Reduction in Balloon Pump Size Reduces Axillary Intraaortic Balloon Pump Failure Risk

Axillary artery intra-aortic balloon pump (axIABP) placement has been implemented as a bridging solution before heart transplantation. This study evaluates complications associated with axIABP support and describes an approach to minimize adverse events. We previously described a percutaneous approach for axIABP placement. However, patients receiving axIABP between September 1, 2017, and September 26, 2019 (n = 32) demonstrated a high rate of balloon pump malfunction (8/32; 25%) and other complications (totaling 15/32; 47%). Sixty-four patients were sequentially treated under a revised protocol. Compared to the initial cohort, no significant differences in demographics were noted. A significant reduction in rate of balloon malfunction (8/32, 25% vs. 1/64, 2%; p < 0.001) and total complications (15/32, 47% vs. 10/64, 16%; p = 0.0025) during the period of support were noted after intervention. Subsequent analysis of total complications per device size (40 vs. ≤ 34 ml balloon) revealed significantly reduced complications in patients with smaller devices (40% vs. 13%, respectively; p = 0.0022). This study provides guidelines to limit complications in patients supported with axIABP, facilitating a protracted period of bridging support.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Cryoballoon vs. laser balloon ablation for atrial fibrillation: a meta-analysis

Background

Cryoballoon ablation (CBA) and laser balloon ablation (LBA) are two innovative ways for the treatment of atrial fibrillation (AF). This study aimed to evaluate the efficacy and safety of cryoballoon ablation and laser balloon ablation in patients with AF.

Methods

We searched Pubmed, Embase, Ovid, Web of Science and other databases for comparative trials comparing CB and LB ablation in the treatment of AF, from establishment of database to August, 2023.

Results

A total of 13 studies and 3,582 patients were included (CBA, n = 2,308; LBA, n = 1,274). There was no difference between CBA and LBA in acute PVI rate per vein, 12-months recurrence rate of AF, 12-months recurrence rate of atrial arrhythmia, occurrence rate of pericardial tamponade, occurrence rate of inguinal complications. LBA presented a lower acute PVI rate per patients (CBA 97.0% vs. LBA 93.4%, RR = 1.04, 95%CI: 1.01-1.07). Transient nerve palsy was more likely to occur after CBA (CBA 2.7% vs. LBA 0.7%, RR = 4.25, 95%CI: 2.06-8.76). However, the occurrence of persistent nerve palsy between CBA and LBA groups were similar (CB 1.4% vs. LB 1.0%, RR = 1.09, 95%CI: 0.55-2.14). In terms of procedural duration, the procedural time of CBA was shorter than that of LBA (WMD = -26.58, 95%CI: -36.71-16.46).

Conclusions

Compared with LBA, CBA had a shorter procedural duration. There was a higher incidence of transient but not persistent phrenic nerve palsy after CBA.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272607 Identifier (CRD42021272607).

Navigating the Complexity: A Comprehensive Review of Managing Pregnancy in Complete Heart Block Cases

This review explores the comprehensive management of pregnancy in cases of complete heart block, a cardiac condition characterized by the dissociation between atrial and ventricular conduction. The review begins with a thorough examination of preconception counseling, emphasizing the assessment of maternal health, the evaluation of cardiac function, and the identification of potential risks. Subsequently, the medical management section delves into using beta-blockers, pacemakers, and antiarrhythmic drugs to monitor cardiac function during pregnancy and adjust medication regimens. Obstetric considerations highlight the importance of antenatal care, fetal monitoring, and thoughtful delivery planning, including the choice between vaginal delivery and cesarean section. The section on complications underscores the risks of arrhythmias, heart failure, premature birth, and neonatal cardiac issues. Looking ahead, the future directions and research section explores ongoing studies in genetics, pharmacology, and technological innovations, envisioning potential advancements in pacing technology and personalized medicine approaches. The conclusion synthesizes key findings, offering recommendations for clinical practice and reflecting on the challenges and opportunities inherent in managing pregnancy in complete heart block cases. The multidisciplinary approach emerges as paramount, with collaborative efforts paving the way for improved patient outcomes and advancements in the field.

Evolving Contemporary Management of Atrial Fibrillation in Hypertrophic Cardiomyopathy

Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM) with clinical and subclinical episodes occurring in nearly one-half of patients. AF in HCM historically has been characterized as a decisive disease complication associated with substantial risk for thromboembolic stroke and increased morbidity and mortality. However, there have been many advances in treatment strategy resulting in improved outcomes for this patient group. For example, stroke risk in HCM has been greatly reduced by using systemic oral anticoagulation initiated after the first clinical (symptomatic) AF episode, usually with preference given to direct anticoagulants over warfarin. In contrast, stroke risk scoring systems (such as CHA2DS2-VASc score) are not informative in HCM given the substantial potential for stroke events in patients with low scores, and therefore should not be used for anticoagulation decisions in this disease. A novel risk score specifically designed for HCM (HCM-AF score) can reliably identify most patients with HCM at risk for future AF. Although a strategy focused on controlling ventricular rate is effective in asymptomatic (or minimally symptomatic) patients with AF, restoring and maintaining sinus rhythm is required for most patients with marked AF symptom burden and impaired quality of life. Several antiarrhythmic drugs such as sotalol, disopyramide, and amiodarone, can be effective in suppressing AF episodes; albeit safe, long-term efficacy is supported by only limited data. Catheter AF ablation has emerged as an important treatment option for some patients, although freedom from AF after a single ablation is relatively low (35% at 3 years), multiple ablations and the concomitant use of antiarrhythmic drugs can control AF with more than two-thirds of patients maintaining sinus rhythm at 5 years. Surgical AF ablation with biatrial Cox-Maze IV performed as an adjunctive procedure during myectomy can reduce symptomatic AF episodes (70% of patients free from AF at 5 years). For the vast majority of patients who have HCM with AF, the implementation of contemporary therapies has allowed for improved quality of life and low HCM-related mortality.

Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios

It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.

Optimization of superior vena cava isolation with aid of ablation index guidance

INTRODUCTION

To investigate the optimal range of quantitative ablation index (AI) value during superior vena cava (SVC) electrical isolation by radiofrequency catheter ablation (RFCA).

METHODS

First, in a development cohort of patients with atrial fibrillation (AF), the RFCA with 40 W was performed to complete SVC isolation guided by the conduction breakthrough point from the right atrium to SVC. Then, the range of AI value was calculated by offline analysis on different segments of SVC. Lastly, for the validation of AF patients, the safety and effectiveness of SVC isolation with the optimized target range of AI value were evaluated with an additional adenosine test.

RESULTS

A total of 101 patients with AF were included in the study (44 patients in the development cohort/57 in the validation cohort). The segmental ablation strategy was applied in 70% of the patients. According to the offline analysis of the AI values in the development cohort, the target AI value range was set as 350-400. The success rate of SVC isolation in the validation cohort was significantly higher than that in the exploration cohort (100% vs. 90.9%, p = .02), and no complications occurred in the exploration cohort. During the adenosine test, the recovery rate of electrical conduction in SVC was significantly lower than that in the pulmonary vein (3.5% vs. 17.5%).

CONCLUSION

The target AI value with a range from 350 to 400 is safe and effective for high-power RFCA to complete SVC isolation.

Bayesian network meta-analysis comparing hot balloon, laser balloon and cryoballoon ablation as initial therapies for atrial fibrillation

BACKGROUND

Balloon-based catheter ablation (CA) technologies, including hot balloon ablation (HBA), laser balloon ablation (LBA) and cryoballoon ablation (CBA) have been introduced in recent years as alternatives to conventional radiofrequency ablation therapy for atrial fibrillation (AF). However, the results remain controversial concerning the optimal approach. Thus, we conducted a network meta-analysis (NMA) to comprehensively evaluate the efficacy and safety of HBA, LBA and CBA.

METHODS

Clinical trials comparing the efficacy and safety of HBA, LBA and CBA were identified through a systematic search up to October 2022. The primary outcomes of interest were the recurrence of AF and procedure-related complications.

RESULTS

Twenty clinical trials with a total of 1,995 patients were included in the meta-analysis. The NMA results demonstrated that HBA, LBA and CBA had comparable AF recurrence rates (HBA vs. CBA: odds ratio OR = 0.88, 95% credible interval CrI: 0.56-1.4; LBA vs. CBA: OR = 1.1, 95% CrI: 0.75-1.5; LBA vs. HBA: OR = 1.2, 95% CrI: 0.70-2.0) and procedure-related complications (HBA vs. CBA: OR = 0.93, 95% CrI: 0.46-2.3; LBA vs. CBA: OR = 1.1, 95% CrI: 0.63-2.1; LBA vs. HBA: OR = 1.2, 95% CrI: 0.44-2.8). The surface under the cumulative ranking curve (SUCRA) suggested that HBA may be the optimal approach concerning the primary outcomes (SUCRA = 74.4%; 61.1%, respectively). However, HBA (40.1%) had a significantly higher incidence of touch-up ablation (TUA) than LBA (8.5%, OR = 2.8, 95% CrI: 1.1-7.1) and CBA (11.9%, OR = 3.7, 95% CrI: 1.9-7.5). LBA required more procedure time than CBA [mean difference (MD = 32.0 min, 95% CrI: 19.0-45.0 min)] and HBA (MD = 26.0 min, 95% CrI: 5.6-45.0 min), but less fluoroscopy time than HBA (MD = -9.4 min, 95% CrI: -17.0--2.4 min).

CONCLUSIONS

HBA, LBA and CBA had comparable efficacy and safety as initial treatments for AF. HBA ranked highest in the primary outcomes, but at the cost of a higher incidence of TUA and longer fluoroscopy time.

SYSTEMATIC REVIEW REGISTRATION

www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022381954, identifier: CRD42022381954.

Standard vs Augmented Ablation of Paroxysmal Atrial Fibrillation for Reduction of Atrial Fibrillation Recurrence: The AWARE Randomized Clinical Trial

Importance

Recurrent atrial fibrillation (AF) commonly occurs after catheter ablation and is associated with patient morbidity and health care costs.

Objective

To evaluate the superiority of an augmented double wide-area circumferential ablation (WACA) compared with a standard single WACA in preventing recurrent atrial arrhythmias (AA) (atrial tachycardia, atrial flutter, or atrial fibrillation [AF]) in patients with paroxysmal AF.

Design, Setting, and Participants

This was a pragmatic, multicenter, prospective, randomized, open, blinded end point superiority clinical trial conducted at 10 university-affiliated centers in Canada. The trial enrolled patients 18 years and older with symptomatic paroxysmal AF from March 2015 to May 2017. Analysis took place between January and April 2022. Analyses were intention to treat.

Interventions

Patients were randomized (1:1) to receive radiofrequency catheter ablation for pulmonary vein isolation with either a standard single WACA or an augmented double WACA.

Main Outcomes and Measures

The primary outcome was AA recurrence between 91 and 365 days postablation. Patients underwent 42 days of ambulatory electrocardiography monitoring after ablation. Secondary outcomes included need for repeated catheter ablation and procedural and safety variables.

Results

Of 398 patients, 195 were randomized to the single WACA (control) arm (mean [SD] age, 60.6 [9.3] years; 65 [33.3%] female) and 203 to the double WACA (experimental) arm (mean [SD] age, 61.5 [9.3] years; 66 [32.5%] female). Overall, 52 patients (26.7%) in the single WACA arm and 50 patients (24.6%) in the double WACA arm had recurrent AA at 1 year (relative risk, 0.92; 95% CI, 0.66-1.29; P = .64). Twenty patients (10.3%) in the single WACA arm and 15 patients (7.4%) in the double WACA arm underwent repeated catheter ablation (relative risk, 0.72; 95% CI, 0.38-1.36). Adjudicated serious adverse events occurred in 13 patients (6.7%) in the single WACA arm and 14 patients (6.9%) in the double WACA arm.

Conclusions and Relevance

In this randomized clinical trial of patients with paroxysmal AF, additional ablation by performing a double ablation lesion set did not result in improved freedom from recurrent AA compared with a standard single ablation set.

Trial Registration

ClinicalTrials.gov Identifier: NCT02150902.

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association

Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.

Development of a clinically relevant ex vivo model of cardiac ablation for testing of ablation catheters

INTRODUCTION

Reliable ex vivo cardiac ablation models have the potential to increase catheter testing throughput while minimizing animal usage. The goal of this work was to develop a physiologically relevant ex vivo swine model of cardiac ablation displaying minimal variability and high repeatability and identify and optimize key parameters involved in ablation outcomes.

METHODS AND RESULTS

A root cause analysis was conducted to identify variables affecting ablation outcomes. Parameters associated with the tissue, bath media, and impedance were identified. Variables were defined experimentally and/or from literature sources to best mimic the clinical cardiac ablation setting. The model was validated by performing three independent replicates of ex vivo myocardial ablation and a direct comparison of lesion outcomes of the ex vivo swine myocardial and in vivo canine thigh preparation (TP) models. Replicate experiments on the ex vivo model demonstrated low variance in ablation depth (6.5 ± 0.6, 6.3 ± 0.6, 6.2 ± 0.4 mm) and width (10.4 ± 1.1, 9.7 ± 1.0, 9.9 ± 0.9 mm) and no significant differences between replicates. In a direct comparison of the two models, the ex vivo model demonstrated ablation depths similar to the canine TP model at 35 W (6.9 ± 1.0, and 7.0 ± 0.9 mm) and 50 W (8.0 ± 0.7, and 8.4 ± 0.7 mm), as well as similar power to depth ratios (15% and 19% for the ex vivo cardiac and in vivo TP models, respectively).

CONCLUSION

The ex vivo model exhibited strong lesion reproducibility and power-to-depth ratios comparable to the in vivo TP model. The optimized ex vivo model minimizes animal usage with increased throughput, lesion characteristics similar to the in vivo TP model, and ability to discriminate minor variations between different catheter designs.

Rationale and study design of the Italian Registry in the setting of Atrial Fibrillation Ablation with Rivaroxaban - IRIS

BACKGROUND

Catheter ablation (CA) of atrial fibrillation (AF) is used routinely to establish rhythm control. There is mounting evidence that CA procedures should be performed during continuous oral anticoagulation and direct oral anticoagulants (DOACs) are considered the first anticoagulation strategy. Few real-life data are now available and even less in the Italian panorama.

METHODS

IRIS is an Italian multicenter, non-interventional, prospective study which will be enrolled consecutive AF patients eligible for CA and treated with Rivaroxaban; patients in treatment with Rivaroxaban proceeded directly to CA while Rivaroxaban-naive patients were scheduled for CA after 4 weeks of uninterrupted anticoagulation unless the exclusion of atrial thrombi. Rivaroxaban was uninterrupted or shortly uninterrupted (<24 hours) prior CA, in line with routinely practice of each operator. Patients will be followed on continuous anticoagulation for 1 month after the ablation. The primary efficacy outcome is the cumulative incidence of all-cause death and systemic embolism while the primary safety outcome is the incidence of major bleeding events. The secondary outcomes are represented by non-major bleeding events. All events must be occurred within the first 30 days after the procedure.

RESULTS

Two hundred fifty patients are expected to be enrolled and the study is estimated to be completed by the end of 2022. Up to now 56 patients have been enrolled.

CONCLUSIONS

This study is the first large Italian prospective study on the management of Rivaroxaban in patients undergoing CA of AF. It aims to depict a comprehensive view of anticoagulation strategy prior CA in several Italian electrophysiology labs.

Best Practice Guide for Cryoballoon Ablation in Atrial Fibrillation: The Compilation Experience of More than 1000 Procedures

Nowadays, the cryoballoon (CB) constitutes an established alternative to radio frequency (RF) ablation for pulmonary vein isolation (PVI), which offers the possibility to isolate the PVs with a single application. Since the introduction of the second-generation CB, we prospectively collected our data to optimize the procedure on >1000 consecutive patients who underwent CB PVI performed in our center. It is expected that subsequent guidelines will suggest first-line PVI through CB in patients with paroxysmal AF with a class I indication. Indeed, in the long-term follow-up (36 months) of the EARLY-AF trial, CB had a lower incidence of persistent atrial fibrillation episodes compared to the anti-arrhythmic drugs group. We now review the current best practices in an effort to drive consistent outcomes and minimize complications. PV isolation through CB is the most studied single-shot technique for atrial fibrillation ablation, having shown the potential to alter the natural history of the arrhythmia. Several procedural tips and tricks can improve procedural flow and effectiveness. In the present article we provided not only technical details but measurable biophysical parameters that can reliably guide the operator into achieving the best outcome for his patients.

Catheter Ablation of Atrial Fibrillation in Hypertrophic Cardiomyopathy: A Proportional Meta-Analysis and Systematic Review of Single Arm Studies

Background

Atrial fibrillation (AF) is the most common arrhythmia in patients with hypertrophic cardiomyopathy (HCM). Limited data exists about the efficacy and clinical outcomes of AF ablation in HCM.

Objective

The purpose of this meta-analysis was to evaluate the role of catheter-based ablation for treatment of AF in patients with HCM.

Methods

PubMed, SCOPUS, Web of Science, Embase, Cochrane library, and ClinicalTrials.gov were searched for studies discussing outcomes of catheter-based ablation for AF in patients with HCM. Two reviewers independently screened studies and extracted relevant data. Incidence rate estimates from individual studies underwent logit transformation to calculate the weighted summary proportion under the random effect model.

Results

A total of 19 reports met the inclusion criteria (1183 patients). The single ablation procedure was successful in 39% patients. Up to 34% patients underwent a repeat ablation. About 41% patients in normal sinus rhythm after successful AF ablation received postprocedure antiarrhythmic drug (AAD) therapy. Patients undergoing successful AF ablation experienced a significant improvement in the New York Heart Association functional class (standardized mean difference -1.03; 95% confidence interval -1.23 to -0.83; P < .00001).

Conclusion

AF ablation appears to be safe and feasible in patients with HCM. Freedom from AF after undergoing successful ablation is associated with significant improvement in heart failure symptoms.

Superiority of complete bi-atrial ablation procedure for atrial fibrillation in rheumatic mitral valve disease

INTRODUCTION

The necessity of complete bi-atrial lesion created by radiofrequency clamp and pen for nonparoxysmal atrial fibrillation (AF) in patients with rheumatic mitral valve disease (RMVD) remains unclear.

METHODS

From January 2014 to December 2018, patients with RMVD concomitant with nonparoxysmal AF who underwent mitral valve surgery concomitant surgical ablation were retrospectively enrolled. We divided patients into Group A (complete bi-atrial lesion set created by radiofrequency clamp and pen) and Group B (simplified lesion sets created by radiofrequency clamp alone including bi-atrial ablation with incomplete mitral isthmus line and stand-alone left atrial ablation) according to the surgical ablation lesion sets. Propensity score matching was applied to analyze freedom from atrial tachyarrhythmias between the two groups.

RESULTS

Two hundred eight (38.5%) and 332 (61.5%) patients were divided into Group A and Group B, respectively. In Group B, the proportion of patients with recurrent atrial flutter in the subgroup of bi-atrial ablation with incomplete mitral isthmus line was higher than that in Group A (p = .044). After propensity score matching, there were 203 patients in each group. Better freedom from atrial tachyarrhythmias without antiarrhythmic drugs was obtained in Group A (83.1%, 79.6%, and 65.4%) than Group B (73.1%, 68.4%, and 52.7%) at 12, 36, and 60 months after operation (p = .012).

CONCLUSION

The application of radiofrequency clamp and pen to create complete bi-atrial lesion set in surgical ablation for nonparoxysmal AF in RMVD was associated with superior long-term efficacy.

Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association

The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.

The prevalence and course of COVID-19 and the Cardiovascular Diseases

Corona pandemic has infected over 277 million people and has claimed more than 5.4 million lives with recovery of 249 million globally by early 2022. The global case fatality rate ranged from 6-7% in United States, Switzerland, Ireland, 12-14% in Sweden, Spain, Netherlands, United Kingdom, Italy, and 15-16% in France and Belgium among hospitalized and non-hospitalized COVID-19 patients, the prevalence of underlying cardiovascular diseases was 9%. The prevalence of cardiovascular diseases among hospitalized COVID-19 patients and those requiring intensive care unit admission were 23% and 29% respectively. The virus continues to evolve into new formats latest being Delta and Omicron variants. In a multicenter study of 8910 COVID-19 patients from 169 hospitals in Asia, Europe and North America, presence of pre-existing coronary artery disease, chronic heart failure and cardiac arrhythmia was associated with increased mortality of 10.2%, 15.3% and 11.5% respectively, compared with 5-6% mortality in those without the above co-morbidities. The systemic inflammation caused by SARS-CoV-2 could lead to a wide spectrum of cardiovascular complications including acute cardiac injury, acute coronary syndrome, coronary artery dissection, acute myocarditis, cardiomyopathy, chronic heart failure, cardiac arrhythmia, pulmonary embolism, cardiogenic shock, circulatory failure or even cardiac arrest.

Augmented wide area circumferential catheter ablation for reduction of atrial fibrillation recurrence (AWARE) trial: Design and rationale

BACKGROUND

Recurrence of atrial fibrillation (AF) after a pulmonary vein isolation procedure is often due to electrical reconnection of the pulmonary veins. Repeat ablation procedures may improve freedom from AF but are associated with increased risks and health care costs. A novel ablation strategy in which patients receive "augmented" ablation lesions has the potential to reduce the risk of AF recurrence.

OBJECTIVE

The Augmented Wide Area Circumferential Catheter Ablation for Reduction of Atrial Fibrillation Recurrence (AWARE) Trial was designed to evaluate whether an augmented wide-area circumferential antral (WACA) ablation strategy will result in fewer atrial arrhythmia recurrences in patients with symptomatic paroxysmal AF, compared with a conventional WACA strategy.

METHODS/DESIGN

The AWARE trial was a multicenter, prospective, randomized, open, blinded endpoint trial that has completed recruitment (ClinicalTrials.gov NCT02150902). Patients were randomly assigned (1:1) to either the control arm (single WACAlesion set) or the interventional arm (augmented- double WACA lesion set performed after the initial WACA). The primary outcome was atrial tachyarrhythmia (AA; atrial tachycardia [AT], atrial flutter [AFl] or AF) recurrence between days 91 and 365 post catheter ablation. Patient follow-up included 14-day continuous ambulatory ECG monitoring at 3, 6, and 12 months after catheter ablation. Three questionnaires were administered during the trial- the EuroQuol-5D (EQ-5D) quality of life scale, the Canadian Cardiovascular Society Severity of Atrial Fibrillation scale, and a patient satisfaction scale.

DISCUSSION

The AWARE trial was designed to evaluate whether a novel approach to catheter ablation reduced the risk of AA recurrence in patients with symptomatic paroxysmal AF.

Characteristics of anatomical difficulty for cryoballoon ablation: insights from CT

Background

The limited availability of balloon sizes for cryoballoon leads to anatomical limitations for pulmonary vein (PV) isolation. We conducted a comprehensive systematic analysis on procedural success rate, atrial fibrillation (AF) recurrence rate and complications of cryoballoon ablation in association with the anatomy of the left atrium and PV based on preprocedural CT to gain insights into proper treatments of patients with AF using cryoballoon.

Method

A systematic search of literature databases, including PubMed, Web of Science and Cochrane Library, from the inception of each database through February 2021 was conducted. Search keywords included ‘atrial fibrillation’, ‘cryoballoon ablation’ and ‘anatomy’.

Results

Overall, 243 articles were identified. After screening, 16 articles comprising 1396 patients were included (3, 5 and 8 for acute success, AF recurrence and complications, respectively). Regarding acute success and AF recurrences, thinner width of the left lateral ridge, higher PV ovality, PV ostium-bifurcation distance, shorter distance from the non-coronary cusp to inferior PVs, shallower angle of right PVs against the atrial septum and larger right superior PV (RSPV) were associated with poor outcomes. Regarding complications, shorter distance between the RSPV ostium and the right phrenic nerve, larger RSPV-left atrium angle, larger RSPV area and smaller right carina width were associated with incidences of phrenic nerve injury.

Conclusion

This study elucidated several key anatomical features of PVs possibly affecting acute success, AF recurrence and complications in patients with AF using cryoballoon ablation. CT analysis has helped to describe benefits and anatomical limitations for cryoballoon ablation.

UBLED AF (Uninterrupted BLackpool EDoxaban vs Warfarin vs Rivaroxaban in Atrial Fibrillation/Flutter ablation) Study

Aim

Catheter ablation in patients with atrial fibrillation (AF)/atrial flutter carries a risk of thromboembolism and major bleeding. In light of recent prospective trial data on the safety and efficacy of uninterrupted edoxaban in patients undergoing AF/flutter ablation, real-world Data was aimed for validation.

Methods

A total of 228 patients who underwent AF/atrial flutter ablation over 14 months at our centre were retrospectively analyzed. All patients received uninterrupted oral anticoagulation for at least 4 weeks prior to ablation and 3 months post-ablation. Both bleeding and thromboembolic events were assessed at 24 hours comparing patients on warfarin, rivaroxaban and edoxaban.

Results

Mean age of patients were 68.5 +/- 8 years in the warfarin group ( N =86), 63.4 +/- 10.6 years; in the edoxaban group ( N =63) and 62.3 +/- 11.6 years in the rivaroxaban group ( N =79). CHADSVASc scores were 2.43 +/- 1.34, 1.68 +/- 1.34 and 1.64 +/- 1.38 respectively. The mean left atrial sizes were 42.7 +/- 6.8 mm, 42.0 +/- 6 mm and 41.1 +/- 6.5 mm respectively. The study endpoint was death, acute thromboembolism or major bleeding. There was 1 pericardial effusion (1.2%) in the warfarin group, 1 pericardial effusion and 1 transient ischaemic attack (2.5%) in the rivaroxaban group and 1 pericardial effusion needing drainage (1.6%) in the edoxaban group. There were no significant differences in the study endpoints between groups.

Conclusion

This real-world study demonstrated no significant difference in safety and efficacy between uninterrupted edoxaban, warfarin and rivaroxaban in patients undergoing AF/flutter ablation.

Efficiency and safety of ablation procedure for the treatment of atrial fibrillation in valve surgery: A PRISMA-compliant cumulative systematic review and meta-analysis

BACKGROUND

Atrial fibrillation is the main complication of patients who suffer from valvular heart disease (VHD), which may lead to an increased susceptibility to ventricular tachycardia, atrial dysfunction, heart failure, and stroke. Therefore, seeking a safe and effective therapy is crucial in prolonging the lives of patients with VHD and improving their quality of life.

METHODS

Our target database included PubMed, Web of Science, Embase, and Cochrane Library, from which published articles were retrieved from inception to June 2020. We retrieved all randomized controlled trials (RCTs) that compared patients undergoing valve surgery with (VSA) or without ablation (VS) procedure. Studies to be included were screened and data extraction was performed independently by 2 investigators. The Cochrane risk-of-bias table was used to evaluate the methodological quality of the included RCTs. The mean difference (MD) with 95% confidence interval (CI) and relative risk (RR) ratio was calculated to analyze the data. Heterogeneity was evaluated using I2 and chi-square tests. Egger test and the trim and fill analysis were used to further determine publication bias.

RESULTS

Fourteen RCTs that included 1376 patients were eventually selected for this meta-analysis. Surgical ablation was found to be effective in restoring sinus rhythm in valvular surgery patients at discharge (RR 2.91, 95% CI [1.17, 7.20], I2 97%, P = .02), 3 to 6 months (RR 2.85, 95% CI [2.27, 3.58], I2 49%, P < .00001), 12 months, and more than 1 year after surgery (RR 3.54, 95% CI [2.78, 4.51], I2 27%, P < .00001). All-cause mortality (RR 0.98, 95% CI [0.64, 1.51], I2 0%, P = .94) and stroke (RR 1.29, 95% CI [0.70, 2.39], I2 0%, P = .57) were similar in the VSA and VS groups. Compared with VS, VSA prolonged cardiopulmonary bypass time (MD 30.44, 95% CI [17.55, 43.33], I2 88%, P < .00001) and aortic cross-clamping time (MD 19.57, 95% CI [11.10, 28.03], I2 89%, P < .00001). No significant differences were found between groups with respect to the risk of bleeding (RR 0.64, 95% CI [0.37, 1.12], I2 0%, P = .12), heart failure (RR 1.11, 95% CI [0.63, 1.93], I2 0%, P = .72), and low cardiac output syndrome (RR 1.41, 95% CI [0.57, 3.46], I2 18%, P = .46). However, the demand for implantation of a permanent pacemaker was significantly higher in the VSA group (RR 1.84, 95% CI [1.15, 2.95], I2 0%, P = .01).

CONCLUSION

Although we found high heterogeneity in the restoration of sinus rhythm at discharge, we assume that the comparison is valid at this time, given the current state in the operating room. This study provides evidence of the efficacy and security of concomitant ablation intervention for patients with VHD and atrial fibrillation. Surgical ablation would increase the safety of implantation of a permanent pacemaker in the population that underwent valve surgery.

Non-pharmaceutical Interventions for Hypertrophic Cardiomyopathy: A Mini Review

Hypertrophic cardiomyopathy is an inherited cardiovascular disease, and 70% of patients have left ventricular outflow tract obstruction. Ventricular septal myectomy has been the gold standard treatment for most patients with refractory symptoms. Due to higher mortality associated with medical facilities with less experience, alcohol septal ablation has been accepted as an alternative to conventional surgical myectomy. It offers lower all-cause in-hospital complications and mortality, which could be potentially more preferable for patients with serious comorbidities. In recent years, radiofrequency ablation, providing another option with reproducibility and a low risk of permanent atrioventricular block, has become an effective invasive treatment to relieve left ventricular outflow tract obstruction. Moreover, substantial progress has been made in gene therapy for hypertrophic cardiomyopathy. The principal objective of this review is to present recent advances in non-pharmaceutical interventions in hypertrophic cardiomyopathy.

Comparative characteristics of a pacemaker implantation after biatrial or left atrial ablation of atrial fibrillation in combination with coronary artery bypass grafting in patients with ischemic heart disease and long-standing persistent atrial fibrillation

Aim      To compare the incidence of a permanent pacemaker (PP) implantation based on the chosen treatment technology (biatrial ablation, BA, or left atrial ablation (LAA) for long-standing persistent atrial fibrillation (AF) with simultaneous coronary bypass (CB).Material and methods  The study included 116 patients with long-standing persistent AF and indications for CB. Patients were randomized to two equal groups (58 patients in each). Group 1 underwent BA in combination with CB; group 2 patients underwent isolated LAA with simultaneous CB under the conditions of artificial circulation. Incidence of PP implantation was assessed during the early (to 30 days) and late (to 60 months) postoperative periods.Results For the observation period, a total of 9 PPs was implanted in both groups, 6 in the BA group and 3 in the LAA group (odds ratio, OR, 0.5; 95 % confidence interval, CI, 0.1-2.4; р=0.490). During the early postoperative period, 5 patients in the BA group and 2 patients in the LAA group were implanted with PP (OR, 0.4; 95 % CI. 0-2.5; р=0.438). During the late postoperative period, one (2%) patient of the BA group was implanted with a permanent PP at 30 months of follow-up due to the development of sick sinus syndrome (SSS); also, one (2%) patient of the LAA group required PP implantation at 54 months of follow-up due to the development of SSS. The causes for PP implantation in the BA group included the development of complete atrioventricular (AV) block in 9 % of cases (95 % CI, 4-19 %); sinus node dysfunction and junctional rhythm in 2 % of cases (95 % CI, 0-9 %). Compared to this group, the LAA group showed a statistically significant difference in the incidence of AV block (0 cases, р=0.047). The major cause for PP implantation in the LAA group was the development of sinus node dysfunction in 3 (5 %) patients (95 % CI, 2-14 %).Conclusion      The use of BA in surgical treatment of long-standing persistent AF with simultaneous myocardial revascularization is associated with a high risk of AV block, which requires permanent PP implantation in the postoperative period. Total incidence of permanent PP implantation for dysfunction of the cardiac conduction system following the combination surgical treatment of long-standing persistent AF and IHD, either CB and LAA or BA, did not differ between the treatment groups both in early and late postoperative periods.

Safety and efficacy of concomitant ablation for atrial fibrillation in rheumatic mitral valve surgery: A meta-analysis

OBJECTIVES

This review aimed to evaluate the safety and efficacy of concomitant surgical ablation (SA) for patients with atrial fibrillation (AF) undergoing rheumatic mitral valve (MV) surgery.

METHODS

A systematic search of relevant studies focusing on SA for patients with AF undergoing rheumatic MV surgery was performed. The primary outcomes included mortality, efficacy, and complications.

RESULTS

Four randomized controlled trials (RCTs) and four observational studies covering 1931 patients met the inclusion criteria. In RCTs, no significant differences in reoperation for bleeding, low cardiac output syndrome, thromboembolic events, and early (risk ratio [RR], 2.07; 95% confidence intervals [CI], 0.37-11.40; p = .41) and midterm all-cause death (RR, 1.07; 95% CI, 0.40-2.88; p = .89) were noted between the SA group and the nonablation group. These results were similar to those obtained from observational studies. However, ablation was associated with a higher incidence of permanent pacemaker implantation (RR, 2.44; 95% CI, 1.15-5.18; p = .02) in observational studies but not in RCTs (RR, 2.03; 95% CI, 0.19-21.26; p = .56). Furthermore, additional SA was significantly more effective in sinus rhythm (SR) restoration than MV surgery alone at discharge and at the 12-month and 3-year follow-ups.

CONCLUSIONS

Concomitant SA during rheumatic MV surgery does not increase perioperative adverse events. In addition, SA promotes considerable restoration of SR. Although some evidence exists that permanent pacemaker implantation is more common after ablation, not all studies support this notion.

Patient-reported quality of life after stand-alone and concomitant arrhythmia surgery: a systematic review and meta-analysis

 

OBJECTIVES

Patient-reported quality of life (QOL) has become an important endpoint for arrhythmia surgery for atrial fibrillation (AF). While studies specifically evaluating the effect of arrhythmia surgery on QOL are scarce, we aimed to summarize current evidence of QOL following concomitant and stand-alone arrhythmia surgery for AF.

METHODS

All studies reporting on QOL using questionnaires from patients undergoing arrhythmia surgery for AF, both stand-alone and concomitant, were included in this systematic review. A meta-analysis was performed on inter-study heterogeneity of changes in QOL on 9 of 12 included studies that used the Short-Form 36 tool and meta-regression based on rhythm outcome after 1 year was executed. Finally, differences in QOL following stand-alone arrhythmia surgery and concomitant procedures were evaluated.

RESULTS

Overall, QOL scores improved 1 year after surgical ablation for AF evaluated by several questionnaires. In stand-alone arrhythmia procedures, meta-regression showed significant improvements in those who were in sinus rhythm compared to those in AF after 1 year. This association between an improved QOL and the procedural effectiveness was also suggested in concomitant procedures. However, when comparing QOL of patients undergoing cardiac surgery with and without add-on surgical ablation for AF, only the variable ‘physical role’ demonstrated a significant improvement.

CONCLUSIONS

In patients with AF, QOL improves after both stand-alone and concomitant arrhythmia surgery. In the concomitant group, this improvement can be attributed to both the cardiac procedure itself as well as the add-on arrhythmia surgery. However, both in stand-alone and concomitant procedures, the improvement in QOL seems to be related to the effectiveness of the procedure to maintain sinus rhythm after 12 months.

Surgical Ablation of Permanent Atrial Fibrillation: Age, LV Dilatation, Obesity

OBJECTIVES

 Although concomitant surgical ablation can help to reach freedom from atrial fibrillation (FREEAF) even in patients with permanent atrial fibrillation (AF), some cardiac surgeons hesitate to perform concomitant ablation to avoid perioperative risk escalation. Here, we investigated outcome and predicators of therapeutic success of concomitant surgical ablation in an all-comers study.

METHODS

 Ablation-naïve patients with formerly accepted permanent AF (FAP, n = 41) or paroxysmal AF (parAF, n = 24) underwent concomitant epicardial bipolar radio frequency ablation and implantable loop recorder (ILR) at two surgical departments. Follow-up examination for 24 months included electrocardiogram, ILR readout, 24h Holter monitoring, echocardiography, and blood sampling.

RESULTS

 Eighty-six percent of parAF and 70% of FAP patients reached FREEAF (month 24). Mortality was low (parAF/FAP: 5.3 ± 0.2%/4.1 ± 0.3%; p < 0.05; EuroScoreII; 6.1 ± 0.7%/6.4 ± 0.4%, p = ns) and no strokes occurred. FREEAF induced atrial reverse remodeling (left atrial [LA] diameter: -6.7 ± 2.2 mm) and improved cardiac function (left ventricular ejection fraction [LVEF]: +7.3 ± 2.8%), while AF resulted in further atrial dilation (+8.0 ± 1.0 mm, p < 0.05) and LVEF reduction (-7.0 ± 1.3%, p < 0.05). Higher LV (odds ratio [OR]: 1.164) and LA diameter (OR: 1.218), age (OR: 1.180) and body mass index (BMI) (OR: 1.503) increased the risk factors of AF recurrence. Patients remaining in sinus rhythm (SR) demonstrated a decrease in BMI, while AF recurrence was associated with stable overweight. Further aging did not reduce FREEAF.

CONCLUSIONS

 Long-term SR is achievable by concomitant surgical ablation even in FAP patients. Therefore, it should be offered routinely. Obesity influences therapeutic long-term success but may also offer addressable therapeutic targets to reach higher FREEAF rates.

Hybrid ablation for atrial fibrillation: A systematic review and meta-analysis

Background

Both catheter and surgical ablation strategies offer effective treatments of atrial fibrillation (AF). The hybrid (joint surgical and catheter) ablation for AF is an emerging rhythm control strategy. We sought to determine the efficacy and safety of hybrid ablation of AF.

Methods

Systematic review and meta-analysis interrogating PubMed, EMBASE, and Cochrane databases from January 1, 1991, to November 30, 2017, using the following search terms: “Cox-maze,” “mini-maze,” “ablation methods (including radiofrequency, cryoablation, cryomaze),” and “surgery.” Included studies required ablation procedures to be hybrid and report rhythm follow-up.

Results

We included 925 patients with AF (38% persistent, 51% longstanding persistent) from 22 single-center studies (mean follow-up of 19 months). The surgical lesion set consisted of pulmonary vein isolation (n = 11) or box lesion (n = 11) with variable additional linear ablation. This was followed by sequential (n = 9), staged (n = 9), or combination (n = 4) catheter-based ablation to ensure isolation of pulmonary veins and to facilitate additional ablation or consolidation of surgically ablated lines. Overall, sinus rhythm maintenance was 79.4% (95% confidence interval [CI], 72.4-85.7] and 70.7% (95% CI, 62.2-78.7) with and without antiarrhythmic drugs, respectively at 19 ± 25 (range, 6-128) months. The use of the bipolar AtriCure Synergy system and left atrial appendage exclusion conferred superior rhythm outcome without antiarrhythmic drugs (P ≤ .01). The overall complication rate was 6.5% (95% CI, 3.4-10.2): mortality 0.2% (95% CI, 0-0.9); stroke 0.3% (95% CI, 0-1.1); reoperation for bleeding 1.6% (95% CI, 0.6-3.0); permanent pacing ~0% (95% CI, 0-0.5); conversion to sternotomy 0.3% (95% CI, 0-1.1); atrioesophageal fistula ~0% (95% CI, 0-0.5); and phrenic nerve injury 0.3% (95% CI, 0-1.1).

Conclusions

Hybrid ablation therapy for AF demonstrates favorable rhythm outcome with acceptable complication rates.

Long-Term Outcomes of Surgical Ablation for Atrial Fibrillation: Impact of Ablation Lesion Sets

BACKGROUND

The lesion sets for surgical ablation of atrial fibrillation (AF) that provide optimal outcomes have remained controversial.

OBJECTIVES

We evaluated the effects of left-atrial (LA) ablation of AF compared with bi-atrial (BA) ablation on the clinical and rhythm outcomes, and examined the predictors for AF recurrence and permanent pacing in consideration of ablation lesion sets.

METHODS

Between 2001 and 2018, 1,965 patients underwent surgical ablation during cardiac surgery at our institution. Among these, 796 and 1,169 patients underwent LA and BA ablation, respectively. The clinical outcomes were evaluated after propensity score adjustment, with death accounting for a competing event. The probability of AF recurrence was estimated with the generalized estimating equations model.

RESULTS

The patients with BA ablation had morbidities greater than those with LA ablation. The probability of AF recurrence at 1 and 5 years was 13.9% and 37.1% in patients with LA ablation, and 11.2% and 30.1% in those with BA ablation (hazard ratio [HR]: 1.24; 95% confidence interval [CI]: 0.96-1.61; P = 0.100). After adjustment, LA ablation was associated with a decreased risk of early death (<30 days) (odds ratio [OR]: 0.56; 95% CI: 0.31-0.96; P = 0.041) and new-onset dialysis (OR 0.47; 95% CI: 0.27-0.78; P = 0.003). However, the risk of overall mortality (HR: 1.03; 95% CI: 0.75-1.41; P = 0.878) and permanent pacing (HR: 0.68; 95% CI: 0.43-1.06; P = 0.091) was comparable between the 2 groups.

CONCLUSIONS

The risk of AF recurrence and adverse events was comparable between the 2 ablation lesion sets. BA ablation was not related to an increased risk of permanent pacing.

Predictors of long-term HRQOL following cardiac surgery: a 5-year follow-up study

Background

The study aimed to evaluate the long-term change of health-related quality of life (HRQOL) and to identify predictors of HRQOL 5 years after cardiac surgery.

Methods

Consecutive adult patients, undergoing elective cardiac surgery were enrolled in the study. HRQOL was measured using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire before and 5-years after cardiac surgery. A multivariate latent change modeling approach was used for data analysis.

Results

210 participants (30.5% female) were reached at 5-year follow-up and included in final data analysis. The study revealed, after controlling for gender effects, a significant long-term positive change, in physical functioning (PF, M_slope = 19.79, p < 0.001), social functioning (SF, M_slope = 17.27, p < 0.001), vitality (VT, M_slope = 6.309, p < 0.001) and mental health (MH, M_slope = 8.40, p < .001) in the total sample. Lower education was associated with an increase in PF (M_slope = 24.09, p < 0.001) and VT (M_slope = 8.39, p < 0.001), more complicated surgery (other than the coronary artery bypass graft (CABG) predicted increase in general health (GH, M_slope = 6.76, p = 0.005). Arrhythmia was a significant predictor for lower pre- and post-operative VT and SF.

Conclusions

Overall HRQOL in our sample improved from baseline to five years postoperatively. Further studies including larger patient groups are needed to confirm these findings.

State-of-the-Art Treatments for Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy

Atrial fibrillation (AF) and hypertrophic cardiomyopathy (HCM) are two very common clinical entities, which often occur simultaneously, giving a hard time to both patients and cardiologists. Myocyte hypertrophy, myocyte disarray and interstitial fibrosis in the left atrium (LA) predisposes to atrial arrhythmias due to modifications of the substrate that promote re-entry. AF is usually poorly tolerated due to the shortening of the diastolic time with rapid heart rates and the lack of the atrial contribution to the diastolic filling in patients who often have a previous diastolic dysfunction. AF onset frequently results in exercise intolerance and recurrent heart failure admissions and also has prognostic implications. Early maintenance of sinus rhythm appears as a worthy approach in these patients, especially when started early in the course of the disease. However, treatment with antiarrhythmic (AA) agents in HCM patients is less effective than in patients without the disease, and concerns regarding safety frequently limit the long-term adherence. Catheter ablation has limited efficacy in patients with persistent AF but can play an important role in patients with paroxysmal AF, emphasizing the importance of an accurate patient selection. The aim of this review is to provide an overview of the pathophysiology of combined HCM and AF and the principal pharmacological and non-pharmacological treatments recommended in this complex clinical scenario.

Bi-atrial or left atrial ablation of atrial fibrillation during concomitant cardiac surgery: A Bayesian network meta-analysis of randomized controlled trials

OBJECTIVE

Surgical ablation of atrial fibrillation (AF) has become a routine procedure during concomitant cardiac surgery, however, the extension of lesion sets remain controversial. We sought to compare the relative benefit and risk of different lesion sets through a Bayesian network meta-analysis (NMA).

METHODS

Pubmed, Embase, and Cochrane Trials databases were searched for randomized controlled trials (RCTs) comparing the rhythm outcome of AF patients undergoing pulmonary vein isolation (PVI), left atrial Maze (LAM), bi-atrial Maze (BAM), or no ablation during concomitant cardiac surgery. An NMA was conducted to explore the difference of over 1 year AF freedom as well as risks for early mortality and permanent pacemaker implantation (PPMI).

RESULTS

A total of 2031 patients of 19 RCTs were included. PVI, LAM, and BAM (OR [95% Cr.I]: 5.02 [2.72, 10.02], 7.97 [4.93, 14.29], 8.29 [4.90, 14.86], p < .05) demonstrated higher freedom of AF compared with no ablation, however, no significant difference of rhythm outcome was found among the three ablation strategies based on the random-effects model. BAM was associated with an increase in early mortality when compared with no ablation (OR [95% Cr.I]: 4.08 [1.23, 17.30], p < .05), while none of the remaining comparisons reached statistical difference in terms of early mortality and PPMI.

CONCLUSION

Bi-atrial ablation is not superior to left atrial ablation strategies in reducing AF recurrence for un-selected surgical patients. BAM has a higher risk of early mortality than no ablation, but no difference was found between bi-atrial and left atrial ablation in regard to early mortality and PPMI based on the current evidence.

Predicting early reconnection after cryoballoon ablation with procedural and biophysical parameters

BACKGROUND

Predicting early reconnection/dormant conduction (ERC) immediately after pulmonary vein isolation (PVI) can avoid a waiting period with adenosine testing.

OBJECTIVE

To identify procedural and biophysical parameters predicting ERC.

METHODS

Consecutive atrial fibrillation (AF) patients undergoing a first cryoballoon ablation (Arctic Front Advance) between 2014 and 2017 were included. ERC was defined as manifest or dormant pulmonary vein (PV) reconnection with adenosine 30 minutes after PVI. Time to isolation (TTI), balloon temperatures (BT), and thawing times were evaluated as potential predictors for ERC. Based on a multivariable model, cut-off-values were defined and a formula was constructed to be used in clinical practice.

RESULTS

A total of 136 patients (60 ± 10 years, 96 male, 95% paroxysmal AF) were included. ERC was found in 40 (29%) patients (ERC group) and in 53 of 575 (9%) veins. Procedural and total ablation time and the number of unsuccessful freezes were significantly longer/higher in the ERC group compared to the non-ERC group (150 ± 40 vs 125 ± 34 minutes; 24 ± 5 vs 17 ± 4 minutes, and 38% vs 24%, respectively (P = .028). Multivariable analysis showed that a higher nadir balloon temperature (hazard ratio [HR] 1.17 [1.09-1.23, P < .001), a higher number of unsuccessful freezes (HR 1.69 [1.15-2.49], P = .008) and a longer TTI (HR 1.02 [1.01-1.03], P < .001) were independently associated with ERC, leading to the following formula: 0.02 × TTI + 0.5 × number of unsuccessful freezes + 0.2 × nadir BT with a cut-off value of ≤-6.7 to refrain from a waiting period with adenosine testing.

CONCLUSION

Three easily available parameters were associated with ERC. Using these parameters during ablation can help to avoid a 30-minute waiting period and adenosine testing.

Comparison between cryoballoon and hot balloon ablation in patients with paroxysmal atrial fibrillation

PURPOSE

Pulmonary vein (PV) isolation using balloon ablation was developed as a technique for patients with paroxysmal atrial fibrillation (PAF). While most studies examined cryoballoon ablation (CBA), there have also been many reports on hot balloon ablation (HBA). We aimed to evaluate the clinical characteristics and outcomes between HBA and CBA.

METHODS

In a total of 103 consecutive patients with PAF who underwent catheter ablation, 60 propensity score-matched (30 CBA and 30 HBA) patients were enrolled. The procedural differences and clinical outcomes between the two groups were analyzed.

RESULTS

The requirement for additional touch-up ablation was more frequent in the left superior pulmonary vein (LSP) in the HBA group than in the CBA group. Pre-procedural computed tomography (CT) images showed that a thicker left pulmonary vein ridge and larger cross-sectional area of the LSPV were significantly associated with residual PV potentials after HBA. However, post-procedural CT images showed that PV stenosis (> 25%) was higher in the HBA group (33%) than in the CBA group (0%). PV stenosis after HBA was observed most frequently in the right superior PV (50%). The atrial fibrillation/atrial tachycardia-free survival rate during follow-up (365 ± 102 days) was similar between the two groups (CBA vs. HBA, 83% vs. 90%).

CONCLUSIONS

Although both balloon modalities can relieve atrial arrhythmia after the procedure, careful attention is required during HBA procedures, especially for the right superior PV, to avoid PV stenosis.

Biparietal bidirectional bipolar radiofrequency in hybrid cardiac ablation: an in vitro evaluation

 

OBJECTIVES

The aim of this study was to evaluate the lesion size and depth of radiofrequency (RF) ablation in a simultaneous biparietal bidirectional bipolar (SBB) approach, compared to a simultaneous and staged unipolar and uniparietal bipolar setup [simultaneous uniparietal bipolar (SiUB) and staged uniparietal bipolar (StUB), respectively].

METHODS

Fresh left atrial porcine tissue was mounted into the ABLA-BOX simulator. Different ablation approaches were tested: (i) SBB: a concept consisting of SBB endo-epicardial ablation, (ii) SiUB: simultaneous epicardial uniparietal bipolar and endocardial unipolar ablation and (iii) StUB: staged epicardial uniparietal bipolar and endocardial unipolar ablation. In the StUB setup, a 1-h interval between the epi-endo ablation was respected.

RESULTS

Transmural lesions were present in 90% of the bipolar biparietal ablations, yet no full transmurality was observed in the simultaneous nor in the staged unipolar with uniparietal bipolar ablation group. In SBB, the area and volume of the ablation lesions were smaller (523.33 mm2/mm and 52.33 mm3/mm, respectively) than in SiUB (588.17 mm2/mm and 58.81 mm3/mm, respectively) and StUB (583.76 mm2/mm and 58.37 mm3/mm, P = 0.044). Also, in SBB, the overall, epicardial and endocardial maximum diameters of the lesions (1.59, 1.57 and 1.52 mm; respectively) were smaller than in SiUB (2.38, 2.26 and 2.33 mm; respectively) and in StUB (2.36, 2.28 and 2.14 mm; respectively, all P < 0.001).

CONCLUSIONS

Although bipolar biparietal bidirectional RF ablation results in smaller lesions than uniparietal bipolar and unipolar ablation, their capacity to penetrate the tissue is much higher. Moreover, in uniparietal RF applications, the energy spreads in the superficial layers of the tissue but fails to penetrate. Therefore, the degree of transmurality is much higher when using such a 'truly bipolar' ablation approach.

New Biparietal Bipolar Catheter Prototype for Hybrid Atrial Fibrillation Ablation

Objective

To evaluate the size and depth of linear lesions by in vitro testing with a custom-made radio frequency biparietal bipolar ablation catheter in a single-stage setting.

Methods

A custom-made catheter was created to generate linear lesions around the left atrium and pulmonary veins of an ex vivo pig. Two frames were made, 1 epicardial and 1 endocardial. A continuous copper braid electrode and an alignment system consisting of 2 parallel rows of neodymium magnets were embedded in a flexible plastic support. After 24 hours of formalin conservation, samples of the left atrium of a freshly slaughtered pig were sliced in a cryotome, thus obtaining a sequence of 100-µm thick layers extending from the endocardial to the epicardial side. After being digitized through a scanner, these layers were evaluated using morphometric computer software. For each slice, we evaluated the maximum length of the lesions, the maximum epicardial length, the maximum endocardial length, the total area of the lesion, and the total volume.

Results

Forty transmural lesions from 40 specimens were obtained. The results were the following (the number in parenthesis is the interquartile range in mm): lesion maximum length (L_MAX) was 7.297 mm (0.006), epicardial maximum length (L_EPI) was 7.291 mm (0.014), and endocardial maximum length was 7.291 mm (0.018). The total area and total volume were 1018.50 ± 36.51 mm² and 101.85 ± 3.65 mm³, respectively.

Conclusions

Our prototype showed very promising results. The next step will be to enhance the design for clinical application.

Texidor’s twinge a rare cause of benign paroxysmal chest pain

Objective: Precordial catch syndrome was described by Miller and Texidor in 1955. It deserves wider recognition because it is rarely discussed in the differential diagnosis of precordial pain. Case summary: Case characteristics include a young 8-year-old female that presented with 4th episode of chest pain to the hospital. On attempting maneuver like deep breaths slowly in lying down position, pain subsided within 5 minutes although all other modalities of chest pain investigation as electrocardiography, echocardiography, chest high-resolution computed tomography, cardiac enzymes were normal. Discussion and conclusion: Various maneuvers like lying down or sitting upright and attempting deep inspiration tends to help in such conditions. This case report is reporting an unusual presentation of this syndrome due to its long duration of episode than the duration described in the previous reports. Prognosis is good. Key words: precordial catch syndrome, sharp chest pain, sagged posture, Texidor’s twinge, case report

Aortic flow below and visceral circulation during aortic counterpulsation: Evaluation of an in vitro model

INTRODUCTION

This study aimed to test a computer-driven cardiovascular model for the evaluation of the visceral flow during intra-aortic balloon pump (IABP) assistance.

METHODS

The model includes a systemic and pulmonary circulation as well as a heart contraction model. The straight polyurethane tube aorta had a single visceral while four windkessel components mimicked resistance compliance of the brachiocephalic, renal and sub-mesenteric, pulmonary, and systemic circulation. Twelve flow probes were placed in the circuit to measure pressures and flows with the IABP on and off.

RESULTS

With the balloon off, the meantime to reach the steady state was 48 ± 16 s; with the balloon on, this figure was 178 ± 20 s. The stability of pressure and flow signals was obtained after 72 ± 11 min. The number of cycles of stability of the system was 93 [86-103]. Measurements were reliable either with samples of 10 or 20 beats. Bland Altman method demonstrated the reliability of measurements. Finally, all measurements were comparable to published in vivo data.

CONCLUSION

The presented mock circulation was reliable and gave values with high accuracy both at baseline and during mechanical assistance. This system allows evaluation of the mesenteric flow during IABP, under different clinical/hemodynamic conditions. Nonetheless, its translational potential needs to be further evaluated.

Surgical Atrial Fibrillation Ablation With and Without Left Atrium Reduction for Patients Scheduled for Mitral Valve Surgery: A Prospective Randomised Study

BACKGROUND

The influence of left atrium (LA) enlargement on atrial arrhythmia recurrence (AAR) after surgical ablation in patients with mitral valve (MV) disease remains unresolved.

OBJECTIVE

Left atrial size is critical to the success of concomitant atrial fibrillation (AF) ablation in patients scheduled for MV surgery. However, a large LA should not be a limiting factor when evaluating surgical candidates with AF if they receive appropriate treatment during concomitant ablation. This randomised study assessed whether adding LA reduction (LAR) to the maze procedure for MV surgery patients can improve freedom from AAR.

METHODS

From September 2014 to September 2017, 140 patients were randomly assigned into two groups. The maze group underwent MV surgery with concomitant surgical AF ablation (n=70). The maze + LA reduction group underwent MV surgery with concomitant AF ablation and LA reduction procedure (n=70). Rhythm outcomes were estimated by Holter monitoring, according to Heart Rhythm Society guidelines.

RESULTS

The concomitant LA reduction procedure did not increase early mortality and complications rates. Significant differences in freedom from AAR were observed at 24 months (maze, 78.4%; maze + LAR group, 92.3%; p=0.025). A significant difference in LA volume was detected at discharge (p<0.0001); however, it was not significantly different at 24 months (p=0.182).

CONCLUSIONS

Adding LA reduction to the maze procedure led to improvements in freedom from AAR for patients with AF and LA enlargement scheduled for MV surgery. A concomitant LA reduction procedure did not increase mortality and perioperative risk.

Intra-aortic balloon pump: Looking at the other side

Intra‐aortic balloon pump has been the most commonly employed cardiac assist device in the past, although, in recent years, its use in cardiogenic shock has been questioned. The pathophysiology of the proximal part of the balloon has been well studied, whereas, hemodynamics and flow below the distal portion of the balloon have not been fully understood yet. The distal flow contains a three‐wave flow pattern during diastolic balloon expansion: a flow reduction in early diastole, a backflow in mid‐diastole followed by a tele‐diastolic flow. More research on this topic is warranted to better understand the physics of the distal part of the balloon and its interaction with the three components of the local regulatory system: intrinsic (local metabolic and myogenic), extrinsic (autonomic nervous system), and humoral (local or circulating vasoactive substances). These new insights will be a guide for new balloon designs that will allow enhanced performance and improved outcomes.

The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.

Isoproterenol Causing Coronary Vasospasm and ST Elevations During Tilt Table Testing

Syncope is a sudden but reversible brief loss of consciousness secondary to an acute reduction of cerebral perfusion. Reflex syncope denotes neurologically mediated syncope, which includes vasovagal, carotid sinus syndrome, and other situational syncope. The most frequent form of syncope is vasovagal, which is triggered by emotional stress or prolonged standing, and may be diagnosed with the tilt table test. A thorough investigation of syncope is necessary as serious cardiovascular disorders may also be a cause. A tilt table test is a widely used tool utilized by clinicians to diagnose vasovagal syncope and is sometimes augmented with isoproterenol, a β-sympathomimetic that acts on the heart. This report seeks to explain a case of a 48-year-old previously healthy woman who experienced inferior wall ST elevations during tilt table test supplemented with isoproterenol. There is reason to believe that the results of this patient's tilt table test were due to vasovagal syncope in conjunction with right coronary artery vasospasm.

Incidence and clinical impact of early recurrence of atrial tachyarrhythmia after surgical ablation for atrial fibrillation

BACKGROUND

Atrial tachyarrhythmias (ATAs) are common within the 3-month blanking period after catheter ablation of atrial fibrillation (AF). However, little evidence is available regarding the current guidelines on the blanking period after surgical AF ablation. We investigate the incidence and significance of early recurrence of atrial tachyarrhythmia (ERAT) and evaluate the optimal blanking period after surgical AF ablation.

METHODS

Data from 259 patients who underwent surgical AF ablation from 2009 to 2016 were collected. ERAT was defined as documented ATA episodes lasting for 30 s. A multivariate Cox proportional hazard model was constructed to evaluate the role of ERAT as a predictor of late recurrences (LR) for AF.

RESULTS

In total, 127 patients (49.0%) experienced their last episodes of ERAT during the first (n = 65), second (n = 14), or third (n = 48) month of the 3-month blanking period (p < .001). One year freedom from ATAs was 97.8% in patients without ERAT compared with 95.4%, 64.3%, and 8.3% in patients with ERAT in the first, second, and third months after the index procedure, respectively (p < .001). Hazard ratios of LR according to the timing of the last episode of ERAT first, second, and third months after the procedure were 2.84, 16.70, and 119.75, respectively.

CONCLUSIONS

The ERAT occurred in 49.0% of patients within the first 3 months after surgical ablation. The occurrence of ERAT within 3 months after surgical AF ablation was a significant independent predictor of LR. Hence, the currently accepted 3-month blanking period may be considered for redefining in patients with AF surgical ablation.