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Romanov A, Martinek M, Pürerfellner H, Chen S, De Melis M, Grazhdankin I, Ponomarev D, Losik D, Strelnikov A, Shabanov V, Karaskov A, Pokushalov E. Incidence of atrial fibrillation detected by continuous rhythm monitoring after acute myocardial infarction in patients with preserved left ventricular ejection fraction: results of the ARREST study. Europace 2017; 20:263-270. [DOI: 10.1093/europace/euw344] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 10/10/2016] [Indexed: 11/13/2022] Open
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153
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Simantirakis EN, Papakonstantinou PE, Chlouverakis GI, Kanoupakis EM, Mavrakis HE, Kallergis EM, Arkolaki EG, Vardas PE. Asymptomatic versus symptomatic episodes in patients with paroxysmal atrial fibrillation via long-term monitoring with implantable loop recorders. Int J Cardiol 2016; 231:125-130. [PMID: 28041713 DOI: 10.1016/j.ijcard.2016.12.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/06/2016] [Accepted: 12/10/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND The presentation of atrial fibrillation (AF) varies remarkably, from totally asymptomatic to symptomatic patients, while the same individual may present symptomatic and asymptomatic episodes. We aimed to identify electrocardiographic differences between symptomatic and asymptomatic episodes and to find parameters related to the appearance of symptoms. METHODS Thirty consecutive patients (age 66.9±10years) with paroxysmal AF received an implantable loop recorder. Three types of episodes were defined: asymptomatic (ASx), symptomatic (Sx), and mixed asymptomatic-symptomatic (AS-Sx). The heart rate (HR) and heart rate variability (HRV) were recorded during the first 2min of each ASx or Sx episode, and during the first 2min of both the symptomatic and asymptomatic periods in AS-Sx. RESULTS Eighty-two episodes from twenty-five patients were evaluated. Mean HR was 142.48±25.84bpm for Sx and 95.71±19.29bpm for ASx (p<0.001). Mean HRV was 92.62±42.29ms for Sx and 150.06±49.68ms for ASx (p<0.001). In AS-Sx, mean HR was 102.91±24.54bpm for the asymptomatic and 141.88±23.43bpm for the symptomatic period (p<0.001). Mean HRV was 173.55±61.30ms for the asymptomatic and 87.33±30.65ms for the symptomatic period (p=0.003). There were no significant correlations between patients' characteristics and the clinical presentation of the arrhythmia. CONCLUSIONS The ASx were characterized by a lower HR and higher HRV compared to Sx. In As-Sx, the asymptomatic period was characterized by a lower HR and higher HRV compared to the symptomatic. These findings suggest a possible contribution of variations in the autonomic nervous system activity to the perception of the arrhythmia.
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Affiliation(s)
- E N Simantirakis
- Department of Cardiology, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece.
| | - P E Papakonstantinou
- Department of Cardiology, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - G I Chlouverakis
- Biostatistics Lab, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - E M Kanoupakis
- Department of Cardiology, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - H E Mavrakis
- Department of Cardiology, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - E M Kallergis
- Department of Cardiology, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - E G Arkolaki
- Department of Cardiology, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - P E Vardas
- Department of Cardiology, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
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154
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Lortz J, Varnavas V, WEIßENBERGER W, Erbel R, Reinsch N. Maintaining Accurate Long-Term Sensing Ability Despite Significant Size Reduction of Implantable Cardiac Monitors. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:1344-1350. [PMID: 27862030 DOI: 10.1111/pace.12977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 10/02/2016] [Accepted: 10/25/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Reveal LINQ™ implantable cardiac monitor (ICM; Medtronic, Minneapolis, MN, USA) is obviously smaller than its precursor (the Reveal XT™), but little is known about its long-term safety. Here, we investigated the long-term R-wave sensing reliability of the Reveal LINQ™ ICM. METHODS We analyzed the sensing quality of the Reveal LINQ™ ICM over time between March 2014 and January 2015. RESULTS A total of 30 patients underwent Reveal LINQ™ implantation. The main reason for implantation was unexplained syncope (60%). We evaluated a total of 305.8 patient-months (median, 10.7 months) of R-wave sensing quality. A comparison of baseline and follow-up R-wave sensing values revealed no difference (0.401 mV ± 0.244 mV vs 0.447 mV ± 0.323 mV; P = 0.225). CONCLUSIONS The consistent detection of events is an important safety feature of an ICM and linked to secure R-wave sensing. Despite the noticeable size reduction, the Reveal LINQ™ ICM retains reliable sensing quality over time.
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Affiliation(s)
- Julia Lortz
- Department of Cardiology, West-German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Varnavas Varnavas
- Department of Cardiology, West-German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Wilko WEIßENBERGER
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Raimund Erbel
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Nico Reinsch
- Division of Electrophysiology, Department of Internal Medicine I and Cardiology, Alfried Krupp Hospital Essen, Essen, Germany
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155
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Silveira I, Sousa MJ, Antunes N, Silva V, Roque C, Pinheiro-Vieira A, Lagarto V, Hipólito-Reis A, Luz A, Torres S. Efficacy And Safety Of Implantable Loop Recorder: Experience Of A Center. J Atr Fibrillation 2016; 9:1425. [PMID: 27909534 DOI: 10.4022/jafib.1425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 08/05/2016] [Accepted: 08/07/2016] [Indexed: 12/28/2022]
Abstract
Introduction: Symptoms like syncope or palpitations frequently present a diagnostic challenge. An implantable loop recorder (ILR) is an important aid in the management of these patients. Methods: A retrospective study of patients that underwent ILR implantation from November 2007 to 2014. For each patient the indication for implantation, baseline characteristics, previous study, complications, recorded tracing and interventions were evaluated. Results: A total of 62 patients were included, 50% men, with a mean age of 62.5±18.8 years old. Previously to ILR implantation 88.7% of patients had performed Holter, 17.7% external events recorder, 33.9% Tilt test and 29% an electrophysiological study. The implantation indications were recurrent syncope in 90.3%, palpitations 8.1% and ischemic stroke in one patient. Mean follow-up time was 17.1±16.3 months. Symptoms were reported in 66.1% of the patients, 46.8% of those yielding a diagnostic finding. In all cases of palpitation complaints with diagnosis we found atrial fibrillation (AF). In patients with syncope atrioventricular conduction disturbance was demonstrated in 19.6%, sinus node dysfunction in 16.1%, paroxysmal supra-ventricular tachycardia 7.1% and AF in 1.8%. These finding resulted in 19 pacemaker and one CRT-D implantation, introduction of anticoagulation in five patients and one ablation of accessory pathway. There were no major complications. Conclusion: ILR proved to be safe and efficient. It has enabled the identification or exclusion of serious rhythm disturbances in more than half of patients and provided a targeted therapeutic intervention.
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Affiliation(s)
- Inês Silveira
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Maria João Sousa
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Nuno Antunes
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Vânia Silva
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Carla Roque
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | | | - Vítor Lagarto
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | | | - André Luz
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Severo Torres
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
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156
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Silveira I, Sousa MJ, Antunes N, Silva V, Roque C, Pinheiro-Vieira A, Lagarto V, Hipólito-Reis A, Luz A, Torres S. Efficacy And Safety Of Implantable Loop Recorder: Experience Of A Center. J Atr Fibrillation 2016. [PMID: 27909534 DOI: 10.4022/jafib.1425.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Introduction: Symptoms like syncope or palpitations frequently present a diagnostic challenge. An implantable loop recorder (ILR) is an important aid in the management of these patients. Methods: A retrospective study of patients that underwent ILR implantation from November 2007 to 2014. For each patient the indication for implantation, baseline characteristics, previous study, complications, recorded tracing and interventions were evaluated. Results: A total of 62 patients were included, 50% men, with a mean age of 62.5±18.8 years old. Previously to ILR implantation 88.7% of patients had performed Holter, 17.7% external events recorder, 33.9% Tilt test and 29% an electrophysiological study. The implantation indications were recurrent syncope in 90.3%, palpitations 8.1% and ischemic stroke in one patient. Mean follow-up time was 17.1±16.3 months. Symptoms were reported in 66.1% of the patients, 46.8% of those yielding a diagnostic finding. In all cases of palpitation complaints with diagnosis we found atrial fibrillation (AF). In patients with syncope atrioventricular conduction disturbance was demonstrated in 19.6%, sinus node dysfunction in 16.1%, paroxysmal supra-ventricular tachycardia 7.1% and AF in 1.8%. These finding resulted in 19 pacemaker and one CRT-D implantation, introduction of anticoagulation in five patients and one ablation of accessory pathway. There were no major complications. Conclusion: ILR proved to be safe and efficient. It has enabled the identification or exclusion of serious rhythm disturbances in more than half of patients and provided a targeted therapeutic intervention.
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Affiliation(s)
- Inês Silveira
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Maria João Sousa
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Nuno Antunes
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Vânia Silva
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Carla Roque
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | | | - Vítor Lagarto
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | | | - André Luz
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Severo Torres
- Pacing and electrophysiology Department, Centro Hospitalar do Porto, Portugal
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Vanegas-Cadavid DI. Uso del monitor cardiaco implantable en fibrilación auricular. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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158
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Chiang CE, Wu TJ, Ueng KC, Chao TF, Chang KC, Wang CC, Lin YJ, Yin WH, Kuo JY, Lin WS, Tsai CT, Liu YB, Lee KT, Lin LJ, Lin LY, Wang KL, Chen YJ, Chen MC, Cheng CC, Wen MS, Chen WJ, Chen JH, Lai WT, Chiou CW, Lin JL, Yeh SJ, Chen SA. 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the management of atrial fibrillation. J Formos Med Assoc 2016; 115:893-952. [PMID: 27890386 DOI: 10.1016/j.jfma.2016.10.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/24/2016] [Accepted: 10/10/2016] [Indexed: 12/21/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia. Both the incidence and prevalence of AF are increasing, and the burden of AF is becoming huge. Many innovative advances have emerged in the past decade for the diagnosis and management of AF, including a new scoring system for the prediction of stroke and bleeding events, the introduction of non-vitamin K antagonist oral anticoagulants and their special benefits in Asians, new rhythm- and rate-control concepts, optimal endpoints of rate control, upstream therapy, life-style modification to prevent AF recurrence, and new ablation techniques. The Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology aimed to update the information and have appointed a jointed writing committee for new AF guidelines. The writing committee members comprehensively reviewed and summarized the literature, and completed the 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the Management of Atrial Fibrillation. This guideline presents the details of the updated recommendations, along with their background and rationale, focusing on data unique for Asians. The guidelines are not mandatory, and members of the writing committee fully realize that treatment of AF should be individualized. The physician's decision remains most important in AF management.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan.
| | - Tsu-Juey Wu
- Cardiovascular Center, Department of Internal Medicine, Taichung Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Kwo-Chang Ueng
- Department of Internal Medicine, School of Medicine, Chung-Shan Medical University (Hospital), Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Chun-Chieh Wang
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jen-Yuan Kuo
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, Mackay Medical College, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Yen-Bin Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kun-Tai Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Jen Lin
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Kang-Ling Wang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | - Ming-Shien Wen
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, Poh-Ai Hospital, Yilan, Taiwan
| | - Jyh-Hong Chen
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chuen-Wang Chiou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jiunn-Lee Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - San-Jou Yeh
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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159
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[Implantable loop recorder in atrial fibrillation and after catheter ablation]. Herzschrittmacherther Elektrophysiol 2016; 27:355-359. [PMID: 27832334 DOI: 10.1007/s00399-016-0471-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 08/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Implantable loop recorders (ILR) are an established diagnostic method for detection of cardiac arrhythmias including atrial fibrillation. OBJECTIVE The aim of this work is to provide an overview of available data and indications of ILR in atrial fibrillation, especially after catheter ablation, in order to illustrate practice-oriented recommendations. MATERIALS AND METHODS We conducted a selective PubMed literature search. RESULTS AND DISCUSSION ILR can record asymptomatic/rare atrial fibrillation episodes and prevent thromboembolic events by allowing timely initiation of oral anticoagulation. They can be used to assess therapeutic success after percutaneous or surgical ablation, if despite increased thromboembolic risk, no oral anticoagulation is desired. ILR equipped with remote monitoring function and special P wave detection algorithms may improve diagnostic confidence.
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160
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Nölker G, Mayer J, Boldt LH, Seidl K, VAN Driel V, Massa T, Kollum M, Brachmann J, Deneke T, Hindricks G, Jung W, Brunner KJ, Kraus S, Hümmer A, Lewalter T. Performance of an Implantable Cardiac Monitor to Detect Atrial Fibrillation: Results of the DETECT AF Study. J Cardiovasc Electrophysiol 2016; 27:1403-1410. [PMID: 27565119 DOI: 10.1111/jce.13089] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/09/2016] [Accepted: 08/12/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Reliable detection and monitoring of atrial fibrillation (AF) is essential for accurate clinical decision making, which can now be done continuously with the introduction of implantable cardiac monitors (ICM) The DETECT AF study evaluated the performance of the Confirm DM2102 ICM (St. Jude Medical, St. Paul, MN, USA) to accurately detect and monitor AF. METHODS Ninety patients previously implanted with the ICM and with either suspected or known paroxysmal AF were enrolled at 12 centers in Germany and The Netherlands. At least 2 weeks after ICM implant, patients wore a Holter monitor for 4 days, while the ICM monitored for AF episodes lasting at least 2 minutes. Holter monitor data was analyzed by a blinded, independent core laboratory and compared to the ICM AF detections. Patient and episode sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive (NPV) were calculated using standard analysis and a generalized estimation equation method where appropriate. RESULTS A total of 79/90 subjects (61% male, 65.7 ± 9.6 years old) were included in the analysis, totaling 6,894 hours of Holter monitoring. Using a per patient analysis SE was 100%, PPV was 64.0%, SP was 85.7%, and NPV was 100%. Using a per episode analysis, SE was 94.0% and PPV was 64.0%. With an AF duration analysis, the SE was 83.9%, PPV was 97.3%, SP was 99.4% with an NPV of 98.5%. CONCLUSION The SJM Confirm DM2102 can accurately and repeatedly detect paroxysmal AF episodes of at least 2 minutes in length.
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Affiliation(s)
- Georg Nölker
- Herz- und Diabeteszentrum Nordrhein-Westfalen - Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | | | - Leif-Hendrik Boldt
- Charité - Universitätsmedizin Berlin Campus Virchow Klinikum, Berlin, Germany
| | | | | | | | - Marc Kollum
- Hegau-Bodensee-Klinikum Singen, Singen, Germany
| | | | | | | | - Werner Jung
- Schwarzwald Baar Klinikum, Villingen-Schwenningen, Germany
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161
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4683] [Impact Index Per Article: 585.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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162
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Steinhaus DA, Zimetbaum PJ, Passman RS, Leong-Sit P, Reynolds MR. Cost Effectiveness of Implantable Cardiac Monitor-Guided Intermittent Anticoagulation for Atrial Fibrillation: An Analysis of the REACT.COM Pilot Study. J Cardiovasc Electrophysiol 2016; 27:1304-1311. [PMID: 27571718 DOI: 10.1111/jce.13090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 07/28/2016] [Accepted: 08/02/2016] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Anticoagulation guidelines for patients with atrial fibrillation (AF) disregard AF burden. A strategy of targeted anticoagulation with novel oral anticoagulants (NOACs) based on continuous rhythm assessment with an implantable cardiac monitor (ICM) has recently been explored. We evaluated the potential cost-effectiveness of this strategy versus projected outcomes with continuous anticoagulation. METHODS AND RESULTS We developed a Markov model using data from the Rhythm Evaluation for AntiCoagulaTion With COntinuous Monitoring (REACT.COM) pilot study (N = 59) and prior NOAC trials to calculate the costs and quality-adjusted life years (QALYs) associated with ICM-guided intermittent anticoagulation for AF versus standard care during a 3-year time horizon. Health state utilities were estimated from the pilot study population using the SF-12. Costs were based on current Medicare reimbursement. Over 14 ± 4 months of follow-up, 18 of 59 patients had 35 AF episodes. The ICM-guided strategy resulted in a 94% reduction in anticoagulant use relative to continuous treatment. There were no strokes, 3 (5.1%) TIAs, 2 major bleeding events (on aspirin) and 3 minor bleeding events with the ICM-guided strategy. The projected total 3-year costs were $12,535 for the ICM-guided strategy versus $13,340 for continuous anticoagulation. Projected QALYs were 2.45 for both groups. CONCLUSION Based on a pilot study, a strategy of ICM-guided anticoagulation with NOACs may be cost-saving relative to expected outcomes with continuous anticoagulation, with similar quality-adjusted survival. This strategy could be attractive from a health economic perspective if shown to be safe and effective in a rigorous clinical trial.
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Affiliation(s)
- Daniel A Steinhaus
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter J Zimetbaum
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rod S Passman
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter Leong-Sit
- Division of Cardiology, Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Matthew R Reynolds
- Harvard Clinical Research Institute, Boston, Massachusetts, USA.,Division of Cardiology, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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164
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Galli A, Ambrosini F, Lombardi F. Holter Monitoring and Loop Recorders: From Research to Clinical Practice. Arrhythm Electrophysiol Rev 2016; 5:136-43. [PMID: 27617093 DOI: 10.15420/aer.2016.17.2] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Holter monitors are tools of proven efficacy in diagnosing and monitoring cardiac arrhythmias. Despite the fact their use is widely prescribed by general practitioners, little is known about their evolving role in the management of patients with cryptogenic stroke, paroxysmal atrial fibrillation, unexplained recurrent syncope and risk stratification in implantable cardioverter defibrillator or pacemaker candidates. New Holter monitoring technologies and loop recorders allow prolonged monitoring of heart rhythm for periods from a few days to several months, making it possible to detect infrequent arrhythmias in patients of all ages. This review discusses the advances in this area of arrhythmology and how Holter monitors have improved the clinical management of patients with suspected cardiac rhythm diseases.
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Affiliation(s)
- Alessio Galli
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Francesco Ambrosini
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Federico Lombardi
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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165
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Battipaglia I, Gilbert K, Hogarth AJ, Tayebjee MH. Screening For Atrial Fibrillation In The Community Using A Novel ECG Recorder. J Atr Fibrillation 2016; 9:1433. [PMID: 27909536 DOI: 10.4022/jafib.1433] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 12/24/2022]
Abstract
Aims: MyDiagnostick (MDK) is a novel portable ECG recorder. We conducted this study to evaluate its role in screening for atrial fibrillation (AF). Methods: The device is a cylindrical rod with metallic electrodes at both ends recording electrocardiogram (ECG) when both electrodes are held. Individuals were requested to hold the device for approximately 15 s, the device was then connected to a laptop (with proprietary software downloaded) and analysed. Anonymised ECGs were stored for further analysis. A total of 855 ECGs were recorded and analysed offline by two arrhythmia specialists assessing ECG quality, in particular the level of noise. A noise score (NS) was devised regarding ECG quality. Results: Seven individuals were found with unknown AF (0,8%). In general ECG quality was good and rhythm diagnosis was certain with total interobserver agreement. Conclusion: The MDK provided a rapid and accurate rhythm analysis and has potential implications in preventing ischaemic cardio-embolic stroke.
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Affiliation(s)
- Irma Battipaglia
- The West Yorkshire Arrhythmia Service, Leeds Teaching Hospitals NHS, Leeds, West Yorkshire, UK
| | - Katrina Gilbert
- The West Yorkshire Arrhythmia Service, Leeds Teaching Hospitals NHS, Leeds, West Yorkshire, UK
| | - Andrew J Hogarth
- The West Yorkshire Arrhythmia Service, Leeds Teaching Hospitals NHS, Leeds, West Yorkshire, UK
| | - Muzahir H Tayebjee
- The West Yorkshire Arrhythmia Service, Leeds Teaching Hospitals NHS, Leeds, West Yorkshire, UK
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166
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1305] [Impact Index Per Article: 163.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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167
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Yang P, Pu L, Yang L, Li F, Luo Z, Guo T, Hua B, Li S. Value of Implantable Loop Recorders in Monitoring Efficacy of Radiofrequency Catheter Ablation in Atrial Fibrillation. Med Sci Monit 2016; 22:2846-51. [PMID: 27518153 PMCID: PMC4993216 DOI: 10.12659/msm.897333] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/08/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the value of the implantable loop recorder (ILR) in diagnosing atrial fibrillation (AF) and assessing the postoperative efficacy of radiofrequency catheter ablation (RFCA). MATERIAL AND METHODS A total of 32 patients who successfully underwent RFCA were selected. These patients discontinued antiarrhythmic medication with no AF recurrence for more than 3 months after RFCA, and underwent ILR placement by a conventional method. The clinical manifestations and information on arrhythmias recorded by the ILR were followed up to assess the efficacy of AF RFCA. RESULTS The mean follow-up period was 24.7±12.5 months. Of 32 patients with ILR information, 27 had successful RFCA and 5 had recurrent AF. The follow-up results obtained by traditional methods showed 29 patients with successful RFCA and 3 with recurrent AF (P<0.05). Among the 18 patients with clinical symptoms, 13 had recorded cardiac arrhythmic events (72.2%) and 5 showed sinus rhythm (27.8%). The ILRs recorded 18 patients with arrhythmic events (56.3%), including 12 cases of atrial arrhythmias, among whom 5 recurred at 9, 12, 16, 17, and 32 months after AF RFCA; there were also 2 patients with ventricular tachycardia (VT) and 4 with bradycardia. CONCLUSIONS The value of ILR in assessing the efficacy of AF RFCA was superior to that of traditional methods. ILR can promptly detect asymptomatic AF, and can monitor electrocardiogram features after RFCA, thus providing objective evidence of efficacy.
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Affiliation(s)
- Ping Yang
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P.R. China
| | - Lijin Pu
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P.R. China
| | - Liuqing Yang
- Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, IL, U.S.A
| | - Fang Li
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P.R. China
| | - Zhiling Luo
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P.R. China
| | - Tao Guo
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P.R. China
| | - Baotong Hua
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P.R. China
| | - Shumin Li
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P.R. China
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168
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BJÖRKENHEIM ANNA, BRANDES AXEL, CHEMNITZ ALEXANDER, MAGNUSON ANDERS, EDVARDSSON NILS, POÇI DRITAN. Rhythm Control and Its Relation to Symptoms during the First Two Years after Radiofrequency Ablation for Atrial Fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:914-25. [DOI: 10.1111/pace.12916] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/06/2016] [Indexed: 11/29/2022]
Affiliation(s)
- ANNA BJÖRKENHEIM
- Department of Cardiology, Faculty of Medicine and Health Örebro University Örebro Sweden
| | - AXEL BRANDES
- Department of Cardiology Odense University Hospital Odense Denmark
| | | | - ANDERS MAGNUSON
- Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health Örebro University Örebro Sweden
| | - NILS EDVARDSSON
- Sahlgrenska Academy at Sahlgrenska University Hospital Göteborg Sweden
| | - DRITAN POÇI
- Department of Cardiology, Faculty of Medicine and Health Örebro University Örebro Sweden
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169
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Usefulness of an Implantable Loop Recorder to Detect Clinically Relevant Arrhythmias in Patients With Advanced Fabry Cardiomyopathy. Am J Cardiol 2016; 118:264-74. [PMID: 27265676 DOI: 10.1016/j.amjcard.2016.04.033] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 11/21/2022]
Abstract
Patients with genetic cardiomyopathy that involves myocardial hypertrophy often develop clinically relevant arrhythmias that increase the risk of sudden death. Consequently, guidelines for medical device therapy were established for hypertrophic cardiomyopathy, but not for conditions with only anecdotal evidence of arrhythmias, like Fabry cardiomyopathy. Patients with Fabry cardiomyopathy progressively develop myocardial fibrosis, and sudden cardiac death occurs regularly. Because 24-hour Holter electrocardiograms (ECGs) might not detect clinically important arrhythmias, we tested an implanted loop recorder for continuous heart rhythm surveillance and determined its impact on therapy. This prospective study included 16 patients (12 men) with advanced Fabry cardiomyopathy, relevant hypertrophy, and replacement fibrosis in "loco typico." No patients previously exhibited clinically relevant arrhythmias on Holter ECGs. Patients received an implantable loop recorder and were prospectively followed with telemedicine for a median of 1.2 years (range 0.3 to 2.0 years). The primary end point was a clinically meaningful event, which required a therapy change, captured with the loop recorder. Patients submitted data regularly (14 ± 11 times per month). During follow-up, 21 events were detected (including 4 asystole, i.e., ECG pauses ≥3 seconds) and 7 bradycardia events; 5 episodes of intermittent atrial fibrillation (>3 minutes) and 5 episodes of ventricular tachycardia (3 sustained and 2 nonsustained). Subsequently, as defined in the primary end point, 15 events leaded to a change of therapy. These patients required therapy with a pacemaker or cardioverter-defibrillator implantation and/or anticoagulation therapy for atrial fibrillation. In conclusion, clinically relevant arrhythmias that require further device and/or medical therapy are often missed with Holter ECGs in patients with advanced stage Fabry cardiomyopathy, but they can be detected by telemonitoring with an implantable loop recorder.
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170
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Sanders P, Pürerfellner H, Pokushalov E, Sarkar S, Di Bacco M, Maus B, Dekker LR. Performance of a new atrial fibrillation detection algorithm in a miniaturized insertable cardiac monitor: Results from the Reveal LINQ Usability Study. Heart Rhythm 2016; 13:1425-30. [DOI: 10.1016/j.hrthm.2016.03.005] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Indexed: 01/15/2023]
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171
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Paroxysmal Atrial Fibrillation: Novel Strategies for Monitoring and Implications for Treatment in Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:52. [DOI: 10.1007/s11936-016-0475-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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172
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DEKKER LUKASRC, POKUSHALOV EVGENY, SANDERS PRASHANTHAN, LINDBORG KATHERINEA, MAUS BÄRBEL, PÜRERFELLNER HELMUT. Continuous Cardiac Monitoring around Atrial Fibrillation Ablation: Insights on Clinical Classifications and End Points. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:805-13. [DOI: 10.1111/pace.12897] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 11/30/2022]
Affiliation(s)
- LUKAS RC DEKKER
- Department of Cardiology; Catharina Hospital; Eindhoven The Netherlands
| | - EVGENY POKUSHALOV
- Arrhythmia Department; State Research Institute of Circulation Pathology; Novosibirsk Russia
| | - PRASHANTHAN SANDERS
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute; University of Adelaide and Royal Adelaide Hospital; Adelaide Australia
| | | | - BÄRBEL MAUS
- Medtronic Bakken Research Center; Maastricht The Netherlands
| | - HELMUT PÜRERFELLNER
- Department of Cardiology; Elisabethinen University Teaching Hospital; Linz Austria
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173
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Mittal S, Rogers J, Sarkar S, Koehler J, Warman EN, Tomson TT, Passman RS. Real-world performance of an enhanced atrial fibrillation detection algorithm in an insertable cardiac monitor. Heart Rhythm 2016; 13:1624-30. [PMID: 27165694 DOI: 10.1016/j.hrthm.2016.05.010] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Insertable cardiac monitors (ICMs) are used for long-term ECG monitoring. The Reveal LINQ ICM has an improved atrial fibrillation (AF) detection algorithm. OBJECTIVE The purpose of this study was to investigate the algorithm's real-world performance in patients with syncope, cryptogenic stroke, and known AF. METHODS Consecutive patients with implanted ICM and AF detection parameters automatically set and maintained depending on the indication for monitoring were included. A single reviewer annotated all stored episodes after ICM implant. A second reviewer annotated a random sample of 10% of all detected AF episodes. The episode detection positive predictive value as well as true and false detection rates were determined for AF episodes of different durations. RESULTS The study enrolled 3759 patients (1604 [43%] with syncope, 1049 [28%] with known AF, 1106 [29%] with cryptogenic stroke). Overall, 20,659 AF episodes were detected in 1020 patients. The gross episode detection positive predictive value was 84%, 73%, and 26% for all episodes (≥2 minutes) and improved to 97%, 95%, and 91% for detected AF episodes ≥1 hour in the syncope, known-AF, and cryptogenic stroke patient cohorts, respectively. The true (and false) detection rate was 0.23 (0.05), 3.8 (1.4), and 0.23 (0.65) per patient-month of monitoring for the syncope, known-AF, and cryptogenic stroke patient cohorts, respectively. Limiting ECG storage to the longest detected AF episode significantly reduced the burden of episode adjudication without significantly compromising the identification of patients with true AF. CONCLUSION The performance of LINQ ICM is dependent on the AF incidence rate in the population being monitored, the programmed sensitivity of AF algorithm, and the duration of detected AF episodes.
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Affiliation(s)
- Suneet Mittal
- Valley Health System of New York and New Jersey, New York, New York.
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174
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Ringwala SM, Tomson TT, Passman RS. Cardiac Monitoring for Atrial Fibrillation in Cryptogenic Stroke. Cardiol Clin 2016; 34:287-97. [DOI: 10.1016/j.ccl.2015.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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175
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Brachmann J, Morillo CA, Sanna T, Di Lazzaro V, Diener HC, Bernstein RA, Rymer M, Ziegler PD, Liu S, Passman RS. Uncovering Atrial Fibrillation Beyond Short-Term Monitoring in Cryptogenic Stroke Patients: Three-Year Results From the Cryptogenic Stroke and Underlying Atrial Fibrillation Trial. Circ Arrhythm Electrophysiol 2016; 9:e003333. [PMID: 26763225 DOI: 10.1161/circep.115.003333] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) can be a cause of previously diagnosed cryptogenic stroke. However, AF can be paroxysmal and asymptomatic, thereby making detection with routine ECG methods difficult. Oral anticoagulation is highly effective in reducing recurrent stroke in patients with AF, but its initiation is dependent on the detection of AF. Cryptogenic Stroke and Underlying Atrial Fibrillation (CRYSTAL AF) is the first randomized study to report the detection of AF in cryptogenic stroke patients using continuous long-term monitoring via insertable cardiac monitors (ICM). METHODS AND RESULTS Patients with prior cryptogenic stroke were randomized to control (n=220) or ICM (n=221) and followed for ≤36 months. Cumulative AF detection rates in the ICM arm increased progressively during this period (3.7%, 8.9%, 12.4%, and 30.0% at 1, 6, 12, and 36 months, respectively), but remained low in the control arm (3.0% at 36 months). This resulted in oral anticoagulation prescription in 94.7% of ICM patients with AF detected at 6 months, 96.6% at 12 months, and 90.5% at 36 months. Among ICM patients with AF detected, the median time to AF detection was 8.4 months, 81.0% of first AF episodes were asymptomatic, and 94.9% had at least 1 day with >6 minutes of AF. CONCLUSIONS Three-year monitoring by ICM in cryptogenic stroke patients demonstrated a significantly higher AF detection rate compared with routine care. Given the frequency of asymptomatic first episodes and the long median time to detection, these findings highlight the limitations of using traditional AF detection methods. The majority of patients with AF were prescribed oral anticoagulation therapy. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov; Unique identifier: NCT00924638.
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Affiliation(s)
- Johannes Brachmann
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.).
| | - Carlos A Morillo
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Tommaso Sanna
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Vincenzo Di Lazzaro
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Hans-Christoph Diener
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Richard A Bernstein
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Marylin Rymer
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Paul D Ziegler
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Shufeng Liu
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Rod S Passman
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
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Miracapillo G, Addonisio L, Breschi M, DE Sensi F, Manfredini E, Corbucci G, Severi S, Barold SS. Left Axillary Implantation of Loop Recorder versus the Traditional Left Chest Area: A Prospective Randomized Study. Pacing Clin Electrophysiol 2016; 39:830-6. [PMID: 27119309 DOI: 10.1111/pace.12875] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/04/2016] [Accepted: 04/06/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Based upon the results of a previous small pilot study, we present the results of a prospective single-center randomized study comparing the performance of the implantable loop recorder (ILR) at two implanting sites. METHODS A group of patients whose ILRs were implanted via a left axillary approach were compared with a group who received an ILR in the traditional left site of the chest. Follow-up (FU) was scheduled every 6 months or when symptoms occurred. All patients enrolled in the study had a complete FU from implantation to explantation. R- and P-wave amplitudes were measured at implantation and during FU. Explantation of the device was programmed at the end of service life or when ILR analysis resulted in a complete and exhaustive diagnosis. RESULTS Sixty-three patients were enrolled (70 ± 12 years, range: 21-92, 59% male): 31 standard and 32 with axillary access. The R-wave amplitude obtained with the new technique was comparable with that obtained with the standard procedure. The diagnostic accuracy of the ILR was comparable in the two groups. The axillary implantation procedure was slightly longer but no complications were observed. CONCLUSION This long-term randomized study confirmed that axillary access for ILR implantation is feasible, safe, well tolerated, and reliable in terms of device performance. Moreover, it is aesthetically superior to the standard approach and carries the potential of minimizing permanent scarring after ILR extraction.
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Affiliation(s)
| | - Luigi Addonisio
- Division of Cardiology, Misericordia Hospital, Grosseto, Italy
| | - Marco Breschi
- Division of Cardiology, Misericordia Hospital, Grosseto, Italy
| | | | | | - Giorgio Corbucci
- Formerly, Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Silva Severi
- Division of Cardiology, Misericordia Hospital, Grosseto, Italy
| | - S Serge Barold
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
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177
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Fengsrud E, Wickbom A, Almroth H, Englund A, Ahlsson A. Total endoscopic ablation of patients with long-standing persistent atrial fibrillation: a randomized controlled study. Interact Cardiovasc Thorac Surg 2016; 23:292-8. [PMID: 27068249 DOI: 10.1093/icvts/ivw088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/04/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Total endoscopic ablation of atrial fibrillation is an alternative to catheter ablation, but its clinical role needs further evaluation. The aim of this study was to compare total endoscopic ablation with rate control in patients with long-standing persistent atrial fibrillation and to examine the effect of endoscopic ablation on heart rhythm, symptoms, physical working capacity and myocardial function during 1 year of follow-up. METHODS In a prospective controlled study, 36 patients aged >50 years with symptomatic long-standing persistent atrial fibrillation were randomized to either total endoscopic ablation (n = 17, after two drop-outs before ablation n = 15) or rate control therapy (n = 19). In the ablation group, a box lesion encircling the pulmonary veins was performed, using temperature-controlled radiofrequency energy. Loop recorders were implanted in all patients. Echocardiography and quality-of-life assessment were performed at 6 and 12 months, and physical working capacity assessment at 6 months. RESULTS There was no mortality or thromboembolic event. In the control group, all patients were in permanent atrial fibrillation during 12 months of follow-up. In the ablation group, the proportion of patients in sinus rhythm without antiarrhythmic drugs was 12/15 (80%) at 12 months. The median freedom of atrial fibrillation at 3-12 months was 95% in the ablation group and the proportion of patients with an atrial fibrillation burden of <5% at 3-12 months was 8/15 (53%). The left ventricular ejection fraction increased during follow-up in the ablation group compared with the control group (from 53.7 ± 8.6 to 58.8 ± 6.5%, P = 0.003), combined with a reduction in the left atrial area (from 29.2 ± 5.5 to 27.2 ± 6.3 cm(2), P = 0.002). The physical working capacity increased in the ablation group compared with the control group (from 94 ± 21.4 to 102.9 ± 14.4%, P = 0.011). The subjective physical and mental capacity scale also improved during follow-up in the ablation group, but not in the control group (P = 0.003 and 0.018, respectively). CONCLUSIONS Total endoscopic ablation in patients with long-standing persistent atrial fibrillation significantly reduced atrial fibrillation burden 12 months after intervention compared with controls. The left ventricular function, physical working capacity and subjective physical and mental health were improved. These results need to be confirmed in larger randomized trials. CLINICALTRIALSGOV IDENTIFIER NCT00940056.
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Affiliation(s)
- Espen Fengsrud
- Department of Cardiology, Örebro University, Örebro, Sweden Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Wickbom
- Department of Cardiothoracic and Vascular Surgery, Örebro University, Örebro, Sweden
| | - Henrik Almroth
- Department of Cardiology, Örebro University, Örebro, Sweden Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Englund
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden Arrhythmia Centre, South General Hospital, Stockholm, Sweden
| | - Anders Ahlsson
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden Department of Cardiothoracic and Vascular Surgery, Örebro University, Örebro, Sweden
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178
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Ad N. Invited Commentary. Ann Thorac Surg 2016; 101:1476. [PMID: 27000571 DOI: 10.1016/j.athoracsur.2015.10.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 10/28/2015] [Accepted: 10/28/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Niv Ad
- Section of Cardiac Surgery, Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042.
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179
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Miller DJ, Shah K, Modi S, Mahajan A, Zahoor S, Affan M. The Evolution and Application of Cardiac Monitoring for Occult Atrial Fibrillation in Cryptogenic Stroke and TIA. Curr Treat Options Neurol 2016; 18:17. [PMID: 26923607 DOI: 10.1007/s11940-016-0400-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT The evaluation of the stroke and transient ischemic attack (TIA) patient has been historically predominated by the initial evaluation in the hospital setting. As the etiology of stroke has eluded us in approximately one third of all acute events, the medical community has been eager to seek the answer to this mystery. In recent years, we have seen an explosion of innovations and trends allowing for a more detailed post stroke assessment strategy aimed at the identification of occult atrial fibrillation as the etiologic cause for the cryptogenic event. This has been achieved through the evolution and aggressive application and study of prolonged and advanced cardiac monitoring. This review is aimed to clarify and elucidate the standard and novel cardiac monitoring methods that have become available for use by the medical community and expected in the higher level care of cryptogenic stroke and TIA patients. These cardiac monitoring methods and devices are as heterogeneous as our patient population and have their own advantages and disadvantages. Many factors may be taken into consideration in choosing the appropriate cardiac monitoring method and are highlighted for consideration in this review. With a judicious approach to investigating the cryptogenic stroke population, and applying a wealth of novel treatment options, we may move forward into a new era of stroke prevention.
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Affiliation(s)
- Daniel J Miller
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Kavit Shah
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Sumul Modi
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Abhimanyu Mahajan
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Salman Zahoor
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Muhammad Affan
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
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Olsen FJ, Biering-Sørensen T, Krieger DW. An update on insertable cardiac monitors: examining the latest clinical evidence and technology for arrhythmia management. Future Cardiol 2016; 11:333-46. [PMID: 26021639 DOI: 10.2217/fca.15.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Continuous cardiac rhythm monitoring has undergone compelling progress over the past decades. Cardiac monitoring has emerged from 12-lead electrocardiograms being performed at the discretion of the treating physician to in-hospital telemetry, Holter monitoring, prolonged external event monitoring and most recently toward insertable device monitoring for several years. Significant advantages and disadvantages pertaining to these monitoring options will be addressed in this review. Insertable cardiac monitors have several advantages over external monitoring techniques and may signify a clinical turning point in the field of arrhythmia management. However, their role in the detection of paroxysmal atrial fibrillation after cryptogenic strokes has yet to evolve. This will be the main focus of this review. Issues surrounding patient selection, clinical relevance and determination of cost-effectiveness for prolonged cardiac monitoring require further studies. Furthermore, insertable cardiac monitoring has not only the potential to augment diagnostic capabilities but also to improve the management of paroxysmal atrial fibrillation.
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Affiliation(s)
- Flemming J Olsen
- 1Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- 1Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Derk W Krieger
- 4Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Burkowitz J, Merzenich C, Grassme K, Brüggenjürgen B. Insertable cardiac monitors in the diagnosis of syncope and the detection of atrial fibrillation: A systematic review and meta-analysis. Eur J Prev Cardiol 2016; 23:1261-72. [PMID: 26864396 DOI: 10.1177/2047487316632628] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 01/25/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Insertable or implantable cardiac monitors (ICMs) continuously monitor the heart rhythm and record irregularities over 3 years, enabling the diagnosis of infrequent rhythm abnormalities associated with syncope and stroke. The enhanced recognition capabilities of recent ICM models are able to accurately detect atrial fibrillation (AF) and have led to new applications of ICMs for the detection and monitoring of AF. METHODS AND RESULTS Based on a systematic literature search, two indications were identified for ICMs for which considerable evidence, including randomized studies, exists: diagnosing the underlying cardiac cause of unexplained recurrent syncope and detecting AF in patients after cryptogenic stroke (CS). Three randomized controlled trials (RCTs) were identified that compared the effectiveness of ICMs in diagnosing patients with unexplained syncope (n = 556) to standard of care. A meta-analysis was conducted in order to generate an overall effect size and confidence interval of the diagnostic yield of ICMs versus conventional monitoring. In the indication CS, one RCT and five observational studies were included in order to assess the performance of ICMs in diagnosing patients with AF (n = 1129). Based on these studies, there is strong evidence that ICMs provide a higher diagnostic yield for detecting arrhythmias in patients with unexplained syncope and for detection of AF in patients after CS compared to conventional monitoring. CONCLUSIONS Prolonged monitoring with ICMs is an effective tool for diagnosing the underlying cardiac cause of unexplained syncope and for detecting AF in patients with CS. In all RCTs, ICMs have a superior diagnostic yield compared to conventional monitoring.
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Affiliation(s)
- Jörg Burkowitz
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Carina Merzenich
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Kathrin Grassme
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Bernd Brüggenjürgen
- Charité University Medicine Berlin, Institute for Social Medicine, Epidemiology and Health Economy, Berlin, Germany
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Lau CP, Siu CW, Yiu KH, Lee KLF, Chan YH, Tse HF. Subclinical atrial fibrillation and stroke: insights from continuous monitoring by implanted cardiac electronic devices. Europace 2016; 17 Suppl 2:ii40-6. [DOI: 10.1093/europace/euv235] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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183
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Carpenter A, Frontera A. Smart-watches: a potential challenger to the implantable loop recorder? Europace 2016; 18:791-3. [DOI: 10.1093/europace/euv427] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 11/21/2015] [Indexed: 11/15/2022] Open
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Malmo V, Nes BM, Amundsen BH, Tjonna AE, Stoylen A, Rossvoll O, Wisloff U, Loennechen JP. Aerobic Interval Training Reduces the Burden of Atrial Fibrillation in the Short Term. Circulation 2016; 133:466-73. [DOI: 10.1161/circulationaha.115.018220] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/07/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Vegard Malmo
- From the K.G. Jebsen Center of Exercise in Medicine (V.M., B.M.N., A.-E.T., U.W., J.P.L.), Department of Circulation and Medical Imaging (B.H.A., A.S., O.R.), Norwegian University of Science and Technology, Trondheim, Norway; and Department of Cardiology, St. Olavs Hospital, Trondheim, Norway (V.M., B.H.A., A.S., O.R., J.P.L.)
| | - Bjarne M. Nes
- From the K.G. Jebsen Center of Exercise in Medicine (V.M., B.M.N., A.-E.T., U.W., J.P.L.), Department of Circulation and Medical Imaging (B.H.A., A.S., O.R.), Norwegian University of Science and Technology, Trondheim, Norway; and Department of Cardiology, St. Olavs Hospital, Trondheim, Norway (V.M., B.H.A., A.S., O.R., J.P.L.)
| | - Brage H. Amundsen
- From the K.G. Jebsen Center of Exercise in Medicine (V.M., B.M.N., A.-E.T., U.W., J.P.L.), Department of Circulation and Medical Imaging (B.H.A., A.S., O.R.), Norwegian University of Science and Technology, Trondheim, Norway; and Department of Cardiology, St. Olavs Hospital, Trondheim, Norway (V.M., B.H.A., A.S., O.R., J.P.L.)
| | - Arnt-Erik Tjonna
- From the K.G. Jebsen Center of Exercise in Medicine (V.M., B.M.N., A.-E.T., U.W., J.P.L.), Department of Circulation and Medical Imaging (B.H.A., A.S., O.R.), Norwegian University of Science and Technology, Trondheim, Norway; and Department of Cardiology, St. Olavs Hospital, Trondheim, Norway (V.M., B.H.A., A.S., O.R., J.P.L.)
| | - Asbjorn Stoylen
- From the K.G. Jebsen Center of Exercise in Medicine (V.M., B.M.N., A.-E.T., U.W., J.P.L.), Department of Circulation and Medical Imaging (B.H.A., A.S., O.R.), Norwegian University of Science and Technology, Trondheim, Norway; and Department of Cardiology, St. Olavs Hospital, Trondheim, Norway (V.M., B.H.A., A.S., O.R., J.P.L.)
| | - Ole Rossvoll
- From the K.G. Jebsen Center of Exercise in Medicine (V.M., B.M.N., A.-E.T., U.W., J.P.L.), Department of Circulation and Medical Imaging (B.H.A., A.S., O.R.), Norwegian University of Science and Technology, Trondheim, Norway; and Department of Cardiology, St. Olavs Hospital, Trondheim, Norway (V.M., B.H.A., A.S., O.R., J.P.L.)
| | - Ulrik Wisloff
- From the K.G. Jebsen Center of Exercise in Medicine (V.M., B.M.N., A.-E.T., U.W., J.P.L.), Department of Circulation and Medical Imaging (B.H.A., A.S., O.R.), Norwegian University of Science and Technology, Trondheim, Norway; and Department of Cardiology, St. Olavs Hospital, Trondheim, Norway (V.M., B.H.A., A.S., O.R., J.P.L.)
| | - Jan P. Loennechen
- From the K.G. Jebsen Center of Exercise in Medicine (V.M., B.M.N., A.-E.T., U.W., J.P.L.), Department of Circulation and Medical Imaging (B.H.A., A.S., O.R.), Norwegian University of Science and Technology, Trondheim, Norway; and Department of Cardiology, St. Olavs Hospital, Trondheim, Norway (V.M., B.H.A., A.S., O.R., J.P.L.)
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Cipriano LE, Sposato LA. Estimating the Sensitivity of Holter to Detect Atrial Fibrillation After Stroke or Transient Ischemic Attack Without a Gold Standard is Challenging. Am J Cardiol 2016; 117:314-6. [PMID: 26684517 DOI: 10.1016/j.amjcard.2015.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 11/03/2015] [Indexed: 10/22/2022]
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Diamantopoulos A, Sawyer LM, Lip GYH, Witte KK, Reynolds MR, Fauchier L, Thijs V, Brown B, Quiroz Angulo ME, Diener HC. Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke. Int J Stroke 2016; 11:302-12. [DOI: 10.1177/1747493015620803] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 10/15/2015] [Indexed: 11/16/2022]
Abstract
Background and aims Documentation of atrial fibrillation is required to initiate oral anticoagulation therapy for recurrent stroke prevention. Atrial fibrillation often goes undetected with traditional electrocardiogram monitoring techniques. We evaluated whether atrial fibrillation detection using continuous long-term monitoring with an insertable cardiac monitor is cost-effective for preventing recurrent stroke in patients with cryptogenic stroke, in comparison to the standard of care. Methods A lifetime Markov model was developed to estimate the cost-effectiveness of insertable cardiac monitors from a UK National Health Service perspective using data from the randomized CRYSTAL-AF trial and other published literature. We also conducted scenario analyses (CHADS2 score) and probabilistic sensitivity analyses. All costs and benefits were discounted at 3.5%. Results Monitoring cryptogenic stroke patients with an insertable cardiac monitor was associated with fewer recurrent strokes and increased quality-adjusted life years compared to the standard of care (7.37 vs 7.22). Stroke-related costs were reduced in insertable cardiac monitor patients, but overall costs remained higher than the standard of care (£19,631 vs £17,045). The incremental cost-effectiveness ratio was £17,175 per quality-adjusted life years gained, compared to standard of care in the base-case scenario, which is below established quality-adjusted life years willingness-to-pay thresholds. When warfarin replaced non-vitamin-K oral anticoagulants as the main anticoagulation therapy, the incremental cost-effectiveness ratio was £13,296 per quality-adjusted life years gained. Conclusion Insertable cardiac monitors are a cost-effective diagnostic tool for the prevention of recurrent stroke in patients with cryptogenic stroke. The cost-effectiveness results have relevance for the UK and across value-based healthcare systems that assess costs relative to outcomes.
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Affiliation(s)
| | | | - Gregory YH Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Klaus K Witte
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Matthew R Reynolds
- Economics and Quality of Life Research, Harvard Clinical Research Institute, Boston, MA, USA
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
| | - Vincent Thijs
- Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
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Lomivorotov VV, Efremov SM, Pokushalov EA, Karaskov AM. New-Onset Atrial Fibrillation After Cardiac Surgery: Pathophysiology, Prophylaxis, and Treatment. J Cardiothorac Vasc Anesth 2016; 30:200-16. [DOI: 10.1053/j.jvca.2015.08.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Indexed: 01/13/2023]
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188
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Maria ED, Giacopelli D. Subclinical Atrial Tachyarrhythmias:Implantable Devices and Remote Monitoring. J Atr Fibrillation 2015; 8:1249. [PMID: 27957222 DOI: 10.4022/jafib.1249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 08/03/2015] [Accepted: 09/07/2015] [Indexed: 12/20/2022]
Abstract
Atrial fibrillation (AF) and Atrial Tachyarrhythmias (AT) are the most common clinical arrhythmias and their worst issue is a well-recognized correlation with ischemic stroke. High incidence of "subclinical" AF/ATs has been demonstrated in several trials (TRENDS, ASSERT, CRYSTAL AF, EMBRACE) in patients with both cardiac implantable electronic devices (CIEDS) and external loop recorders. Moreover, a relationship between device-detected AF/ATs and stroke risk has been observed in the same studies. However, while the net clinical benefit of the antithrombotic treatment is well established in patients with "clinical" atrial fibrillation, there may be a lower benefit in patients with device-detected arrhythmias. Subclinical AF/ATs may be considered as a marker of stroke risk rather than the proximate cause and their burden may be used in combination with CHA2DS2-VASC and HAS-BLED scores to identify high-risk population who deserves anticoagulation. Today the remote monitoring associated with the CIEDs is effective in the early detecting of AF/ATs by avoiding delays in the therapy evaluation, as demonstrated by several trials (TRUST, CONNECT, COMPAS). However clinical evidence for stroke risk reduction by remote monitoring is still awaited; the recent trial IMPACT failed to demonstrate that the handling of the anticoagulation therapy guided by device-detected ATs and remote monitoring improves the patients' outcome. The challenges for clinicians are to deal with the huge data entry, to define new organizational models, to improve device patient management and to continuously update AF guidelines in according to the great amount of data offered by the new technology.
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Affiliation(s)
- Elia De Maria
- Arrhythmology Cath Lab, Cardiology Unit, Ramazzini Hospital, Via Molinari 1, 41012, Carpi (Modena), Italy
| | - Daniele Giacopelli
- Biotronik Italia, Via Delle Industrie 11, 20090 Vimodrone (Milano), Italy
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Blaschke F, Lacour P, Walter T, Wutzler A, Huemer M, Parwani A, Attanasio P, Boldt LH, Markowski M, Denecke T, Haverkamp W. Cardiovascular Magnetic Resonance Imaging in Patients with an Implantable Loop Recorder. Ann Noninvasive Electrocardiol 2015; 21:319-324. [PMID: 26701418 DOI: 10.1111/anec.12333] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Implantable loop recorders (ILRs) allow continuous cardiac monitoring for 3-6 years and are a valuable tool for the investigation of syncopal episodes, palpitations, and atrial fibrillations as well as risk stratification after myocardial infarction. Although magnetic resonance imaging (MRI) in patients with ILRs has been shown to be safe, the impact of ILRs on cardiac MRI image quality has not been investigated yet. Thus, we tested the diagnostic value of cardiac MRI in patients with various types of ILRs. METHODS Two patients with an ILR and a clinical indication to assess myocardial burden of scarring and fibrosis or stress-induced myocardial ischemia underwent cardiac MRI. Device interrogation was performed prior to, immediately after, and 3 months after cardiac MRI. RESULTS The post-MRI follow-ups revealed no change in programmed ILR parameters, sensing fidelity, and battery parameters. However, ILRs caused significant, uninterpretable hyperintensity artifacts in cardiac MRI. CONCLUSIONS Further clinical studies are warranted to investigate whether modified MRI techniques are helpful to eliminate imaging artifacts.
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Affiliation(s)
- Florian Blaschke
- Department of Cardiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Philipp Lacour
- Department of Cardiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Thula Walter
- Department of Radiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Alexander Wutzler
- Department of Cardiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Martin Huemer
- Department of Cardiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Abdul Parwani
- Department of Cardiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Philipp Attanasio
- Department of Cardiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Leif-Hendrik Boldt
- Department of Cardiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Marcus Markowski
- Department of Radiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Timm Denecke
- Department of Radiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Wilhelm Haverkamp
- Department of Cardiology, Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Berlin, Germany
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Thijs VN, Brachmann J, Morillo CA, Passman RS, Sanna T, Bernstein RA, Diener HC, Di Lazzaro V, Rymer MM, Hogge L, Rogers TB, Ziegler PD, Assar MD. Predictors for atrial fibrillation detection after cryptogenic stroke: Results from CRYSTAL AF. Neurology 2015; 86:261-9. [PMID: 26683642 DOI: 10.1212/wnl.0000000000002282] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 09/16/2015] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE We assessed predictors of atrial fibrillation (AF) in cryptogenic stroke (CS) or transient ischemic attack (TIA) patients who received an insertable cardiac monitor (ICM). METHODS We studied patients with CS/TIA who were randomized to ICM within the CRYSTAL AF study. We assessed whether age, sex, race, body mass index, type and severity of index ischemic event, CHADS2 score, PR interval, and presence of diabetes, hypertension, congestive heart failure, or patent foramen ovale and premature atrial contractions predicted AF development within the initial 12 and 36 months of follow-up using Cox proportional hazards models. RESULTS Among 221 patients randomized to ICM (age 61.6 ± 11.4 years, 64% male), AF episodes were detected in 29 patients within 12 months and 42 patients at 36 months. Significant univariate predictors of AF at 12 months included age (hazard ratio [HR] per decade 2.0 [95% confidence interval 1.4-2.8], p = 0.002), CHADS2 score (HR 1.9 per one point [1.3-2.8], p = 0.008), PR interval (HR 1.3 per 10 milliseconds [1.2-1.4], p < 0.0001), premature atrial contractions (HR 3.9 for >123 vs 0 [1.3-12.0], p = 0.009 across quartiles), and diabetes (HR 2.3 [1.0-5.2], p < 0.05). In multivariate analysis, age (HR per decade 1.9 [1.3-2.8], p = 0.0009) and PR interval (HR 1.3 [1.2-1.4], p < 0.0001) remained significant and together yielded an area under the receiver operating characteristic curve of 0.78 (0.70-0.85). The same predictors were found at 36 months. CONCLUSION Increasing age and a prolonged PR interval at enrollment were independently associated with an increased AF incidence in CS patients. However, they offered only moderate predictive ability in determining which CS patients had AF detected by the ICM.
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Affiliation(s)
- Vincent N Thijs
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX.
| | - Johannes Brachmann
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Carlos A Morillo
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Rod S Passman
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Tommaso Sanna
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Richard A Bernstein
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Hans-Christoph Diener
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Vincenzo Di Lazzaro
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Marilyn M Rymer
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Laurence Hogge
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Tyson B Rogers
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Paul D Ziegler
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
| | - Manish D Assar
- From the Florey Institute of Neuroscience and Mental Health and Austin Health Department of Neurology (V.N.T.), Heidelberg, Australia; Hospital Klinikum Coburg (J.B.), Teaching Hospital of the University of Würzburg, Coburg, Germany; Population Health Research Institute (C.A.M.), McMaster University, Hamilton, Canada; Northwestern University Feinberg School of Medicine (R.S.P.), Chicago, IL; Institute of Cardiology (T.S.), Catholic University of the Sacred Heart, Rome, Italy; Davee Department of Neurology (R.A.B.), Northwestern University, Chicago, IL; Department of Neurology (H.-C.D.), University Hospital Essen University Duisburg-Essen, Germany; Institute of Neurology (V.D.L.), University Campus Bio-Medico of Rome, Rome, Italy; University of Kansas Medical Center (M.M.R.), Kansas City; Medtronic (L.H.), Maastricht, Netherlands; Medtronic (T.B.R., P.D.Z.), Mounds View, Minneapolis, MN; and Baylor University Medical Center (M.D.A.), Dallas, TX
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Petrovičová A, Kurča E, Brozman M, Hasilla J, Vahala P, Blaško P, Andrášová A, Hatala R, Urban L, Sivák Š. Detection of occult paroxysmal atrial fibrilation by implantable long-term electrocardiographic monitoring in cryptogenic stroke and transient ischemic attack population: a study protocol for prospective matched cohort study. BMC Cardiovasc Disord 2015; 15:160. [PMID: 26631084 PMCID: PMC4668651 DOI: 10.1186/s12872-015-0160-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/30/2015] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cardio-embolic etiology is the most frequently predicted cause of cryptogenic stroke/TIA. Detection of occult paroxysmal atrial fibrillation is crucial for selection of appropriate medication. METHODS Enrolment of eligible cryptogenic stroke and TIA patients began in 2014 and will continue until 2018. The patients undergo long-term (12 months) ECG monitoring (implantable loop recorder) and testing for PITX2 (chromosome 4q25) and ZFHX3 (chromosome 16q22) gene mutations. There will be an appropriate control group of age- and sex-matched healthy volunteers. To analyse the results descriptive statistics, statistical tests for group differences, and correlation analyses will be used. DISCUSSION In our study we are focusing on a possible correlation between detection of atrial fibrillation by an implantable ECG recorder, and PITX2 and/or ZFHX3 gene mutations in cryptogenic stroke/TIA patients. A correlation could lead to implementation of this genomic approach to cryptogenic stroke/TIA diagnostics and management. The results will be published in 2018. TRIAL REGISTRATION ClinicalTrials.gov: NCT02216370 .
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Affiliation(s)
- Andrea Petrovičová
- Department of Neurology, Faculty Hospital, Constantine Philosopher University, Špitálska 6, 94901, Nitra, Slovak Republic.
| | - Egon Kurča
- Clinic of Neurology, Jessenius Faculty of Medicine, Comenius University, Kollárova 2, 03659, Martin, Slovak Republic.
| | - Miroslav Brozman
- Department of Neurology, Faculty Hospital, Constantine Philosopher University, Špitálska 6, 94901, Nitra, Slovak Republic.
| | - Jozef Hasilla
- Clinic of Cardiology, Faculty Hospital, Constantine Philosopher University, Špitálska 6, 94901, Nitra, Slovak Republic.
| | - Pavel Vahala
- Clinic of Cardiology, Faculty Hospital, Constantine Philosopher University, Špitálska 6, 94901, Nitra, Slovak Republic.
| | - Peter Blaško
- Kardiocentrum Nitra s.r.o, Špitálska 1, 94901, Nitra, Slovak Republic.
| | - Andrea Andrášová
- Kardiocentrum Nitra s.r.o, Špitálska 1, 94901, Nitra, Slovak Republic.
| | - Robert Hatala
- Department of Arrhythmias and Cardiac Pacing, The National Institute of Cardiovascular Diseases, Pod Krásnou hôrkou 1, 83348, Bratislava, Slovak Republic.
| | - Luboš Urban
- Department of Arrhythmias and Cardiac Pacing, The National Institute of Cardiovascular Diseases, Pod Krásnou hôrkou 1, 83348, Bratislava, Slovak Republic.
| | - Štefan Sivák
- Clinic of Neurology, Jessenius Faculty of Medicine, Comenius University, Kollárova 2, 03659, Martin, Slovak Republic.
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192
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Mascarenhas DAN, Farooq MU, Ziegler PD, Kantharia BK. Role of insertable cardiac monitors in anticoagulation therapy in patients with atrial fibrillation at high risk of bleeding. Europace 2015; 18:799-806. [PMID: 26614520 DOI: 10.1093/europace/euv350] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 09/22/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS We aimed to ascertain whether an insertable cardiac monitor (ICM)-guided rhythm-control strategy and assessment of atrial fibrillation (AF) burden may allow safe withdrawal and obviate long-term use of oral anticoagulants (OACs) in AF patients at high bleeding risk. METHODS AND RESULTS We implanted ICMs in 70 patients with AF with high risk of stroke (CHADS2 ≥2, CHA2DS2-VASc score ≥2) and bleeding (HAS-BLED score ≥3) after restoration of normal sinus rhythm (NSR) for continuous rhythm monitoring and optimization of antiarrhythmic drugs (AADs) when necessary. Patients were categorized into: (i) Group A (NSR/low AF burden, <1%), (ii) Group B (moderate/variable AF burden), and (iii) Group C (high AF burden, always AF). At patients' insistence, OACs were discontinued after proper counselling only if they maintained NSR/low AF burden for ≥3 consecutive months. All patients (age 73.3 ± 11.7 years; 53% male) were followed clinically and with ICM monitoring for 23.5 ± 10.5 months for outcomes including stroke, bleeding, death, device malfunction or infection, and AADs' adverse effects. Patients in Group A (n = 43), Group B (n = 20), and Group C (n = 7) had similar CHADS2 (2.09 ± 0.65, 2.05 ± 0.51, and 2.14 ± 0.38, respectively), CHA2DS2-VASc (3.05 ± 1.05, 2.85 ± 0.99, and 2.42 ± 0.53, respectively), and HAS-BLED (3.02 ± 1.01, 3.40 ± 0.68, and 3.00 ± 0.58, respectively) scores (P > 0.05). In 53 (76%) patients (Group A = 41 and Group B = 12) who maintained NSR/low AF burden, OACs were discontinued without adverse events. Severe bleeding occurred in 4 of 17 (24%) patients who remained on OACs. CONCLUSION In AF patients with high bleeding risk, ICM-guided rhythm control with AADs and assessment of AF burden may allow safe discontinuation of OACs.
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Affiliation(s)
| | | | - Paul D Ziegler
- Medtronic Diagnostics and Monitoring Research, Mounds View, MN, USA
| | - Bharat K Kantharia
- Cardiovascular and Heart Rhythm Consultants, 30 West 60th Street, Suite 1U, New York, NY 10023, USA
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Passman R, Leong-Sit P, Andrei AC, Huskin A, Tomson TT, Bernstein R, Ellis E, Waks JW, Zimetbaum P. Targeted Anticoagulation for Atrial Fibrillation Guided by Continuous Rhythm Assessment With an Insertable Cardiac Monitor: The Rhythm Evaluation for Anticoagulation With Continuous Monitoring (REACT.COM) Pilot Study. J Cardiovasc Electrophysiol 2015; 27:264-70. [PMID: 26511221 DOI: 10.1111/jce.12864] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/26/2015] [Accepted: 10/08/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Chronic anticoagulation is recommended for patients with AF and additional stroke risk factors, even during long periods of sinus rhythm. Continuous rhythm assessment with an insertable cardiac monitor (ICM) and use of rapid onset novel oral anticoagulants (NOACs) allow for targeted anticoagulation only around an AF episode, potentially reducing bleeding complications without compromising stroke risk. METHODS This multicenter, single-arm study enrolled patients on NOAC with nonpermanent AF and CHADS2 score 1 or 2. After a 60-day run-in with no AF episodes ≥ 1 hour, NOACs were discontinued but reinitiated for 30 days following any AF episode ≥ 1 hour diagnosed through daily ICM transmissions. Major endpoints included time on NOAC, stroke, and bleeding. RESULTS Among 59 enrollees, 75% were male, age 67 ± 8 years, 76% paroxysmal AF, 69% had prior AF ablation, and mean CHADS2 score 1.3 ± 0.5. Over 466 ± 131 mean days of follow-up there were 24,004 ICM transmissions with a compliance rate of 98.7%. A total of 35 AF episodes ≥ 1 hour occurred in 18 (31%) patients, resulting in a total time on NOAC of 1,472 days. This represents a 94% reduction in the time on NOAC compared to chronic anticoagulation. There were three traumatic bleeds (all on aspirin), three potential transient ischemic attacks (all on aspirin with CHADS2 score of 1), and no strokes or deaths. CONCLUSIONS A targeted strategy of ICM-guided intermittent NOAC administration is feasible. A large-scale trial is necessary to evaluate the safety of this approach.
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Affiliation(s)
- Rod Passman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | - Anna Huskin
- Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Todd T Tomson
- Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Richard Bernstein
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ethan Ellis
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jonathan W Waks
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Peter Zimetbaum
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Podd SJ, Sugihara C, Furniss SS, Sulke N. Are implantable cardiac monitors the 'gold standard' for atrial fibrillation detection? A prospective randomized trial comparing atrial fibrillation monitoring using implantable cardiac monitors and DDDRP permanent pacemakers in post atrial fibrillation ablation patients. Europace 2015; 18:1000-5. [PMID: 26585596 DOI: 10.1093/europace/euv367] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/13/2015] [Indexed: 12/12/2022] Open
Abstract
AIMS Implantable devices are widely accepted, but not proven, to be the most reliable monitoring method to assess atrial fibrillation (AF) therapies. We compared REVEAL(®)XT implantable cardiac monitors (ICMs) and permanent pacemakers (PPMs). METHODS AND RESULTS Fifty patients with paroxysmal AF were randomized to ICM or PPM implant 6 weeks prior to pulmonary vein isolation. Permanent pacemakers were programmed to monitoring only (ODO). Device downloads were performed at 0, 3, 6, 9, and 12 months. All patients underwent 7-day external loop recorder. Device ECGs and EGMs were compared for AF burden. A total of 20 744 and 11 238 arrhythmia episodes were identified in the ICM and PPM groups, respectively. Correct identification of AF was significantly better in the PPM group (97 vs. 55% P < 0.001). In the ICM group, 26% of ECGs were un-interpretable. Sensitivity and specificity for each episode of AF was significantly better in the PPM group (100 vs. 79% and 98 vs. 66%, respectively, P < 0.001). The positive predictive value for the detection of any AF was significantly better in the PPM than the ICM (100 vs. 58%, P = 0.03). The negative predictive value for the absence of all AF was not significantly different between the PPM and ICM (100% vs. 92%, P = 0.76). CONCLUSION Permanent pacemakers Holters are the most accurate method of evaluating arrhythmia burden and the therapeutic efficacy of novel AF therapies. ICM has a high degree of artefact, which reduces its specifity and sensitivity. Despite the deficiencies of ICM monitoring the negative predictive value of the ICM is satisfactory if zero AF burden is the aim of therapy.
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Affiliation(s)
- Steven J Podd
- Cardiology Research Department, East Sussex Healthcare NHS Trust, Eastbourne Gen Hospital, East Sussex, UK
| | - Conn Sugihara
- Cardiology Research Department, East Sussex Healthcare NHS Trust, Eastbourne Gen Hospital, East Sussex, UK
| | - Stephen S Furniss
- Cardiology Research Department, East Sussex Healthcare NHS Trust, Eastbourne Gen Hospital, East Sussex, UK
| | - Neil Sulke
- Cardiology Research Department, East Sussex Healthcare NHS Trust, Eastbourne Gen Hospital, East Sussex, UK
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195
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Damiano RJ, Lawrance CP, Saint LL, Henn MC, Sinn LA, Kruse J, Gleva MJ, Maniar HS, McCarthy PM, Lee R. Detection of Atrial Fibrillation After Surgical Ablation: Conventional Versus Continuous Monitoring. Ann Thorac Surg 2015; 101:42-7; discussion 47-8. [PMID: 26507426 DOI: 10.1016/j.athoracsur.2015.07.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 07/08/2015] [Accepted: 07/13/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current guidelines recommend at least 24-hour Holter monitoring at 6-month intervals to evaluate the recurrence of atrial fibrillation (AF) after surgical ablation. In this prospective multicenter study, conventional intermittent methods of AF monitoring were compared with continuous monitoring using an implantable loop recorder (ILR). METHODS From August 2011 to January 2014, 47 patients receiving surgical treatment for AF at 2 institutions had an ILR placed at the time of operation. Each atrial tachyarrhythmia (ATA) of 2 minutes or more was saved. Patients transmitted ILR recordings bimonthly or after any symptomatic event. Up to 27 minutes of data was stored before files were overwritten. Patients also underwent electrocardiography (ECG) and 24-hour Holter monitoring at 3, 6, and 12 months. ILR compliance was defined as any transmission between 0 and 3 months, 3 and 6 months, or 6 and 12 months. Freedom from ATAs was calculated and compared. RESULTS ILR compliance at 12 months was 93% compared with ECG and Holter monitoring compliance of 85% and 76%, respectively. ILR devices reported a total of 20,878 ATAs. Of these, 11% of episodes were available for review and 46% were confirmed as AF. Freedom from ATAs was no different between continuous and intermittent monitoring at 1 year. Symptomatic events accounted for 187 episodes; however, only 10% were confirmed as AF. CONCLUSIONS ILR was equivalent at detecting ATAs when compared with Holter monitoring or ECG. However, the high rate of false-positive readings and the limited number of events available for review present barriers to broad implementation of this form of monitoring. Very few symptomatic events were AF on review.
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Affiliation(s)
- Ralph J Damiano
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri.
| | - Christopher P Lawrance
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Lindsey L Saint
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Matthew C Henn
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Laurie A Sinn
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Jane Kruse
- Division of Cardiothoracic Surgery, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | - Marye J Gleva
- Division of Cardiology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Hersh S Maniar
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Patrick M McCarthy
- Division of Cardiothoracic Surgery, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | - Richard Lee
- Center for Comprehensive Cardiovascular Care, Saint Louis University, St. Louis, Missouri
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196
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Sangha RS, Bernstein R. Advances in the Detection and Monitoring of Atrial Fibrillation for Patients with Cryptogenic Ischemic Stroke. Curr Atheroscler Rep 2015; 17:71. [DOI: 10.1007/s11883-015-0544-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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197
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Kennedy HL. Silent Atrial Fibrillation: Definition, Clarification, and Unanswered Issues. Ann Noninvasive Electrocardiol 2015; 20:518-25. [PMID: 26446367 PMCID: PMC6931649 DOI: 10.1111/anec.12307] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Indexed: 12/19/2022] Open
Abstract
Silent or subclinical asymptomatic atrial fibrillation has currently gained wide interest in the epidemiologic, neurologic and cardiovascular communities. The association of brief episodes of paroxysmal atrial fibrillation or surrogate atrial arrhythmias which predict future clinical adverse events have been established. Nevertheless there exists a confounding array of definitions to indicate its presence without discrete indication of which populations should be examined. Moreover the term "atrial fibrillation burden" (AFB) has emerged from such studies with a plethora of descriptions to prognosticate both arrhythmic and clinical adverse events. This presentation suggests clarification of diagnostic definitions associated with silent atrial fibrillation, and a more precise description of AFB. It examines the populations across the current disease and cardiovascular invasive therapeutic spectrum that lead to both silent atrial fibrillation and AFB. It describes the diagnostic methods of arrhythmia detection utilizing the surface ECG, subcutaneous ECG or intra-cardiac devices and their relationship in seeking meaningful arrhythmic markers of silent atrial fibrillation. Whereas a wide range of clinical risk factors of silent atrial fibrillation have been validated in the literature, there is an ongoing search for those arrhythmic risk factors that precisely identify and prognosticate outcome events in diverse populations at risk of atrial fibrillation and its complications. This presentation identifies this chaos, and focuses attention on the issues to be addressed to facilitate descriptive and comparative scientific studies in the future. It is a call to action specifically to the medical arrhythmic community and its specialty societies (i.e., ISHNE, HRS, EHRA) to begin a quest to unravel the arrhythmic quagmire associated with "silent atrial fibrillation."
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Affiliation(s)
- Harold L Kennedy
- Cardiovascular Disease and Medicine University of South Florida, Tampa, FL
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198
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Charitos EI, Ziegler PD, Stierle U, Graf B, Sievers HH, Hanke T. Long-term outcomes after surgical ablation for atrial fibrillation in patients with continuous heart rhythm monitoring devices. Interact Cardiovasc Thorac Surg 2015; 21:712-21. [PMID: 26362625 DOI: 10.1093/icvts/ivv248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 07/31/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Surgical ablation for atrial fibrillation (AF) is an established therapy for the treatment of concomitant AF in cardiac surgery patients. We aim to present our prospective experience with 99 continuously monitored patients and investigate whether enhanced monitoring can identify patterns and factors influencing AF recurrence after surgical AF ablation. METHODS Ninety-nine patients (73 males; age: 68.0 ± 9.2 years) with documented preoperative AF (paroxysmal: 29; persistent: 18; long-lasting persistent: 52, mean preoperative duration: 46 ± 53 months) underwent concomitant biatrial surgical ablation (Cox Maze III: 29), full set left atrial cryoablation (n = 22), high-intensity focused ultrasound (HIFU) box lesion (n = 46) or right-sided ablation (n = 2). Postoperative rhythm disclosure was provided via an implantable device. Scheduled follow-up was performed quarterly (mean ± standard deviation: 1.75 ± 1.16 years, 173.7 patient-years). RESULTS The mean postoperative AF burden during the follow-up was 7 ± 19% (median: 0.2%). Seventy-one and 82 patients had AF burden <1% and <5%, respectively. The preoperative AF duration, preoperative ejection fraction, mitral valve surgery and HIFU in patients with more persistent AF were associated with statistically significant higher postoperative AF burdens. The pattern of AF recurrence during the 3-month blanking period was associated with the amount of later AF recurrence. CONCLUSIONS Continuous rhythm disclosure reveals that very small amounts of AF burden after surgical ablation are common. The preoperative duration of AF and the use of a box lesion only in patients with longer AF persistence history were independently associated with higher postoperative AF burden recurrence. The temporal AF pattern during the blanking period after ablation should be considered for further patient management and might serve as a prognostic factor.
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Affiliation(s)
| | | | - Ulrich Stierle
- Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany
| | - Bernhard Graf
- Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany
| | - Hans-Hinrich Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany
| | - Thorsten Hanke
- Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany
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199
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Gerstenfeld EP, Duggirala S. Atrial Fibrillation Ablation: Indications, Emerging Techniques, and Follow-Up. Prog Cardiovasc Dis 2015; 58:202-12. [DOI: 10.1016/j.pcad.2015.07.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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200
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Tutuianu C, Szilagy J, Pap R, Sághy L. Very Long-Term Results Of Atrial Fibrillation Ablation Confirm That This Therapy Is Really Effective. J Atr Fibrillation 2015; 8:1226. [PMID: 27957186 DOI: 10.4022/jafib.1226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/17/2015] [Accepted: 06/25/2015] [Indexed: 01/29/2023]
Abstract
Catheter ablation -in general- is a highly effective and "curative" intervention for a broad spectrum of supraventricular and ventricular arrhythmias. After a successful procedure eliminating a simple arrhythmia substrate, the recurrence rate is low and the short term success correlates well with the long term freedom from the arrhythmia.
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Affiliation(s)
- Cristina Tutuianu
- 2nd Department of Medicine and Cardiology Center, Electrophysiology Division, University of Szeged, Szeged Hungary
| | - Judit Szilagy
- 2nd Department of Medicine and Cardiology Center, Electrophysiology Division, University of Szeged, Szeged Hungary
| | - Robert Pap
- 2nd Department of Medicine and Cardiology Center, Electrophysiology Division, University of Szeged, Szeged Hungary
| | - László Sághy
- 2nd Department of Medicine and Cardiology Center, Electrophysiology Division, University of Szeged, Szeged Hungary
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