Impact of dense "smoke" detected on transesophageal echocardiography on stroke risk in patients with atrial fibrillation undergoing catheter ablation

Relationship of inflammatory indices with left atrial appendage thrombus or spontaneous echo contrast in patients with atrial fibrillation

BACKGROUND

Inflammatory indices derived from complete blood tests have been reported to be associated with poor outcomes in patients with atrial fibrillation (AF). The data about the relationship between inflammatory indices and left atrial appendage thrombus (LAAT) or dense spontaneous echo contrast (SEC) are limited.

AIM

To explore the value of inflammatory indices for predicting the presence of LAAT or dense SEC in nonvalvular AF patients.

METHODS

A total of 406 patients with nonvalvular AF who underwent transesophageal echocardiography were included and divided into two groups based on the presence (study group) or absence (control group) of LAAT or dense SEC. Inflammatory indices, including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR), were calculated from complete blood analysis. The associations of inflammatory indices with LAAT/dense SEC were analyzed using logistic regression.

RESULTS

LAAT and dense SEC were detected in 11 (2.7%) and 42 (10.3%) patients, respectively. The PLR only showed an association with LAAT/dense SEC in the univariate model. Elevated NLR (odds ratio [OR] = 1.48, 95% confidence interval [CI]: 1.11-1.98, P = 0.007) and reduced LMR (OR = 0.59, 95%CI: 0.41-0.83, P = 0.003) were found to be independent risk factors for the presence of LAAT/dense SEC. The areas under the NLR and LMR curves for predicting LAAT/dense SEC were 0.73 (95%CI: 0.66-0.80, P < 0.001) and 0.73 (95%CI: 0.65-0.81, P < 0.001), respectively, while the cutoff values were 2.8 (sensitivity: 69.8%; specificity: 64.0%) and 2.4 (sensitivity: 71.7%; specificity: 60.6%), respectively.

CONCLUSION

Increased NLR and decreased LMR may predict LAAT/dense SEC in patients with nonvalvular AF.

Freedom from atrial arrhythmia and other clinical outcomes at 5 years and beyond after catheter ablation of atrial fibrillation: a systematic review and meta-analysis

AIMS

Catheter ablation of atrial fibrillation (AF) is now a mainstream procedure although long-term outcomes are uncertain. We performed a systematic review and meta-analysis of procedural outcomes at 5 years and beyond.

METHODS AND RESULTS

We searched PubMed and Embase and after the screening, identified 73 studies (67 159 patients) reporting freedom from atrial arrhythmia, all-cause death, stroke, and major bleeding at ≥5 years after AF ablation. The pooled mean age was 59.7y, 71.5% male, 62.2% paroxysmal AF, and radiofrequency was used in 78.1% of studies. Pooled incidence of freedom from atrial arrhythmia at 5 years was 50.6% (95%CI 45.5-55.7%) after a single ablation and 69.7% [95%CI (confidence interval) 63.8-75.3%) after multiple procedures. The incidence was higher among patients with paroxysmal compared with non-paroxysmal AF after single (59.7% vs. 33.3%, p = 0.002) and multiple (80.8% vs. 60.6%, p < 0.001) ablations but was comparable between radiofrequency and cryoablation. Pooled incidences of other outcomes were 6.0% (95%CI 3.2-9.7%) for death, 2.4% (95%CI 1.4-3.7%) for stroke, and 1.2% (95%CI 0.8-2.0%) for major bleeding at 5 years. Beyond 5 years, freedom from arrhythmia recurrence remained largely stable (52.3% and 64.7% after single and multiple procedures at 10 years), while the risk of stroke and bleeding increased over time.

CONCLUSION

Nearly 70% of patients having multiple ablations remained free from atrial arrhythmia at 5 years, with the incidence slightly decreasing beyond this period. Risk of death, stroke, and major bleeding at 5 years were low but increased over time, emphasizing the importance of long-term thromboembolism prevention and bleeding risk management.

Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS-AF Score

Background Transesophageal echocardiography-guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. Methods and Results We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS-AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P>0.05). CHADS2VASc, though significant on univariate analysis (P<0.001), was not significant after adjustment (P=0.12). The novel CLOTS-AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m2), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752-0.887). The weighted CLOTS-AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. Conclusions The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.

Relation of a Filling Defect of Left Atrial Appendage by Contrast Computed Tomography Image With Subsequent Clinical Events in Patients With Atrial Fibrillation Receiving Catheter Ablation Procedures

Filling defect (FD) in left atrial appendage (LAA) is commonly observed in contrast computed tomography (CT) among patients with atrial fibrillation (AF), although its prognostic impact has not been well explored. We enrolled 1,019 consecutive patients who underwent AF ablation with baseline contrast CT images. FD in LAA was graded into 3 groups: grade 0 for complete filling (79.7%), grade 1 for incomplete filling (12.6%), and grade 2 for complete FD (7.8%). We evaluated the impact of the FD grade on the long-term clinical outcomes during the mean follow-up of 4.4 ± 2.0 years. Patients with grade 2 FD had higher prevalence of nonparoxysmal AF, higher brain natriuretic peptide level, and larger left atrial volume than those with grade 0 or 1 FD. The 5-year cumulative incidence of recurrent atrial tachyarrhythmias was higher in patients with grade 2 FD than those with grade 0 or 1 FD (74.0% vs 38.8% and 62.1%, log-rank p <0.001). The 5-year cumulative incidence of major adverse cardiovascular events (MACEs), defined as a composite of all-cause death, heart failure hospitalization, and ischemic stroke, was also significantly higher in patients with grade 2 FD (19.4% vs 5.6% and 9.5%, log-rank p <0.001). Follow-up CT images acquired in 87.1% of patients at median interval of 98 days showed significantly decreased FD (grade 1 in 4.5% and grade 2 in 2.1%, p <0.001). The residual grade 2 FD at follow-up was associated with significantly higher risk for subsequent MACEs. In conclusion, among patients with AF receiving catheter ablation, severe FD in LAA in contrast CT was associated with higher incidence of arrhythmia recurrence and MACEs during follow-up.

The Comparison of the Diagnostic Value of Left Atrial Pulmonary Vein Single-Phase and Dual-Phase Enhanced CT Scanning for Left Atrial Appendage Thrombosis and SEC in Patients with Atrial Fibrillation

Objective

The accuracy of left atrial pulmonary vein CT enhanced single-phase and dual-phase scanning in the detection of left atrial appendage (LAA) thrombosis and spontaneous echo contrast (SEC) before radio frequency ablation was compared in atrial fibrillation patients, so as to optimize the scanning scheme.

Methods

78 patients with atrial fibrillation who were admitted to Cangzhou Central Hospital from October 2020 to September 2021 and underwent bilateral enhanced CT scan of left atrial pulmonary vein and transesophageal echocardiography (TEE) examination for planned frequency ablation were selected. TEE results were used as the “gold standard” to compare the diagnostic efficacy of the first phase, second phase, and double-phase comprehensive mode of enhanced left atrial pulmonary vein CT in detecting left atrial thrombosis and SEC.

Results

The sensitivity, specificity, positive predictive value, and negative predictive value were 88.9%, 84.1%, 42.1%, and 98.3%, respectively, in the detection of left atrial thrombosis and SEC by the first phase of CT enhanced scan. The sensitivity, specificity, positive predictive value, and negative predictive value were 22.2%, 98.6%, 66.6%, and 90.7%, respectively, in the detection of left atrial thrombosis and SEC by the second phase of CT enhanced scan. The sensitivity, specificity, positive predictive value, and negative predictive value were 88.9%, 84.1%, 42.1%, and 98.3%, respectively, in the detection of left atrial thrombosis and SEC by the double-phase comprehensive mode of CT enhanced scan. There was no statistically significant difference in the accuracy of CT diagnosis of left atrial appendage thrombosis and SEC between the three modes of the first phase, the second phase, and the double-phase comprehensive CT (P > 0.05). The mean effective radiation dose of double-phase enhanced scan was 7.49 ± 1.02 mSv.

Conclusion

Single-phase enhanced CT scan of left atrial pulmonary vein can meet clinical requirements and significantly reduce the radiation dose compared with double-phase enhanced CT scan. Therefore, it is recommended as an initial screening examination for patients with atrial fibrillation before radiofrequency ablation.

The Prognostic Nutritional Index May Predict Left Atrial Appendage Thrombus or Dense Spontaneous Echo Contrast in Patients With Atrial Fibrillation

Objectives

The prognostic nutritional index (PNI) is an independent predictor of adverse outcomes in patients with cardiovascular diseases. The presence of left atrial appendage thrombus (LAAT) or spontaneous echo contrast (SEC) is associated with ischemic stroke. The present study aimed to investigate the relationship between the PNI and LAAT/dense SEC in patients with non-valvular atrial fibrillation (AF).

Methods

In patients with non-valvular AF, we compared demographics, clinical characteristics, and prevalence of LAAT/dense SEC according to the levels of the PNI. The relationship between the PNI and LAAT/dense SEC was observed.

Results

A total of 406 patients with non-valvular AF were consecutively included from March 2015 to February 2019. Of the study population, 53 patients had LAAT/dense SEC. The percentages of LAAT/dense SEC were 20.4, 14.1, and 4.5% in subjects from the lowest to the highest tertile of the PNI, respectively. Multivariate logistic analysis demonstrated that the PNI was an independent predictor for LAAT/dense SEC (OR 0.89; 95% CI, 0.82–0.97; P = 0.007). Receiver operating characteristic curve analysis revealed that the optimal cutoff value of the PNI for predicting LAAT/dense SEC was 48.0 (area under the curve: 0.68; 95% CI, 0.61–0.75; P &lt; 0.001). The sensitivity and specificity were 83.0 and 47.6%, respectively. The risk of LAAT/dense SEC in patients with a PNI ≤ 48.0 was 2.57-fold higher than that in those with a PNI &gt; 48.0.

Conclusion

The PNI, calculated based on serum albumin and lymphocyte count, was inversely correlated with LAAT/dense SEC in patients with non-valvular AF. Therefore, it may be considered a predictor for LAAT/dense SEC.

Left Atrial Spontaneous Echo Contrast and Ischemic Stroke in Patients Undergoing Percutaneous Left Atrial Appendage Closure

Objectives: Spontaneous echo contrast (SEC) in the left atrium (LA) is frequently observed in atrial fibrillation (AF) patients and may lead to thromboembolic events. We aimed to investigate both periprocedural and long-term stroke risks associated with LA SEC in AF patients undergoing percutaneous left atrial appendage closure (LAAC). Methods: A total of 408 consecutive AF patients treated with LAAC between March 2015 and February 2019 were divided into two groups based on preprocedural transesophageal echocardiography: the study group (moderate/severe LA SEC; n = 41) and the control group (none, mild, or mild to moderate LA SEC; n = 367). To attenuate the observed imbalance in baseline covariates, a propensity score matching technique was used. Results: No periprocedural stroke/transient ischemic attack (TIA) was documented. The incidence of device-related thrombus was higher in the study group than in the control group (8.8 vs. 1.3%; P = 0.025). The mean follow-up period was 3.2 ± 1.1 years, during which 8 patients (2.2%) in the control group and 4 (9.8%) in the study group experienced stroke/TIA (P = 0.024). Moderate/severe LA SEC was identified as an independent predictor of stroke/TIA in both the original population (HR = 5.71, 95% CI 1.47-22.19, P = 0.012) and the matched population (HR = 9.79, 95% CI 1.44-66.86, P = 0.020). Conclusions: LA SEC did not show a relationship with periprocedural stroke events in patients undergoing percutaneous LAAC. However, moderate/severe LA SEC increased the incidence of device-related thrombus and the risk of late stroke/TIA.

Clinical Risk Factors Associated with Ambulatory Outcome in Acute Ischemic Stroke Patients Smokers Treated with Thrombolytic Therapy

BACKGROUND

Patients who have suffered an acute ischemic stroke (AIS) and are smokers may have a better outcome following thrombolytic therapy when compared with non-smokers. While this finding is controversial, data on baseline clinical risk factors to predict treatment efficacy of thrombolytic therapy using ambulatory status in patients who suffered AIS and are smokers is not common.

METHODS

Between 2010 and 2016, retrospective data on patients who have suffered an AIS and received recombinant tissue plasminogen activator (rtPA) were obtained from Greenville health system registry. Assessment of clinical risk factors and the likelihood of an improvement in post-stroke ambulation among smokers and non-smokers was carried out using multivariate logistic regression.

RESULTS

Of 1001 patients, 70.8% were smokers and 29.2% non-smokers. Among the smokers and non-smokers, 74.6% and 84.6% improvement in ambulation respectively at discharge. The odds of improved ambulation decrease among smokers as age group increases compared to those below 50 [(60-69 years, aOR, 0.30, 95% C.I, 0.108-0.850, p < 0.05), (70-79 years aOR, 0.27, 95% C.I, 0.096-0.734, p < 0.05), (80+ years aOR, 0.16, 95% C.I, 0.057-0.430, P < 0.01). Patients with National Institute of Health Stroke Scale Score (NIHSS) score > 7 (reference <7) were 91% less likely to have improved ambulation among smokers and non-smokers (aOR, 0.09, 95% C.I, 0.055-0.155, P = 0.01), and (aOR, 0.08, 95% C.I, 0.027-0.214, P = 0.01) respectively. Atrial fibrillation was an independent predictor of decreased improvement in ambulation only among smokers (aOR, 0.58, 95% C.I, 0.356-0.928 P < 0.05).

CONCLUSION

Our findings suggest that elderly smokers with atrial fibrillation would benefit more from aggressive management of atrial fibrillation than non-smokers.

Gender differences in comorbidities and risk factors in ischemic stroke patients with a history of atrial fibrillation

BACKGROUND

Atrial Fibrillation (AF) is a common cardiac arrhythmia and has been identified as a major risk factor for acute ischemic stroke (AIS). Gender differences in the disease process, causative mechanisms and outcomes of AF have been investigated. In the current study, we determined whether there is a gender-based disparity in AIS patients with baseline AF, and whether such a discrepancy is associated with specific risk factors and comorbidities.

METHODS

Baseline factors including comorbidities, risk and demographic factors associated with a gender difference were examined using retrospective data collected from a registry from January 2010 to June 2016 in a regional stroke center. Univariate analysis was used to differentiate between genders in terms of clinical risk factors and demographics. Variables in the univariate analysis were further analyzed using logistic regression. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each factor were used to predict the increasing odds of an association of a specific comorbidity and risk factor with the male or female AIS with AF.

RESULTS

In the population of AIS patients with AF, a history of drug and alcohol use (OR = 0.250, 95% CI, 0.497-1.006, P = 0.016), sleep apnea (OR = 0.321, 95% CI, 0.133-0.777, P = 0.012), and higher serum creatinine (OR = 0.693, 95% CI, 0.542-0.886 P = 0.003) levels were found to be significantly associated with the male gender. Higher levels of HDL-cholesterol (OR = 1.035, 95% CI, 1.020-1.050, P < 0.001), LDL-cholesterol (OR = 1.006, 95% CI, 1.001-1.011, P = 0.012), and the inability to ambulate on admission to hospital (OR = 2.258, 95% CI, 1.368-3.727, P = 0.001) were associated with females.

CONCLUSION

Our findings reveal that in the AIS patients with atrial fibrillation, migraines, HDL, LDL and poor ambulation were associated with females, while drugs and alcohol, sleep apnea, and serum creatinine level were associated with male AIS patients with AF. Further studies are necessary to determine whether gender differences in risk factor profiles and commodities require consideration in clinical practice when it comes to AF as a risk factor management in AIS patients.

Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.