Corticosteroid use during pulmonary vein isolation is associated with a higher prevalence of dormant pulmonary vein conduction

The role of inflammation in the pathogenesis and treatment of arrhythmias

The pathogenesis of arrhythmias is complex and multifactorial. The role of inflammation in the pathogenesis of both atrial and ventricular arrhythmias (VA) has been explored. However, developing successful pharmacotherapy regimens based on those pathways has proven more of a challenge. This narrative review provides an overview of five common arrhythmias impacted by inflammation, including atrial fibrillation (AF), myocardial infarction, arrhythmogenic cardiomyopathy, cardiac sarcoidosis, and QT prolongation, and the potential role for anti-inflammatory therapy in their management. We identified arrhythmias and arrhythmogenic disease states with the most evidence linking pathogenesis to inflammation and conducted comprehensive searches of United States National Library of Medicine MEDLINE^® and PubMed databases. Although a variety of agents have been studied for the management of AF, primarily in an effort to reduce postoperative AF following cardiac surgery, no standard anti-inflammatory agents are used in clinical practice at this time. Although inflammation following myocardial infarction may contribute to the development of VA, there is no clear benefit with the use of anti-inflammatory agents at this time. Similarly, although inflammation is clearly linked to the development of arrhythmias in arrhythmogenic cardiomyopathy, data demonstrating a benefit with anti-inflammatory agents are limited. Cardiac sarcoidosis, an infiltrative disease eliciting an immune response, is primarily treated by immunosuppressive therapy and steroids, despite a lack of primary literature to support such regimens. In this case, anti-inflammatory agents are frequently used in clinical practice. The pathophysiology of arrhythmias is complex, and inflammation likely plays a role in both onset and duration, however, for most arrhythmias the role of pharmacotherapy targeting inflammation remains unclear.

Sequential versus optimized pulmonary vein isolation for paroxysmal atrial fibrillation: a pilot study

PURPOSE

We aimed to investigate whether the sequence of wide circumferential pulmonary vein isolation (PVI) ablation had an effect on the acute reconnection or long-term effectiveness in patients with paroxysmal atrial fibrillation (AF).

METHODS

One hundred consecutive paroxysmal AF patients, who were scheduled to accept PVI, were enrolled and randomized into two groups: (1) optimized group. Lesions were first applied to the anterior/posterior carina and the ridge between the left atrial (LA) appendage and the left pulmonary vein (PV). Then both circles were closed with continuous lesions. (2) Sequential group-continuous circular lesions were created counter-clockwise and started from the site of 6 o'clock. The primary endpoint was the freedom from non-blanking period recurrence of any atrial tachyarrhythmias lasting for 30 s or longer during the 1-year follow-up period after a single procedure. The secondary endpoint included safety endpoints, LA dwelling time, and fluoroscopy time/dose.

RESULTS

Forty-nine patients in the optimized group and 48 patients in the sequential group were available for analysis. There was no difference between the AF-free rate of the optimized group and the sequential group (75.5% vs. 72.9%, p = 0.7715). Cox regression analysis found that acute reconnection had the potential to predict long-term recurrence at 1 year (Risk ratio 2.175, p = 0.0818). Both groups had similar safety endpoints, LA dwelling time, and fluoroscopy time/dose.

CONCLUSIONS

Adjusting the ablation sequence of PVI by ablating the anterior/posterior carina and the ridge between the left PV and the LA appendage first did not improve 1-year AF-free rate for paroxysmal AF.

The Efficacy of Anti-inflammatory Agents in the Prevention of Atrial Fibrillation Recurrences

Several studies have indicated an association between inflammation and the recurrence of Atrial Fibrillation (AF), especially after ablation, which is a therapeutic option leading to local inflammation. On the other hand, each AF can lead to another AF, as a general rule. Thus, preventing recurrences of AF is extremely important for patient outcomes. In this paper, we attempted to review the effect of medicinal agents with anti-inflammatory properties on the prevention of AF recurrence. There are several randomized controlled trials (RCTs) and meta-analyses on the prevention of AF recurrence using agents with anti-inflammatory properties, which include steroids, colchicine, statins, and n-3 fatty acids (n-3 FA). Clinical trials evaluating the efficacy of anti-inflammatory drugs in preventing the recurrence of AF led to inconsistent results for corticosteroids, statins and n-3 FAs. These results may be related to the fact that inflammation is not the only factor responsible for triggering recurrences of AF. For example, the presence of structural, mechanical and electrical remodeling could potentially be the most important factors that trigger recurrences of AF but these factors have not been addressed in most of the reported studies. Therefore, future clinical trials are needed to compare the efficacy of anti-inflammatory drugs in AF patients with, or without other factors. For colchicine, a potent anti-inflammatory drug, there are limited studies. However, all the studies investigating colchicine in the context of AF were consistent and promising, especially when colchicine was used on a short-term basis following ablation in patients with paroxysmal AF. Therefore, colchicine could be a promising candidate for further clinical studies involving recurrent AF.

Incidence and predictors of postoperative nausea and vomiting in children undergoing electrophysiology ablation procedures

BACKGROUND

Postoperative nausea and vomiting remains a significant concern for patients undergoing general anesthesia for percutaneous radiofrequency catheter ablation and cryoablation for tachyarrhythmias.

AIM

Our objective was to examine the incidence and risk factors for nausea and vomiting in the recovery room.

METHODS

Children aged > 2 and ≤ 18 years who underwent general anesthesia for a percutaneous radiofrequency catheter ablation or cryoablation for a tachyarrhythmia between January 1, 2013, and January 1, 2016, were retrospectively reviewed. Outcomes included postoperative nausea, vomiting, and a composite of postoperative nausea and vomiting in the recovery room.

RESULTS

We identified 611 patients with a mean age of 13.3 ± 3.9 years, 54.5% male, and a mean length of anesthesia was 3.9 ± 1.0 hours. Vomiting or retching in the postanesthesia care unit occurred in 7.4% of patients and nausea in an additional 12.4%. A composite of nausea and vomiting occurred in 95 patients (15.5%). On multivariable analysis, a subhypnotic propofol infusion (OR 0.45, 95% CI 0.23-0.88, P = .019) and shorter anesthetic duration (OR 0.81 per 30 minutes, 95% CI 0.70-0.94, P = .006) were independently associated with less vomiting in the recovery room. A history of PONV (OR 2.24, 95% CI 1.24-4.05, P = .007) was independently associated with a composite of nausea and vomiting in the recovery room.

CONCLUSIONS

A shorter anesthetic time and a subhypnotic propofol infusion were predictive of a lower rate of postoperative vomiting in patients undergoing general anesthesia for electrophysiologic ablation procedures.

Steroids prevent early recurrence of atrial fibrillation following catheter ablation: a systematic review and meta-analysis

Previous studies have reported that steroids may reduce the risk of atrial fibrillation (AF) recurrence after catheter ablation, but data regarding this issue have been controversial. Therefore, we conducted a meta-analysis of randomized clinical trials (RCTs) and observational studies to ascertain the association of steroids and AF recurrence after ablation. PubMed, Embase, and Cochrane online databases were searched from inception to December 2017. The primary outcome of the meta-analysis was short-term or long-term AF recurrence following a single ablation procedure with or without the use of steroids. Both fixed- and random-effects models were used to calculate the overall effect estimates. Eight studies (four RCTs and four observational studies), with a total 992 patients, were included in the present study. Our meta-analysis shows that steroid use was associated with reduced AF occurrence at 3 months (odd ratio (OR) = 0.53, 95% confidence interval (CI) = 0.31–0.90, P=0.02) and 12–14 months (OR = 0.67, 95% CI = 0.47–0.95, P=0.02) after radiofrequency (RF) catheter ablation (RFCA). No clear benefit was observed for AF recurrence at 2–3 days, 1 or 24 months of follow-up. Steroid use was associated with decreased risk of early AF recurrence 3 and 12–14 months after ablation. No clear relationship was observed for 2–3 days, 1 and 24 months of follow-up and further data are needed to clarify these results.

Effect of corticosteroids on atrial fibrillation after catheter ablation: a meta-analysis. J Zhejiang Univ Sci B 2018;19:57-64. [PMID: 29308608 DOI: 10.1631/jzus.b1600529]

OBJECTIVE

The purpose of this meta-analysis was to explore the effect of corticosteroids on atrial fibrillation (AF) following catheter ablation.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for published articles describing the effect of corticosteroids in preventing AF recurrence after catheter ablation. Data on study and patient were extracted. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated by use of a random-effect model, and P values of <0.05 were considered significant.

RESULTS

Two randomized controlled trials (RCTs) and three cohort studies involving 846 patients were included in this meta-analysis. Within one month of catheter ablation, corticosteroid use was associated with a declined risk of recurrence of AF in RCT (RR 0.57, 95% CI 0.39 to 0.85, P=0.005), but without significant effect in cohort studies (RR 1.01, 95% CI 0.79 to 1.30, P=0.94). After three months of catheter ablation, corticosteroids did not have a significant effect in the prevention of late recurrence of AF in either RCT (RR 0.78, 95% CI 0.38 to 1.59, P=0.49) or cohort studies (RR 0.96, 95% CI 0.70 to 1.31, P=0.78).

CONCLUSIONS

Our meta-analysis suggested that periprocedural administration of corticosteroids of catheter ablation was associated with reduction of early but not late recurrence of AF.

Use of Oral Steroid and its Effects on Atrial Fibrillation Recurrence and Inflammatory Cytokines Post Ablation - The Steroid AF Study

Background

Use of corticosteroids before and after atrial fibrillation (AF) ablation can decrease acute inflammation and reduce AF recurrence.

Purpose

To assess the efficacy of oral prednisone in improving the outcomes of pulmonary vein isolation with radiofrequency ablation and its effect on inflammatory cytokine.

Methods

A total of 60 patients with paroxysmal AF undergoing radiofrequency ablation were randomized (1:1) to receive either 3 doses of 60 mg daily of oral prednisone or a placebo. Inflammatory cytokine levels (TNF-α, IL-1, IL6, IL-8) were measured at baseline, prior to ablation, immediately after ablation, and 24 hours post ablation. Patients underwent 30 day event monitoring at 3 months, 6 months and 12 months post procedure.

Results

Immediate post ablation levels of inflammatory cytokines were lower in the steroid group when compared to the placebo group; IL-6: 9.0 ±7 vs 15.8 ±13 p=0.031; IL-8: 10.5 ±9 vs 15.3 ±8; p=0.047 respectively. Acute PV reconnection rates during the procedure (7/23% vs 10/36%; p = 0.39), and RF ablation time (51±13 vs 56±11 min, p = 0.11) trended to be lower in the placebo group than the steroid group. There was no difference in the incidence of early recurrence of AF during the blanking period and freedom from AF off AAD at 12 months between both groups (5/17% vs 8/27%; p = 0.347 and 21/70% vs 18/60%; p=0.417 in placebo and steroid groups respectively).

Conclusion

Although oral corticosteroids have significant effect in lowering certain cytokines, it did not impact the clinical outcomes of AF ablation.

The relation between oxidative stress biomarkers and atrial fibrillation after pulmonary veins isolation

INTRODUCTION

The current paradigm claims a link between oxidative stress and atrial fibrillation. The aim of our research was to study a relation between the percentage of time spent in atrial fibrillation (AF burden) and concentrations of oxidative stress biomarkers, before and after pulmonary veins isolation (PVI).

METHODOLOGY

We included 19 patients (mean age 55±10years, 4 females and 15 males) with implanted loop recorders undergoing PVI. Plasmatic concentrations of advanced glycation end-products (AGEs), fructosamine, advanced oxidation protein products and thiobarbituric-acid reacting substances (TBARS) were measured and AF burden was recorded immediately before and 3months after the PVI. AF burden was also recorded 9months after the PVI.

RESULTS

Post procedural AGEs concentration significantly negatively correlated with AF burden after 3months (ρ=-0.63; p<0.01) and 9months (ρ=-0.5; p=0.04), respectively as well as TBARS concentration significantly negatively correlated with AF burden after 9months (ρ=-0.61; p=0.01).

CONCLUSION

Our study showed AGEs and TBARS to be potential predictors for AF burden after the PVI. We suppose that the more oxidative stress after the PVI is provoked, the more fibrotic tissue is produced. That means a better electrical isolation of pulmonary veins and consequently a lower AF burden.

Effect of Short-Term Steroid Therapy on Early Recurrence During the Blanking Period After Catheter Ablation of Atrial Fibrillation

BACKGROUND

Early recurrence (ER) of atrial tachyarrhythmias during the first 3 months (blanking period) after atrial fibrillation ablation can be highly symptomatic, often requiring emergency treatment. Short-term steroid therapy may suppress ER during the blanking period.

METHODS AND RESULTS

We prospectively enrolled 138 patients who were randomly assigned to 2 groups (steroid group and control group). An intravenous bolus of 0.5 mg/kg of methylprednisolone for 2 days followed by 12 mg daily of oral methylprednisolone for 4 days was given to the steroid group patients. The primary end point was ER during the blanking period (3 months post ablation). During the blanking period, 51 of the 138 (37.0%) patients experienced ER after atrial fibrillation ablation. The steroid group had a lower rate of ER than the control group (15/64 [23.4%] versus 36/74 [48.6%], P=0.003). There was no difference between the 2 groups about late recurrence during a 24-month follow-up (log-rank test, P=0.918). In a multivariate analysis, short-term steroid therapy was independently associated with a lower rate of ER during the blanking period (adjusted OR, 0.45; 95% confidence interval, 0.25-0.83; P=0.01).

CONCLUSIONS

Periprocedural short-term moderate intensity steroid therapy reduces ER (≈3 months) after catheter ablation of atrial fibrillation. It is not effective in preventing late (3≈24 m) atrial fibrillation recurrence.

CLINICAL TRIAL REGISTRATION

URL: www.who.int/ictrp; Unique identifier: KCT0000107.

Inflammation and the pathogenesis of atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia. However, the development of preventative therapies for AF has been disappointing. The infiltration of immune cells and proteins that mediate the inflammatory response in cardiac tissue and circulatory processes is associated with AF. Furthermore, the presence of inflammation in the heart or systemic circulation can predict the onset of AF and recurrence in the general population, as well as in patients after cardiac surgery, cardioversion, and catheter ablation. Mediators of the inflammatory response can alter atrial electrophysiology and structural substrates, thereby leading to increased vulnerability to AF. Inflammation also modulates calcium homeostasis and connexins, which are associated with triggers of AF and heterogeneous atrial conduction. Myolysis, cardiomyocyte apoptosis, and the activation of fibrotic pathways via fibroblasts, transforming growth factor-β and matrix metalloproteases are also mediated by inflammatory pathways, which can all contribute to structural remodelling of the atria. The development of thromboembolism, a detrimental complication of AF, is also associated with inflammatory activity. Understanding the complex pathophysiological processes and dynamic changes of AF-associated inflammation might help to identify specific anti-inflammatory strategies for the prevention of AF.