CI) 2.2-5.2], p <0.01), persistent AF (OR 1.8 [95% CI 1.1-3.0], p=0.02), age ≥70 years (OR 2.3 [95% CI 1.5-3.4], p <0.01), elevated brain natriuretic peptide ≥100 pg/ml or N-terminal pro-brain natriuretic peptide ≥400 pg/ml (OR 1.7 [95% CI 1.02-2.8], p=0.04), and diabetes mellitus (OR 1.8 [95% CI 1.1-2.8], p=0.02). LVAs were more frequent in patients with a higher SPEED score, and prevalence increased with each additional SPEED score point (OR 2.4 [95% CI 2.0-2.8], p <0.01).
Conclusion
The SPEED score accurately predicts the prevalence of LVAs in patients undergoing ablation for AF. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
Matsuda Y, Masuda M, Asai M, Iida O, ... Uematsu H, Mano T
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966648
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Impact:
Abstract

Healthcare Utilization and Cost in Patients with Atrial Fibrillation and Heart Failure Undergoing Catheter Ablation.

Field ME, Gold MR, Rahman M, Goldstein L, ... Piccini JP, Friedman DJ
Background
Catheter ablation is an effective treatment for patients with atrial fibrillation (AF) and heart failure (HF). However, little is known how healthcare utilization and cost change after ablation in this population. We sought to determine healthcare utilization and cost patterns among patients with AF and HF undergoing ablation.
Methods
Using a large US administrative database, we identified (n=1,568) treated with ablation with a primary and secondary diagnosis of AF and HF, respectively, were evaluated 1-year pre- and post-ablation for outcomes including inpatient admissions (AF or HF), emergency department (ED) visits, cardioversions, length of stay (LOS), and cost. A secondary analysis was extended to 3-years post-ablation.
Results
Reductions were observed in AF-related admissions (64%), LOS (65%), cardioversions (52%), ED visits (51%, all values, p<0.0001), and HF-related admissions (22%, p=0.01). There was a 40% reduction in inpatient admission cost ($4,165 pre-ablation to $2,510 post-ablation, p<0.0001). In a sensitivity analysis excluding repeat-ablation patients, greater reduction in overall AF management cost was observed compared to the full cohort (-43% vs -2%). Comparing 1-year pre- to 3-years post-ablation, both total mean AF-management cost ($850 per-patient per-month 1-year pre- to $546 3-years post-ablation, p<0.0001) and AF-related healthcare utilization was reduced.
Conclusions
Catheter ablation in patients with AF and HF resulted in significant reductions in healthcare utilization and cost through 3-years of follow-up. This reduction was observed regardless of whether repeat ablation was performed, reflecting positive impact of ablation on longer-term cost reduction. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Field ME, Gold MR, Rahman M, Goldstein L, ... Piccini JP, Friedman DJ
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022815
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Abstract

Supraventricular Tachycardia in Patients with Coronary Sinus Stenosis/Atresia: Prevalence, Anatomical Features, and Ablation Outcomes.

Weng S, Tang M, Zhou B, Yu F, ... Fang P, Zhang S
Background
Supraventricular tachycardia (SVT) with coronary sinus (CS) ostial atresia (CSA) or CS stenosis (CSS) causes difficulty in electrophysiological procedures, but its characteristics are poorly understood.
Objective
Study the anatomical and clinical features of SVT patients with CSA/CSS.
Methods
Of 6,128 SVT patients undergoing electrophysiological procedures, consecutive patients with CSA/CSS were enrolled, and the baseline characteristics, imaging materials, intraoperative data, and follow-up outcomes were analyzed.
Results
Thirteen patients, 7 with CSA and 6 with CSS, underwent the electrophysiological procedure. Decapolar catheters were placed into the proximal CS in 3 cases, while the rest were placed at the free-wall of the right atrium. Fourteen arrhythmias were confirmed: 4 atrioventricular nodal reentrant tachycardias, 5 left-sided accessory pathways, 3 paroxysmal atrial fibrillations, and 2 atrial flutters. In addition to 3 patients who underwent only an electrophysiological study, the acute ablation success rate was 100% in 10 cases, with no procedure-related complications. After a median follow-up period of 59.6 months, only 1 case of atypical atrial flutter recurred. For those cases (7 CSA and 2 CSS) with a total of 10 anomalous types of CS drainage, three types were classified: from the CS to the persistent left superior vena cava (n=3), from an unroofed CS (n=3), and from the CS to the small cardiac vein (n=3) or Thebesian vein (n=1).
Conclusion
Patients with CSA/CSS may develop different kinds of SVT. Electrophysiological procedures for such patients are feasible and effective. An individualized mapping strategy based on the three types of CS drainage will be helpful. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Weng S, Tang M, Zhou B, Yu F, ... Fang P, Zhang S
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022772
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Impact:
Abstract

Management of ventricular electrical storm: a contemporary appraisal.

Kowlgi GN, Cha YM

Ventricular electrical storm (VES) is a clinical scenario characterized by the clustering of multiple episodes of sustained ventricular arrhythmias (VA) over a short duration. Patients with VES are prone to psychological disorders, heart failure decompensation, and increased mortality. Studies have shown that 10-28% of the patients with secondary prevention ICDs can sustain VES. The triad of a susceptible electrophysiologic substrate, triggers, and autonomic dysregulation govern the pathogenesis of VES. The rate of VA, underlying ventricular function, and the presence of implantable cardioverter-defibrillator (ICD) determine the clinical presentation. A multi-faceted approach is often required for management consisting of acute hemodynamic stabilization, ICD reprogramming when appropriate, antiarrhythmic drug therapy, and sedation. Some patients may be eligible for catheter ablation, and autonomic modulation with thoracic epidural anesthesia, stellate ganglion block, or cardiac sympathetic denervation. Hemodynamically unstable patients may benefit from the use of left ventricular assist devices, and extracorporeal membrane oxygenation. Special scenarios such as idiopathic ventricular fibrillation, Brugada syndrome, Long and short QT syndrome, early repolarization syndrome, catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular cardiomyopathy, and cardiac sarcoidosis have been described as well. VES is a cardiac emergency that requires swift intervention. It is associated with poor short and long-term outcomes. A structured team-based management approach is paramount for the safe and effective treatment of this sick cohort.

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

Europace: 26 Sep 2020; epub ahead of print
Kowlgi GN, Cha YM
Europace: 26 Sep 2020; epub ahead of print | PMID: 32984880
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Abstract

The \'double transition\': a novel electrocardiogram sign to discriminate posteroseptal accessory pathways ablated from the right endocardium from those requiring a left-sided or epicardial coronary venous approach.

Pascale P, Hunziker S, Denis A, Gómez Flores JR, ... Jaïs P, Haïssaguerre M
Aims
The precise localization of manifest posteroseptal accessory pathways (APs) often poses diagnostic challenges considering that a small area may encompass AP that may be ablated from the right or left endocardium, or epicardially within the coronary sinus (CS). We sought to explore whether the QRS transition pattern in the precordial lead may help to discriminate the necessary ablation approach.
Methods and results
Consecutive patients who underwent a successful ablation of a single manifest AP over a 5-year period were included. Standard 12-lead electrocardiograms were reviewed. A total of 273 patients were identified. Mean age was 31 ± 15 years and 62% were male. Of the 110 identified posteroseptal AP, 64 were ablated from the right endocardium, 33 from the left endocardium, and 13 inside the CS. While a normal precordial QRS transition was most often observed, a subset of 33 patients presented an atypical \'double transition\' pattern which specifically identified right endocardial AP. The combination of a q wave in V1 with a proportion of the positive QRS component in V1 < V2 > V3, predicted a right endocardial AP with a 100% specificity. In case of a positive QRS sum in V2, this \'double transition\' pattern predicted a posteroseptal right endocardial AP with 99.5% specificity and 44% sensitivity. The positive predictive value was 97%. The only false positive was a midseptal AP. In the case of a negative or isoelectric QRS sum in V2, APs were located more laterally on the tricuspid annulus.
Conclusion
The combination of a q wave in V1 with a double QRS transition pattern in the precordial leads is highly specific of a right endocardial AP and rules out the need for CS or left-sided mapping.

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

Europace: 26 Sep 2020; epub ahead of print
Pascale P, Hunziker S, Denis A, Gómez Flores JR, ... Jaïs P, Haïssaguerre M
Europace: 26 Sep 2020; epub ahead of print | PMID: 32984869
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Abstract

A unified theory for the circuit of atrioventricular nodal re-entrant tachycardia.

Katritsis DG

Atrioventricular nodal re-entrant tachycardia (AVNRT) is the most common regular tachycardia in the human, but its exact circuit remains elusive. In this article, recent evidence about the electrophysiological characteristics of AVNRT and new data on the anatomy of the atrioventricular node, are discussed. Based on this information, a novel, unified theory for the nature of the circuit of the tachycardia is presented.

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

Europace: 25 Sep 2020; epub ahead of print
Katritsis DG
Europace: 25 Sep 2020; epub ahead of print | PMID: 32978626
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Impact:
Abstract

Revascularisation therapies improve the outcomes of ischemic stroke patients with atrial fibrillation and heart failure.

Pana TA, Mohamed MO, Clark AB, Fahy E, Mamas MA, Myint PK
Background
Atrial fibrillation (AF) and heart failure (HF) carry a poor prognosis in acute ischaemic stroke (AIS). The impact of revascularisation therapies on outcomes in these patients is not fully understood.
Method
National Inpatient Sample (NIS) AIS admissions (January 2004-September 2015) were included (n = 4,597,428). Logistic regressions analysed the relationship between exposures (neither AF nor HF-reference, AF-only, HF-only, AF + HF) and outcomes (in-hospital mortality, length-of-stay >median and moderate-to-severe disability on discharge), stratifying by receipt of intravenous thrombolysis (IVT) or endovascular thrombectomy (ET).
Results
69.2% patients had neither AF nor HF, 16.5% had AF-only, 7.5% had HF-only and 6.7% had AF + HF. 5.04% and 0.72% patients underwent IVT and/or ET, respectively. AF-only and HF-only were each associated with 75-85% increase in the odds of in-hospital mortality. AF + HF was associated with greater than two-fold increase in mortality. Patients with AF-only, HF-only or AF + HF undergoing IVT had better or at least similar in-hospital outcomes compared to their counterparts not undergoing IVT, except for prolonged hospitalisation. Patients undergoing ET with AF-only, HF-only or AF + HF had better (in-hospital mortality, discharge disability, all-cause bleeding) or at least similar (length-of-stay) outcomes to their counterparts not undergoing ET. Compared to AIS patients without AF, AF patients had approximately 50% and more than two-fold increases in the likelihood of receiving IVT or ET, respectively.
Conclusions
We confirmed the combined and individual impact of co-existing AF or HF on important patient-related outcomes. Revascularisation therapies improve these outcomes significantly in patients with these comorbidities.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 02 Oct 2020; epub ahead of print
Pana TA, Mohamed MO, Clark AB, Fahy E, Mamas MA, Myint PK
Int J Cardiol: 02 Oct 2020; epub ahead of print | PMID: 33022289
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Impact:
Abstract

Within patient comparison of His-bundle pacing, right ventricular pacing and right ventricular pacing avoidance algorithms in patients with PR prolongation: Acute haemodynamic study.

Keene D, Shun-Shin MJ, Arnold AD, March K, ... Francis DP, Whinnett ZI
Aims
A prolonged PR interval may adversely affect ventricular filling and therefore cardiac function. AV delay can be corrected using right-ventricular-pacing (RVP) but this induces ventricular dyssynchrony, itself harmful. Therefore, in intermittent heart-block, pacing-avoidance algorithms are often implemented. We tested His-bundle pacing (HBP) as an alternative.
Methods
Out-patients with a long PR interval(>200ms) and intermittent need for ventricular pacing were recruited. We measured within patient differences in high-precision haemodynamics between AV-optimized RVP, and HBP, as well as a pacing-avoidance algorithm [Managed Ventricular Pacing (MVP)].
Results
We recruited 18 patients. Mean left ventricular ejection fraction was 44.3±9%. Mean intrinsic PR interval was 266±42ms and QRS duration was 123±29ms. RVP lengthened QRS duration(+54 ms, 95%CI 42 to 67ms, p<0.0001) whilst HBP delivered a shorter QRS duration than RVP(-56 ms, 95%CI -67 to -46ms, p<0.0001). HBP did not increase QRS duration(-2ms 95%CI -8 to 13ms, p=0.6). HBP improved acute systolic blood pressure by mean of 5.0 mmHg(95%CI 2.8 to 7.1mmHg, p<0.0001) compared to RVP and by 3.5 mmHg(95%CI 1.9 to 5.0mmHg, p=0.0002) compared to the pacing avoidance algorithm. There was no significant difference in haemodynamics between RVP and ventricular pacing avoidance (p=0.055).
Conclusions
HBP provides better acute cardiac function than pacing avoidance algorithms and RVP, in patients with prolonged PR intervals. HBP allows normalisation of prolonged AV delays (unlike pacing avoidance) and does not cause ventricular dyssynchrony (unlike RVP). Clinical trials may be justified to assess whether these acute improvements translate into longer term clinical benefits in patients with bradycardia indications for pacing. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 24 Sep 2020; epub ahead of print
Keene D, Shun-Shin MJ, Arnold AD, March K, ... Francis DP, Whinnett ZI
J Cardiovasc Electrophysiol: 24 Sep 2020; epub ahead of print | PMID: 32976636
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Impact:
Abstract

Impedance decrement indexes for avoiding steam-pop during bipolar radiofrequency ablation: an experimental study using a dual-bath preparation.

Saitoh O, Oikawa A, Sugai A, Chinushi M
Introduction
This experimental study was conducted to explore impedance monitoring for safely performing bipolar (BIP) radiofrequency (RF) ablation targeted to arrhythmia focus.
Methods and results
Using a newly designed dual-bath experimental model, contact-force-controlled (20-g) BIP ablation (50 W, 60-sec) was attempted for porcine left ventricle (17.0±2.7 mm thickness). BIP ablation was successfully accomplished for 60-sec in 75 of the 89 RF applications (84.3%), whereas audible steam-pop occurred in the other 14 RF applications (15.7%). Receiver operating characteristic analysis demonstrated the optimal predictive values regarding the occurrence of steam-pop as follows; thinner myocardial wall (≤ 14.8 mm), low minimum impedance (≤ 89 ohm), greater total impedance decrement (TID) (≤ -25 ohm) and %-TID (≤ -22.5%). Greater impedance decrement was not observed immediately preceding the occurrence of steam-pop but appeared around 15-sec prior to. Four steam-pops happened before reaching the optimal predictive values of minimum impedance, whereas all 14 steam-pops developed 11.5±9.2 and 8.1±8.1 sec after reaching the optimal predictive values of TID and %-TID, respectively. Total lesion depth (endocardial plus epicardial) was 10.7±1.2 mm on average, and was well correlated with TID and %-TID. Transmural lesion through the myocardial wall was created in 22 RF applications.
Conclusions
Relatively thinner areas of the myocardium are likely to be at greater risk for steam-pop during bipolar RF ablation. Lowering the RF application energy to reduce the impedance decrement may help to lessen this risk. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 26 Sep 2020; epub ahead of print
Saitoh O, Oikawa A, Sugai A, Chinushi M
J Cardiovasc Electrophysiol: 26 Sep 2020; epub ahead of print | PMID: 32981132
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Impact:
Abstract

Screening for atrial fibrillation: predicted sensitivity of short, intermittent electrocardiogram recordings in an asymptomatic at-risk population.

Quer G, Freedman B, Steinhubl SR
Aims
Screening for asymptomatic atrial fibrillation (AF) could prevent strokes and save lives, but the AF burden of those detected can impact prognosis. New technologies enable continuous monitoring or intermittent electrocardiogram (ECG) snapshots, however, the relationship between AF detection rates and the burden of AF found with intermittent strategies is unknown. We simulated the likelihood of detecting AF using real-world 2-week continuous ECG recordings and developed a generalizable model for AF detection strategies.
Methods and results
From 1738 asymptomatic screened individuals, ECG data of 69 individuals (mean age 76.3, median burden 1.9%) with new AF found during 14 days continuous monitoring were used to simulate 30 seconds ECG snapshots one to four times daily for 14 days. Based on this simulation, 35-66% of individuals with AF would be detected using intermittent screening. Twice-daily snapshots for 2 weeks missed 48% of those detected by continuous monitoring, but mean burden was 0.68% vs. 4% in those detected (P < 0.001). In a cohort of 6235 patients (mean age 69.2, median burden 4.6%) with paroxysmal AF during clinically indicated monitoring, simulated detection rates were 53-76%. The Markovian model of AF detection using mean episode duration and mean burden simulated actual AF detection with ≤9% error across the range of screening frequencies and durations.
Conclusion
Using twice-daily ECG snapshots over 2 weeks would detect only half of individuals discovered to have AF by continuous recordings, but AF burden of those missed was low. A model predicting AF detection, validated using real-world data, could assist development of optimized AF screening programmes.

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

Europace: 29 Sep 2020; epub ahead of print
Quer G, Freedman B, Steinhubl SR
Europace: 29 Sep 2020; epub ahead of print | PMID: 32995870
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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,
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: 01 Oct 2020; epub ahead of print
Proietti M, Lip GYH, Laroche C, Fauchier L, ... Boriani G,
Europace: 01 Oct 2020; epub ahead of print | PMID: 33006613
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Impact:
Abstract

Electrophysiology in the time of coronavirus: coping with the great wave.

Li J, Mazzone P, Leung LWM, Lin W, ... Lin J, Gallagher MM
Aims 
To chart the effect of the COVID-19 pandemic on the activity of interventional electrophysiology services in affected regions.
Methods and results 
We reviewed the electrophysiology laboratory records in three affected cities: Wenzhou in China, Milan in Italy, and London in the UK. We inspected catheter lab records and interviewed electrophysiologists in each centre to gather information on the impact of the pandemic on working patterns and on the health of staff members and patients. There was a striking decline in interventional electrophysiology activity in each of the centres. The decline occurred within a week of the recognition of widespread community transmission of the virus in each region and shows a striking correlation with the national figures for new diagnoses of COVID-19 in each case. During the period of restriction, workflow dropped to <5% of normal, consisting of emergency cases only. In two of three centres, electrophysiologists were redeployed to perform emergency work outside electrophysiology. Among the centres studied, only Wenzhou has seen a recovery from the restrictions in activity. Following an intense nationwide programme of public health interventions, local transmission of COVID-19 ceased to be detectable after 18 February allowing the electrophysiology service to resume with a strict testing regime for all patients.
Conclusion 
Interventional electrophysiology is vulnerable to closure in times of great social difficulty including the COVID-19 pandemic. Intense public health intervention can permit suppression of local disease transmission allowing resumption of some normal activity with stringent precautions.

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

Europace: 29 Sep 2020; epub ahead of print
Li J, Mazzone P, Leung LWM, Lin W, ... Lin J, Gallagher MM
Europace: 29 Sep 2020; epub ahead of print | PMID: 32995866
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Impact:
Abstract

Late gadolinium enhancement role in arrhythmic risk stratification of patients with LMNA cardiomyopathy: results from a long-term follow-up multicentre study.

Peretto G, Barison A, Forleo C, Di Resta C, ... Della Bella P, Sala S
Aims
We aimed at addressing the role of late gadolinium enhancement (LGE) in arrhythmic risk stratification of LMNA-associated cardiomyopathy (CMP).
Methods and results
We present data from a multicentre national cohort of patients with LMNA mutations. Of 164 screened cases, we finally enrolled patients with baseline cardiac magnetic resonance (CMR) including LGE sequences [n = 41, age 35 ± 17 years, 51% males, mean left ventricular ejection fraction (LVEF) by echocardiogram 56%]. The primary endpoint of the study was follow-up (FU) occurrence of malignant ventricular arrhythmias [MVA, including sustained ventricular tachycardia (VT), ventricular fibrillation, and appropriate implantable cardioverter-defibrillator (ICD) therapy]. At baseline CMR, 25 subjects (61%) had LGE, with non-ischaemic pattern in all of the cases. Overall, 23 patients (56%) underwent ICD implant. By 10 ± 3 years FU, eight patients (20%) experienced MVA, consisting of appropriate ICD shocks in all of the cases. In particular, the occurrence of MVA in LGE+ vs. LGE- groups was 8/25 vs. 0/16 (P = 0.014). Of note, no significant differences between LGE+ and LGE- patients were found in currently recognized risk factors for sudden cardiac death (male gender, non-missense mutations, baseline LVEF <45% and non-sustained VT), all P-value >0.05.
Conclusions
In LMNA-CMP patients, LGE at baseline CMR is significantly associated with MVA. In particular, as suggested by this preliminary experience, the absence of LGE allowed to rule-out MVA at 10 years mean FU.

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

Europace: 29 Sep 2020; epub ahead of print
Peretto G, Barison A, Forleo C, Di Resta C, ... Della Bella P, Sala S
Europace: 29 Sep 2020; epub ahead of print | PMID: 32995851
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Abstract

Intra-day change in occurrence of out-of-hospital ventricular fibrillation in Japan: The JCS-ReSS study.

Otsuki S, Aiba T, Tahara Y, Nakajima K, ... Kusano K,
Background
Real-world evidence of out-of-hospital ventricular fibrillation (VF), especially regarding intra-day change, remains unclear. We aimed to investigate that age- and gender-dependent difference of intra-day change of VF occurrence.
Method
We enrolled 71,692 patients (males: 56,419 [78.7%], females: 15,273 [21.3%]) in whom cardiac VF had been documented from the 2005-2015 All-Japan Utstein Registry data. Subjects were divided into four groups: group-I (<18 years old), group-II (18-39), group-III (40-69), and group-IV (≥70). Among four groups in each of male and female, we compared the intra-day change of VF occurrence, and evaluated the risk factors of the unfavorable neurologic outcomes at 1 month after VF.
Results
Regardless of age, the incidence of VF was significantly greater in male than in female subjects. In male subjects, VF in group-I, III and IV occurred higher at daytime, however, group-II had no intra-day difference because group-II had a higher VF events at midnight~ early morning compared with other aged groups (Poisson regression analysis, p = .03). While in female, each group showed similar intra-day pattern of VF occurrence. Logistic regression analysis revealed that some of the clinical parameters such as time periods from call receipt to first shock and the presence of bystander cardiopulmonary resuscitation were important for risk of 30-day neurologically unfavorable outcomes.
Conclusions
The intra-day change of VF occurrence was age-dependently different in males but not in females, suggesting age- and gender-dependent differences in underlying cardiac diseases. These might affect the significant difference in unfavorable neurologic outcome.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 31 Oct 2020; 318:54-60
Otsuki S, Aiba T, Tahara Y, Nakajima K, ... Kusano K,
Int J Cardiol: 31 Oct 2020; 318:54-60 | PMID: 32569698
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Abstract

Thromboembolic and bleeding risk in obese patients with atrial fibrillation according to different anticoagulation strategies.

Patti G, Pecen L, Manu MC, Huber K, ... Kirchhof P, Caterina R
Background
Data on the relationship between body mass index (BMI), thromboembolic events (TEE) and bleeding in patients with atrial fibrillation (AF) are controversial, and further evidence on the risk of such events in obese patients with AF receiving different anticoagulant therapies (OAC) is needed.
Methods and results
We divided a total of 9330 participants from the prospective PREFER in AF and PREFER in AF PROLONGATION registries into BMI quartiles at baseline. Outcome measures were TEE and major bleeding complications at the 1-year follow-up. Without OAC, there was a ≥6-fold increase of TEE in the 4th vs other BMI quartiles (P = .019). OAC equalized the rates of TEE across different BMI strata. The occurrence of major bleeding was highest in patients with BMI in the 1st as well as in the 4th BMI quartile [OR 1.69, 95% CI 1.03-2.78, P = .039 and OR 1.86, 95% CI 1.13-3.04, P = .014 vs those in the 3rd quartile, respectively]. At propensity score-adjusted analysis, the incidence of TEE and major bleeding in obese patients receiving non-vitamin K antagonist oral anticoagulants (NOACs) or vitamin K-antagonist anticoagulants (VKAs) was similar (P ≥ .34).
Conclusions
Our real-world data suggest no obesity paradox for TEE in patients with AF. Obese patients are at higher risk of TEE, and here OAC dramatically reduces the risk of events. We here found a comparable clinical outcome with NOACs and VKAs in obese patients. Low body weight and obesity were also associated with bleeding, and therefore OAC with the best safety profile should be considered in this setting.

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

Int J Cardiol: 31 Oct 2020; 318:67-73
Patti G, Pecen L, Manu MC, Huber K, ... Kirchhof P, Caterina R
Int J Cardiol: 31 Oct 2020; 318:67-73 | PMID: 32574823
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