Digitalis therapy is associated with higher comorbidities and poorer prognosis in patients undergoing ablation of atrial arrhythmias: data from the German Ablation Registry

Mortality and rehospitalization in patients with pre-existing implantable pacemakers undergoing catheter ablation are related to increased comorbidity burden-data from the German Ablation Registry

BACKGROUND

Catheter ablation of atrial fibrillation and atrial flutter is routinely performed in patients with implantable devices. The aim of the present study was to assess success rates and potential complications in a large registry cohort of patients with cardiac pacemakers.

METHODS AND RESULTS

The German Ablation Registry is a nationwide, prospective registry with a 1-year follow-up investigating patients who underwent catheter ablation of supraventricular arrhythmias in 51 German centers. The present analysis focussed on the presence of cardiac pacemakers in 591 patients undergoing catheter ablation of atrial fibrillation or atrial flutter. These were compared to 7393 patients without a pacemaker. Patients with pacemakers were significantly older and presented more comorbidities like diabetes, renal failure, cardiovascular disease, or previous stroke. One-year mortality (2.4% vs. 1.3%, p = 0.022) and a combined endpoint of death, myocardial infarction, and stroke (3.6% vs. 2.1%, p = 0.014) were significantly elevated in patients with pacemakers. Re-hospitalization was also more common in patients with a pacemaker (53.3% vs. 45.0%, p < 0.01). After adjustment for important comorbidities, pre-existing pacemaker systems did not show any negative effect. Procedural success was reported in 98.8% vs. 98.4% (p = 0.93). Device-related complications were only observed in 0.4% of patients with pacemakers.

CONCLUSION

Patients with pacemaker systems undergoing catheter ablation of atrial fibrillation or atrial flutter demonstrate an increased risk of death, cardiovascular events, and re-hospitalization. This observation can be largely attributed to an older patient population and an increased rate of comorbidities.

The new European Society of Cardiology guideline for the management of cardiomyopathies: key messages for cardiac electrophysiologists

Electrocardiographic findings and arrhythmias are common in cardiomyopathies. Both may be an early indication of a specific diagnosis or may occur due to myocardial fibrosis and/or reduced contractility. Brady- and tachyarrhythmias significantly contribute to increased morbidity and mortality in patients with cardiomyopathies. Antiarrhythmic therapy including risk stratification is often challenging and plays a major role for these patients. Thus, an "electrophysiological" perspective on guidelines on cardiomyopathies may be warranted. As the European Society of Cardiology (ESC) has recently published a new guideline for the management of cardiomyopathies, this overview aims to present key messages of these guidelines. Innovations include a new phenotype-based classification system with emphasis on a multimodal imaging approach for diagnosis and risk stratification. The guideline includes detailed chapters on dilated and hypertrophic cardiomyopathy and their phenocopies, arrhythmogenic right ventricular cardiomyopathy, and restrictive cardiomyopathy as well as syndromic and metabolic cardiomyopathies. Patient pathways guide clinicians from the initial presentation to diagnosis. The role of cardiovascular magnetic resonance imaging and genetic testing during diagnostic work-up is stressed. Concepts of rhythm and rate control for atrial fibrillation have led to new recommendations, and the role of defibrillator therapy in primary prevention is discussed in detail. Whilst providing general guidelines for management, the primary objective of the guideline is to ascertain the disease etiology and disease-specific, individualized management.

Digitalis therapy in patients with ventricular tachyarrhythmias

Objective. The study sought to assess the prognostic value of treatment with digitalis on long-term prognosis in patients with ventricular tachyarrhythmias and atrial fibrillation (AF) and/or heart failure (HF). Background. Data regarding the outcome of digitalis therapy following ventricular tachyarrhythmias is limited. Methods. A large retrospective registry was used including consecutive patients with episodes of ventricular tachycardia (VT) or fibrillation (VF) from 2002 to 2015. Patients treated with digitalis were compared to patients without. The primary prognostic endpoint was all-cause mortality at 3 years, secondary endpoints comprised a composite arrhythmic endpoint (i.e. recurrences of ventricular tachyarrhythmias, appropriate implantable cardioverter defibrillator (ICD) therapies, sudden cardiac death) and cardiac rehospitalization. Kaplan Mayer survival curves, multivariable cox regression, and time trend analyses were applied for statistics. Results. Eight hundred and thirty-one patients were included (20% treated with digitalis and 80% without). At 3 years, digitalis treatment was not associated with all-cause mortality following ventricular tachyarrhythmias (24 vs. 21%, log-rank p = .736; HR = 1.063; 95% CI 0.746-1.515; p = .736). However, digitalis therapy was associated with an increased risk of the composite arrhythmic endpoint (38 vs. 23%; log-rank p = .001; HR = 1.719; 95% CI 1.279-2.311; p = .001) and cardiac rehospitalization (31 vs. 18%; log-rank p = .001; HR = 1.829; 95% CI 1.318-2.538; p = .001), which was still evident within multivariable Cox regression analyses. Finally, digitoxin may be associated with a worse prognosis than digoxin. Conclusion. Digitalis therapy was not associated with mortality in patients with ventricular tachyarrhythmias, but with increased risk of the composite arrhythmic endpoint and cardiac rehospitalization at 3 years.

[Atrial Flutter: up-to-date Problem Evaluation with Clinical Positions]

The review provides current ideas about the etiology and prevalence of atrial flutter (AF), mechanism and substrate of arrhythmogenesis, and principles of clinical and electrophysiological classification of this arrhythmia. Methods for conservative and surgical treatments of AF, including their comparative aspect, are described in detail. The review presented recent data on efficacy and potential risks of different approaches to reversing the arrhythmia. The authors indicated a need for early diagnosis and strict control of the sinus rhythm in AF, which would help a successful intervention not only to completely cure the existing arrhythmia but also to prevent other heart rhythm disorders, primarily atrial fibrillation.

Symptomatic arrhythmias after catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT): results from the German Ablation Registry

BACKGROUND

In atrioventricular nodal reentrant tachycardia (AVNRT), catheter ablation is considered as first-line therapy. Despite high success rates, some patients present with arrhythmia recurrence or develop other types of arrhythmias over time.

OBJECTIVE

To assess the incidence of symptomatic arrhythmias after initially successful AVNRT ablation and to analyze their clinical implications in a real-world cohort.

METHODS

We included 2,795 patients from the German Ablation Registry undergoing first ablation of AVNRT between 01/2007 and 01/2010. In patients alive at long-term follow-up, patient-specific characteristics and long-term follow-up data were compared between patients with (group A) and without (group B) any symptomatic arrhythmia during follow-up.

RESULTS

Symptomatic arrhythmias occurred in 17.2% of patients during a mean follow-up of 678 days after AVNRT ablation. The patients with symptomatic arrhythmias were more often female and suffered from structural heart disease. Arrhythmia occurrence was clinically relevant regarding symptoms and patient satisfaction. Serious adverse events including stroke, transient ischemic attack, pacemaker implantation, as well as continued use of antiarrhythmic medication occurred more often in group A. A second ablation procedure was performed in 26% of symptomatic patients to optimize the symptomatic outcome, whereas cardiovascular events or patient satisfaction were not further improved.

CONCLUSION

During long-term follow-up, one out of six patients experienced symptomatic arrhythmias after AVNRT ablation, associated with an increase of serious adverse events. A subset of patients required medical or interventional antiarrhythmic therapy, possibly attributable to the co-existence of other arrhythmias. Screening for arrhythmic and cardiac co-morbidity before and after ablation may support comprehensive therapy planning and outcome.