Topic: Electrophysiology

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

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

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

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

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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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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Abstract

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

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

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

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

Association of Septal Late Gadolinium Enhancement on Cardiac Magnetic Resonance with Ventricular Tachycardia Ablation Targets in Nonischemic Cardiomyopathy.

Kuo L, Liang JJ, Han Y, Frankel DS, ... Desjardins B, Nazarian S
Background
Ablation of septal substrate-associated ventricular tachycardia (VT) in patients with nonischemic cardiomyopathy (NICM) is challenging. We sought to standardize the characterization of septal substrates on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) and to examine the association of that substrate with VT exit and isthmus sites on invasive mapping.
Methods
LGE-CMR was performed prior to EAM mapping and ablation for VT in 20 NICM patients. LGE extent and distribution were quantified using myocardial signal intensity z-scores (SI-Z). The SI-Z thresholds correlating to previously validated voltage thresholds, for abnormal tissue and dense scar were defined.
Results
Bipolar and unipolar (EGM) voltage amplitude measurements from the LV and RV were negatively associated with SI-Z from LGE-CMR imaging (p<0.05). SI-Z thresholds for appropriate CMR identification of septal substrates were determined to be >-0.15 for border zone and >0.03 for dense scar. Among all patients, 34 critical VT sites were identified with SI-Z distribution in range of -0.97~2.06. Thirty (88.2%) critical sites were located in the dense LGE, 1 (2.9%) in the border zone, and 3 (8.9%) in healthy tissue but within 7 mm of LGE. Of note, critical VT sites were all located at the basal septum close to valves (distance to aortic valve: 17.5±31.2 mm, mitral valve: 21.2±8.7 mm) in non-sarcoidosis cases.
Conclusions
Critical sites of septal VT in NICM patients are predominantly in the CMR defined dense scar when using standardized signal intensity thresholds. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Oct 2020; epub ahead of print
Kuo L, Liang JJ, Han Y, Frankel DS, ... Desjardins B, Nazarian S
J Cardiovasc Electrophysiol: 17 Oct 2020; epub ahead of print | PMID: 33070414
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Abstract

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

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

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

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

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

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

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

Europace: 15 Oct 2020; epub ahead of print
Kim D, Yang PS, Jang E, Yu HT, ... Lip GYH, Joung B
Europace: 15 Oct 2020; epub ahead of print | PMID: 33063123
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Abstract

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

Frausing MHJP, Kronborg MB, Johansen JB, Nielsen JC

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

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

Europace: 15 Oct 2020; epub ahead of print
Frausing MHJP, Kronborg MB, Johansen JB, Nielsen JC
Europace: 15 Oct 2020; epub ahead of print | PMID: 33063088
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Abstract

Magnetic resonance-guided re-ablation for atrial fibrillation is associated with a lower recurrence rate: a case-control study.

Quinto L, Cozzari J, Benito E, Alarcón F, ... Guasch E, Mont L
Aims
Our aim was to analyse whether using delayed enhancement cardiac magnetic resonance imaging (DE-CMR) to localize veno-atrial gaps in atrial fibrillation (AF) redo ablation procedures improves outcomes during follow-up.
Methods and results
We conducted a case-control study with 35 consecutive patients undergoing a DE-CMR-guided Repeat-pulmonary vein isolation (Re-PVI) procedure. Those with more extensive ablations (e.g. roof lines, box) were excluded. Patients were matched for age, sex, AF pattern, and left atrial dimension with 35 patients who had undergone a conventional Re-PVI procedure guided with a three dimensional (3D)-navigation system. Procedural characteristics were recorded, and patients were followed for 24 months in a specialized outpatient clinic. The primary endpoint was freedom from recurrent AF, atrial tachycardia, or flutter. The duration of CMR-guided procedures was shorter compared to the conventional group (161 ± 52 vs. 195 ± 72 min, respectively, P = 0.049), with no significant differences in fluoroscopy or total radiofrequency time. At the 2-year follow-up, more patients in the DE-CMR-guided group remained free from recurrences compared with the conventional group (70% vs. 39%, respectively, P = 0.007). In univariate Cox-regression analyses, AF pattern [persistent AF, hazard ratio (HR) 2.66 (1.27-5.46), P = 0.006] and the use of DE-CMR [HR 0.36 (0.17-0.79), P = 0.009] predicted recurrences during follow-up; both factors remained independent predictors in multivariate analyses.
Conclusion
The substrate characterization provided by DE-CMR facilitates the identification of anatomical veno-atrial gaps and associates with shorter procedures and better clinical outcomes in repeated AF ablation procedures.

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

Europace: 15 Oct 2020; epub ahead of print
Quinto L, Cozzari J, Benito E, Alarcón F, ... Guasch E, Mont L
Europace: 15 Oct 2020; epub ahead of print | PMID: 33063124
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Abstract

Prospective use of ablation index for the ablation of right ventricle outflow tract premature ventricular contractions: a proof of concept study.

Gasperetti A, Sicuso R, Dello Russo A, Zucchelli G, ... Tondo C, Casella M
Aims
Radiofrequency catheter ablation (RFCA) represents an effective option for idiopathic premature ventricular contractions (PVCs) treatment. Ablation Index (AI) is a novel ablation marker incorporating RF power, contact force, and time of delivery into a single weighted formula. Data regarding AI-guided PVCs RFCA are currently lacking. Aim of the study was to compare AI-guided and standard RFCA outcomes in patients with PVCs originating from the right ventricle outflow tract (RVOT).
Methods and results
Consecutive patients undergoing AI-guided RFCA of RVOT idiopathic PVCs were prospectively enrolled. Radiofrequency catheter ablation was performed following per-protocol target cut-offs of AI, depending on targeted area (RVOT free wall AI cut-off: 590; RVOT septum AI cut-off: 610). A multi-centre cohort of propensity-matched (age, sex, ejection fraction, and PVC site) patients undergoing standard PVCs RFCA was used as a comparator. Sixty AI-guided patients (44.2 ± 18.0 years old, 58% male, left ventricular ejection fraction 56.2 ± 3.8%) were enrolled; 34 (57%) were ablated in RVOT septum and 26 (43%) patients in the RVOT free wall area. Propensity match with 60 non-AI-guided patients was performed. Acute outcomes and complications resulted comparable. At 6 months, arrhythmic recurrence was more common in non-AI-guided patients whether in general (28% vs. 7% P = 0.003) or by ablated area (RVOT free wall: 27% vs. 4%, P = 0.06; RVOT septum 29% vs. 9% P = 0.05). Ablation Index guidance was associated with improved survival from arrhythmic recurrence [overall odds ratio 6.61 (1.95-22.35), P = 0.001; RVOT septum 5.99 (1.21-29.65), P = 0.028; RVOT free wall 11.86 (1.12-124.78), P = 0.039].
Conclusion
Ablation Index-guidance in idiopathic PVCs ablation was associated with better arrhythmic outcomes at 6 months of follow-up.

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

Europace: 15 Oct 2020; epub ahead of print
Gasperetti A, Sicuso R, Dello Russo A, Zucchelli G, ... Tondo C, Casella M
Europace: 15 Oct 2020; epub ahead of print | PMID: 33063099
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Abstract

Premature Atrial Complexes and Atrial Couplets - What is the Mechanism?

Pfenniger A, Knight BP

A 25-year-old female with no evidence of structural disease was referred for frequent, symptomatic, monomorphic premature atrial complexes (PACs) that often occurred in couplets or triplets. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Oct 2020; epub ahead of print
Pfenniger A, Knight BP
J Cardiovasc Electrophysiol: 17 Oct 2020; epub ahead of print | PMID: 33070415
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Abstract

Population Trends in All-Cause Mortality and Cause Specific-Death With Incident Atrial Fibrillation.

Singh SM, Abdel-Qadir H, Pang A, Fang J, ... Wijeysundera HC, Ko DT

Background Limited studies have evaluated population-level temporal trends in mortality and cause of death in patients with contemporary managed atrial fibrillation. This study reports the temporal trends in 1-year overall and cause-specific mortality in patients with incident atrial fibrillation. Methods and results Patients with incident atrial fibrillation presenting to an emergency department or hospitalized in Ontario, Canada, were identified in population-level linked administrative databases that included data on vital statistics and cause of death. Temporal trends in 1-year all-cause and cause-specific mortality was determined for individuals identified between April 1, 2007 (fiscal year [FY] 2007) and March 31, 2016 (FY 2015). The study cohort consisted of 110 302 individuals, 69±15 years of age with a median congestive heart failure, hypertension, age (≥75 years), diabetes mellitus, stroke (2 points), vascular disease, age (≥65 years), sex category (female) score of 2.8. There was no significant decline in the adjusted 1-year all-cause mortality between the first and last years of the study period (adjusted mortality: FY 2007, 8.0%; FY 2015, 7.8%; P for trend=0.68). Noncardiovascular death accounted for 61% of all deaths; the adjusted 1-year noncardiovascular mortality rate rose from 4.5% in FY 2007 to 5.2% in FY 2015 (P for trend=0.007). In contrast, the 1-year cardiovascular mortality rate decreased from 3.5% in FY 2007 to 2.6% in FY 2015 (P for trend=0.01). CONCLUSIONS Overall 1-year all-cause mortality in individuals with incident atrial fibrillation has not improved despite a significant reduction in the rate of cardiovascular death. These findings highlight the importance of recognizing and managing concomitant noncardiovascular conditions in patients with atrial fibrillation.



J Am Heart Assoc: 19 Oct 2020; 9:e016810
Singh SM, Abdel-Qadir H, Pang A, Fang J, ... Wijeysundera HC, Ko DT
J Am Heart Assoc: 19 Oct 2020; 9:e016810 | PMID: 32924719
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Abstract

Unmasking Arrhythmogenic Hubs of Reentry Driving Persistent Atrial Fibrillation for Patient-Specific Treatment.

Hansen BJ, Zhao J, Helfrich KM, Li N, ... Hummel JD, Fedorov VV

Background Atrial fibrillation (AF) driver mechanisms are obscured to clinical multielectrode mapping approaches that provide partial, surface-only visualization of unstable 3-dimensional atrial conduction. We hypothesized that transient modulation of refractoriness by pharmacologic challenge during multielectrode mapping improves visualization of hidden paths of reentrant AF drivers for targeted ablation. Methods and Results Pharmacologic challenge with adenosine was tested in ex vivo human hearts with a history of AF and cardiac diseases by multielectrode and high-resolution subsurface near-infrared optical mapping, integrated with 3-dimensional structural imaging and heart-specific computational simulations. Adenosine challenge was also studied on acutely terminated AF drivers in 10 patients with persistent AF. Ex vivo, adenosine stabilized reentrant driver paths within arrhythmogenic fibrotic hubs and improved visualization of reentrant paths, previously seen as focal or unstable breakthrough activation pattern, for targeted AF ablation. Computational simulations suggested that shortening of atrial refractoriness by adenosine may (1) improve driver stability by annihilating spatially unstable functional blocks and tightening reentrant circuits around fibrotic substrates, thus unmasking the common reentrant path; and (2) destabilize already stable reentrant drivers along fibrotic substrates by accelerating competing fibrillatory wavelets or secondary drivers. In patients with persistent AF, adenosine challenge unmasked hidden common reentry paths (9/15 AF drivers, 41±26% to 68±25% visualization), but worsened visualization of previously visible reentry paths (6/15, 74±14% to 34±12%). AF driver ablation led to acute termination of AF. Conclusions Our ex vivo to in vivo human translational study suggests that transiently altering atrial refractoriness can stabilize reentrant paths and unmask arrhythmogenic hubs to guide targeted AF driver ablation treatment.



J Am Heart Assoc: 19 Oct 2020; 9:e017789
Hansen BJ, Zhao J, Helfrich KM, Li N, ... Hummel JD, Fedorov VV
J Am Heart Assoc: 19 Oct 2020; 9:e017789 | PMID: 33006292
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Abstract

Computerized Analysis of the Ventricular Fibrillation Waveform Allows Identification of Myocardial Infarction: A Proof-of-Concept Study for Smart Defibrillator Applications in Cardiac Arrest.

Thannhauser J, Nas J, Rebergen DJ, Westra SW, ... Bonnes JL, Brouwer MA

Background In cardiac arrest, computerized analysis of the ventricular fibrillation (VF) waveform provides prognostic information, while its diagnostic potential is subject of study. Animal studies suggest that VF morphology is affected by prior myocardial infarction (MI), and even more by acute MI. This experimental in-human study reports on the discriminative value of VF waveform analysis to identify a prior MI. Outcomes may provide support for in-field studies on acute MI. Methods and Results We conducted a prospective registry of implantable cardioverter defibrillator recipients with defibrillation testing (2010-2014). From 12-lead surface ECG VF recordings, we calculated 10 VF waveform characteristics. First, we studied detection of prior MI with lead II, using one key VF characteristic (amplitude spectrum area [AMSA]). Subsequently, we constructed diagnostic machine learning models: model A, lead II, all VF characteristics; model B, 12-lead, AMSA only; and model C, 12-lead, all VF characteristics. Prior MI was present in 58% (119/206) of patients. The approach using the AMSA of lead II demonstrated a C-statistic of 0.61 (95% CI, 0.54-0.68). Model A performance was not significantly better: 0.66 (95% CI, 0.59-0.73), =0.09 versus AMSA lead II. Model B yielded a higher C-statistic: 0.75 (95% CI, 0.68-0.81), <0.001 versus AMSA lead II. Model C did not improve this further: 0.74 (95% CI, 0.67-0.80), =0.66 versus model B. Conclusions This proof-of-concept study provides the first in-human evidence that MI detection seems feasible using VF waveform analysis. Information from multiple ECG leads rather than from multiple VF characteristics may improve diagnostic accuracy. These results require additional experimental studies and may serve as pilot data for in-field smart defibrillator studies, to try and identify acute MI in the earliest stages of cardiac arrest.



J Am Heart Assoc: 19 Oct 2020; 9:e016727
Thannhauser J, Nas J, Rebergen DJ, Westra SW, ... Bonnes JL, Brouwer MA
J Am Heart Assoc: 19 Oct 2020; 9:e016727 | PMID: 33003984
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Abstract

Patients with diabetes mellitus and atrial fibrillation treated with NOACs: Meta-analysis of 8 outcomes in 58, 634 patients across 4 randomized controlled trials.

Plitt A, Zelniker TA, Park JG, McGuire DK, ... Braunwald E, Giugliano RP
Aims
Concomitant atrial fibrillation (AF) and diabetes mellitus (DM) increases risk of stroke and systemic embolic events. This meta-analysis assessed the benefit/risk balance of non-vitamin K antagonist oral anticoagulants (NOACs) vs warfarin, and explored whether there was effect modification by DM or heterogeneity in outcomes between NOACs in patients with and without DM.
Methods
We performed a meta-analysis of 58,634 patients from four phase 3 trials of NOAC vs warfarin in patients with AF, comparing the primary outcomes of efficacy and safety and 6 other secondary outcomes in patients stratified by the presence of DM. Interaction testing was used to assess for heterogeneity of treatment effects. A meta-regression was performed to evaluate the influence of baseline characteristics.
Results
NOACs reduced the risk of stroke/SEE in 18,134 patients with DM [hazard ratio (HR) 0.80; 95% confidence interval (CI) (0.69-0.93), I2 3.90] to a similar degree as in 40,500 patients without DM [HR 0.82; 95% CI (0.74-0.91)], I2 16.33 p-int 0.81). There was no effect modification of DM on the relative reduction with NOACs vs warfarin in major bleeding (DM : 0.95, 95% CI 0.75-1.20, I2 43.83; no DM: 0.83, 95% CI 0.55-1.24; I2 87.90; p-int 0.37). Intracranial Haemorrhage (HRs 0.51 and 0.47, p-int 0.70) and cardiovascular death (HRs 0.87 and 0.90, p-int 0.70) were significantly reduced by NOACs in the presence or absence of DM.
Conclusion
NOACs are more effective and safer than warfarin in AF patients with or without DM and absent contraindications, NOACs should be the anticoagulation treatment choice in diabetics.

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

Eur Heart J Cardiovasc Pharmacother: 15 Oct 2020; epub ahead of print
Plitt A, Zelniker TA, Park JG, McGuire DK, ... Braunwald E, Giugliano RP
Eur Heart J Cardiovasc Pharmacother: 15 Oct 2020; epub ahead of print | PMID: 33063112
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This program is still in alpha version.