Procedural complications, rehospitalizations, and repeat procedures after catheter ablation for atrial fibrillation

Bleeding sites and treatment strategies for cardiac tamponade by catheter ablation requiring thoracotomy: risks of catheter ablation in patients with left atrial diverticulum

BACKGROUND

There is insufficient information regarding the bleeding sites and surgical strategies of cardiac tamponade during catheter ablation for atrial fibrillation (AF).

CASE PRESENTATION

Of the five patients with cardiac tamponade, three required surgical intervention and two required pericardiocentesis. In the first case of three cardiac tamponades requiring surgical intervention, considering that the peripheral route was used, the catecholamines did not reach the heart, and due to unstable vital signs, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was inserted. No bleeding point was identified, but a thrombus had spread around the left atrium (LA) with diverticulum. Hemostasis was achieved with adhesives placed around the LA under on-pump beating. In the second case, pericardiocentesis was performed, but the patient showed heavy bleeding and unstable vital signs. Thus, VA-ECMO was inserted. Heavy bleeding was expected, and safety was enhanced by attaching a reservoir to the VA-ECMO. The bleeding point was found between the left upper pulmonary artery and LA under cardiac arrest to obtain a good surgical view for suturing repair. In the third case, the LA diverticulum was damaged. Pericardiocentesis resulted in stable vitals, but sustained bleeding was present. A bleeding point was found at the LA diverticulum, and suture repair under on-pump beating was performed.

CONCLUSIONS

When cardiac tamponade occured in any patient with LA diverticulum, treatment could not be completed with pericardiocentesis alone, and thoracotomy was likely to be necessary. If the bleeding point could be confirmed, suturing technique is a more reliable surgical strategy than adhesive alone that leads to pseudoaneurysm. If the bleeding point is unclear, it is important to confirm the occurrence of LA diverticulum using a preoperative CT, and if confirmed, cover it with adhesive due to a high possibility of diverticulum bleeding. The necessity of CPB should be determined based on whether these operations can be completed while maintaining vital stability.

Respiratory control minimizes diaphragmatic contraction and dry cough during pulsed-field ablation of atrial fibrillation

AIMS

Pulsed-field ablation (PFA) is a promising new ablation modality to treat atrial fibrillation. However, PFA can cause varying degrees of diaphragmatic contraction and dry cough, especially under conscious sedation. This prospective study presents a method to minimize the impact of PFA on diaphragmatic contraction and dry cough during the procedure.

METHODS AND RESULTS

Twenty-eight patients underwent PFA for pulmonary vein (PV) and superior vena cava isolation under conscious sedation. Each patient received two groups of ablations in each vein: the control group allowed PFA application during any phase of respiratory cycle, while the test group used respiratory control, delivering PFA energy only at the end of expiration. A rating score system was developed to assess diaphragmatic contraction and dry cough. A total of 1401 control ablations and 4317 test ablations were performed. The test group had significantly lower scores for diaphragmatic contraction (P < 0.01) and dry cough (P < 0.001) in all PVs compared to the control group. The average relative reductions in scores for all PVs were 33-47% for diaphragmatic contraction and 67-83% for dry cough. The percentage of ablations with scores ≧2 for diaphragmatic contraction decreased significantly from 18.5-28.0% in the control group to 0.4-2.6% in the test group (P < 0.001). For dry cough, the percentage decreased from 11.9-43.7% in the control group to 0.7-2.1% in the test group.

CONCLUSION

Pulsed-field ablation application at the end of expiration can reduce the severity of diaphragmatic contraction and eliminate moderate and severe dry cough during PV isolation performed under conscious sedation.

Major in-hospital complications after catheter ablation of cardiac arrhythmias: individual case analysis of 43 031 procedures

AIMS

In-hospital complications of catheter ablation for atrial fibrillation (AF), atrial flutter (AFL), and ventricular tachycardia (VT) may be overestimated by analyses of administrative data.

METHODS AND RESULTS

We determined the incidences of in-hospital mortality, major bleeding, and stroke around AF, AFL, and VT ablations in four German tertiary centres between 2005 and 2020. All cases were coded by the G-DRG- and OPS-systems. Uniform code search terms were applied defining both the types of ablations for AF, AFL, and VT and the occurrence of major adverse events including femoral vascular complications, iatrogenic tamponade, stroke, and in-hospital death. Importantly, all complications were individually reviewed based on patient-level source records. Overall, 43 031 ablations were analysed (30 361 AF; 9364 AFL; 3306 VT). The number of ablations/year more than doubled from 2005 (n = 1569) to 2020 (n = 3317) with 3 times and 2.5 times more AF and VT ablations in 2020 (n = 2404 and n = 301, respectively) as compared to 2005 (n = 817 and n = 120, respectively), but a rather stable number of AFL ablations (n = 554 vs. n = 612). Major peri-procedural complications occurred in 594 (1.4%) patients. Complication rates were 1.1% (n = 325) for AF, 1.0% (n = 95) for AFL, and 5.3% (n = 175) for VT. With an increase in complex AF/VT procedures, the overall complication rate significantly increased (0.76% in 2005 vs. 1.81% in 2020; P = 0.004); but remained low over time. Following patient-adjudication, all in-hospital cardiac tamponades (0.7%) and strokes (0.2%) were related to ablation. Major femoral vascular complications requiring surgical intervention occurred in 0.4% of all patients. The in-hospital mortality rate adjudicated to be ablation-related was lower than the coded mortality rate: AF: 0.03% vs. 0.04%; AFL: 0.04% vs. 0.14%; VT: 0.42% vs. 1.48%.

CONCLUSION

Major adverse events are low and comparable after catheter ablation for AFL and AF (∼1.0%), whereas they are five times higher for VT ablations. In the presence of an increase in complex ablation procedures, a moderate but significant increase in overall complications from 2005-20 was observed. Individual case analysis demonstrated a lower than coded ablation-related in-hospital mortality. This highlights the importance of individual case adjudication when analysing administrative data.

Machine learning-based risk models for procedural complications of radiofrequency ablation for atrial fibrillation

BACKGROUND

Radiofrequency ablation (RFA) for atrial fibrillation (AF) is associated with a risk of complications. This study aimed to develop and validate risk models for predicting complications after radiofrequency ablation of atrial fibrillation patients.

METHODS

This retrospective cohort study included 3365 procedures on 3187 patients with atrial fibrillation at a single medical center from 2018 to 2021. The outcome was the occurrence of postoperative procedural complications during hospitalization. Logistic regression, decision tree, random forest, gradient boosting machine, and extreme gradient boosting were used to develop risk models for any postoperative complications, cardiac effusion/tamponade, and hemorrhage, respectively. Patients' demographic characteristics, medical history, signs, symptoms at presentation, electrocardiographic features, procedural characteristics, laboratory values, and postoperative complications were collected from the medical record. The prediction results were evaluated by performance metrics (i.e., the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, F score, and Brier score) with repeated fivefold cross-validation.

RESULTS

Of the 3365 RFA procedures, there were 62 procedural complications with a rate of 1.84% in the entire cohort. The most common complications were cardiac effusion/tamponade (28 cases, 0.83%), and hemorrhage (21 cases, 0.80%). There was no procedure-related mortality. The machine learning algorithms of random forest (RF) outperformed other models for any complication (AUC 0.721 vs 0.627 to 0.707), and hemorrhage (AUC 0.839 vs 0.649 to 0.794). The extreme gradient boosting (XGBoost) model outperformed other models for cardiac effusion/tamponade (AUC 0.696 vs 0.606 to 0.662).

CONCLUSIONS

The developed risk models using machine learning algorithms showed good performance in predicting complications after RFA of AF patients. These models help identify patients at high risk of complications and guiding clinical decision-making.

New horizons in the analysis of hospital readmissions of older adults

This short communication highlights analytical methods that can be usefully applied to the problem of hospital readmissions of older adults. The limitations of the models currently used in studies of hospital readmissions are described. In summary, analyses of hospital readmissions face two important methodological and statistical problems not accounted for by these currently used statistical models: the potential recurrence of readmissions, and death, a terminal event which absorbs the readmission process. Not addressing the issue raised by recurrent events and terminal event generates biased estimates. We discuss an approach for the analysis of hospital readmission risk and death in the same framework. Understanding the features of this kind of approaches is essential at a time when high-quality data on hospital readmission in older patients are becoming available to a large number of researchers. Models adapted for the analysis of recurrent and terminal events are presented, and their application to studies of hospital readmission are explained, with reference to two cohorts of several thousand older individuals.

Determinants of Atrial Fibrillation Progression and Its Influence on Overall Mortality in a Cohort of Patients From South India

BACKGROUND

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia associated with increased morbidity and mortality. However, factors influencing AF progression and their impact on all-cause mortality in South Indian patients remain poorly understood.

METHODS

We conducted a retrospective cohort study involving 500 individuals diagnosed with AF. Patient characteristics, including age, sex, and comorbidities, were collected. Left atrial diameter (LAD) and left ventricular ejection fraction (LVEF) were measured via echocardiography. Participants were followed for a median of three years. Cox proportional hazard regression was used to analyze factors associated with AF progression and all-cause mortality.

RESULTS

Of the participants, 60% exhibited persistent or permanent AF, and 40% had paroxysmal AF. The mean age was 63.5 ± 10.8 years, with 60% males and 40% females. Common comorbidities included hypertension (80%), diabetes (50%), and coronary artery disease (35%). The mean LAD was 42.3 ± 5.6 mm and the mean LVEF was 52.7 ± 6.8%; left atrial appendage thrombus (LAAT) was present in 15% of patients. Over the follow-up, 24% experienced all-cause mortality. Multivariate analysis revealed age, hypertension, diabetes, LAD, and LVEF as significant predictors of AF progression (p<0.05). Patients with persistent or permanent AF exhibited a higher risk of progression than those with paroxysmal AF (hazard ratio=1.74, 95% CI, 1.23-2.45). Age, hypertension, heart failure, and AF progression were independent predictors of all-cause mortality (p<0.05).

CONCLUSION

Our study identified age, hypertension, diabetes, LAD, and LVEF as independent predictors of AF progression. Additionally, age, hypertension, heart failure, and AF progression independently predicted all-cause mortality. These findings underscore the need for early detection and management of AF progression and comorbidities to improve outcomes in South Indian AF patients. Prospective studies with larger cohorts are warranted to confirm these findings and explore interventions to prevent AF progression and enhance patient outcomes.

Early mortality after inpatient versus outpatient catheter ablation in patients with atrial fibrillation

BACKGROUND

Rates of early mortality and complications after catheter ablation (CA) of atrial fibrillation (AF) vary across health care settings.

OBJECTIVE

The purpose of this study was to identify the rate and predictors of early mortality (within 30 days) after CA in the inpatient and outpatient settings.

METHODS

Using the Medicare Fee for Service database, we analyzed 122,289 patients who underwent CA for treatment of AF between 2016 and 2019 to define 30-day mortality in both inpatients and outpatients. Odds of adjusted mortality were assessed with several methods, including inverse probability of treatment weighting.

RESULTS

Mean age was 71.9 ± 6.7 years, 44% were women, and mean CHA2DS2-VASc score was 3.2 ± 1.7. Overall, 82% underwent AF ablation as an outpatient. Mortality rate 30 days after CA was 0.6%, with inpatients accounting for 71.5% of deaths (P <.001). Early mortality rates were 0.2% for outpatient procedures and 2.4% for inpatient procedures. The prevalence of comorbidities was significantly higher in patients with early mortality. Patients with early mortality had significantly higher rates of postprocedural complications. After adjustment, inpatient ablation was significantly associated with early mortality (adjusted odds ratio [aOR] 3.81; 95% confidence interval [CI] 2.87-5.08; P <.001). Hospitals with high overall ablation volume had 31% lower odds of early mortality (highest vs lowest tertile: aOR 0.69; 95% CI 0.56-0.86; P <.001).

CONCLUSION

AF ablation conducted in the inpatient setting is associated with a higher rate of early mortality compared with outpatient AF ablation. Comorbidities are associated with enhanced risk of early mortality. High overall ablation volume is associated with a lower risk of early mortality.

Epidemiology, Trends, Utilization Disparities, and Outcomes of Catheter Ablation and Its Association With Coronary Vasospasm Amongst Patients With Non-valvular Atrial Fibrillation: A Nationwide Burden of Last Decade

BACKGROUND

Catheter ablation (CA) is an important curative treatment for non-valvular atrial fibrillation (NVAF), however, nationwide data on its utilization and disparities is limited. Coronary vasospasm is a rare, life-threatening, peri-operative complication of CA with limited literature in Caucasians.

METHODS

We performed a retrospective study on adult hospitalizations in the USA from 2007 to 2017 by obtaining the data from National Inpatient Sample. The primary endpoints of our study were to identify the utilization rate of CA, disparities in utilization, and study the outcomes associated with CA. The secondary endpoints of the study were to identify the incidence of coronary vasospasm amongst patients who underwent CA, evaluate their association, and identify the predictors of coronary vasospasm.

RESULTS

From 35,906,946 patients with NVAF, 343641 (0.96%) underwent CA. Its utilization decreased from 1% in 2007 to 0.71% in 2017. Patients who underwent CA, compared to those without CA, fared better in terms of hospital length of stay, mortality rate, disability rate, and discharge to the non-home facility. Patients in the 50-75 years age group, Native Americans, those with private insurance, and median household income of 76-100th percentile were associated with higher odds of CA utilization. Urban teaching hospitals and large-bedded hospitals performed more ablations, while the Mid-West region fared lower than the South, the West, and the Northeast. The prevalence of coronary vasospasm was higher amongst CA in comparison without CA, however, in regression analysis, no significant association was demonstrated between CA and coronary vasospasm.

CONCLUSION

CA is an important treatment modality that is associated with improved clinical outcomes. Identification of factors associated with lower utilization of CA and its disparities will help to mitigate the burden associated with NVAF.

Procedure-Related Complications of Catheter Ablation for Atrial Fibrillation

BACKGROUND

Catheter ablation of atrial fibrillation (AF) is a commonly performed procedure. However, it is associated with potentially significant complications. Reported procedure-related complication rates are highly variable, depending in part on study design.

OBJECTIVES

The purpose of this systematic review and pooled analysis was to determine the rate of procedure-related complications associated with catheter ablation of AF using data from randomized control trials and to assess temporal trends.

METHODS

MEDLINE and EMBASE databases were searched from January 2013 to September 2022 for randomized control trials that included patients undergoing a first ablation procedure of AF using either radiofrequency or cryoballoon (PROSPERO, CRD42022370273).

RESULTS

A total of 1,468 references were retrieved, of which 89 studies met inclusion criteria. A total of 15,701 patients were included in the current analysis. Overall and severe procedure-related complication rates were 4.51% (95% CI: 3.76%-5.32%) and 2.44% (95% CI: 1.98%-2.93%), respectively. Vascular complications were the most frequent type of complication (1.31%). The next most common complications were pericardial effusion/tamponade (0.78%) and stroke/transient ischemic attack (0.17%). The procedure-related complication rate during the most recent 5-year period of publication was significantly lower than during the earlier 5-year period (3.77% vs 5.31%; P = 0.043). The pooled mortality rate was stable over the 2 time periods (0.06% vs 0.05%; P = 0.892). There was no significant difference in complication rate according to pattern of AF, ablation modality, or ablation strategies beyond pulmonary vein isolation.

CONCLUSIONS

Procedure-related complications and mortality rates associated with catheter ablation of AF are low and have declined in the past decade.

Hospital outcomes of patients receiving catheter ablation of atrial fibrillation, left atrial appendage closure, or both

BACKGROUND

Catheter ablation (CA) and left atrial appendage closure (LAAC) require transseptal access; combining both in a single procedure may have advantages. However, the safety of this approach has not been extensively studied. The objective of this study was to compare in hospital outcomes among patients receiving CA, LAAC, and combination of both treatments on the same day.

METHODS

We conducted a retrospective cohort analysis of the National Inpatient Sample database. The primary outcome was the presence of major adverse cardiovascular and cerebrovascular events (MACCE) during index hospitalization. Secondary outcomes included stroke, pericardial effusion, pericardiocentesis, and bleeding.

RESULTS

A total of 69,285 hospitalizations with AF were included in the analysis, of which 71.7% received LAAC, 27.8% received CA, and 0.5% received combination of both treatments on the same day. MACEE (OR, 1.63; 95% CI, 0.39-6.70), stroke (OR, 2.98; 95% CI, 0.55-16.01), pericardial effusion (OR, 0.33; 95% CI, 0.07-1.41), pericardiocentesis (OR, 1.00; 95% CI, 0.25-3.86), and bleeding (OR, 3.25; 95% CI, 0.87-12.07) did not differ significantly between CA and combination treatment. Similarly, MACCE (OR, 1.11; 95% CI, 0.28-4.41), stroke (OR, 1.03; 95% CI, 0.24-4.35), pericardial effusion (OR, 0.45; 95% CI, 0.11-1.90), pericardiocentesis (OR, 0.63; 95% CI, 0.14-2.83), and bleeding (OR, 2.04; 95% CI, 0.65-6.39) did not differ significantly between LAAC and combination treatment.

CONCLUSIONS

The combined approach is infrequently used in clinical practice (< 1%). However, major life-threatening adverse events did not differ between CA and LAAC when performed in isolation or combined in a single procedural stage on the same day.

Optimal Rhythm Control Strategy in Patients With Atrial Fibrillation

In the recent EAST-AFNET 4 trial, early rhythm control reduced the risk of adverse cardiovascular events compared with usual care in patients recently diagnosed as atrial fibrillation (AF). Recent observational studies from Korean nationwide claim data confirmed and extended the findings from controlled trials. The beneficial effect of rhythm control on cardiovascular outcomes was not obvious in those who had been diagnosed with AF more than 1 year ago. Especially, early initiation of rhythm control was related to the lower risk of stroke and hospitalization due to heart failure. Finally, early rhythm control treatment was also effective in patients with asymptomatic AF but less effective in older adults. Therefore, in patients with AF, rhythm control should be considered at the earliest stage, regardless of symptom.

For almost 20 years, data regarding the effect of rhythm control therapy for atrial fibrillation (AF) on cardiovascular prognosis in comparison with rate control therapy has not been conclusive. The safety of rhythm control and anticoagulation therapy has generally improved. Recently, it was revealed that a rhythm-control strategy reduced the risk of adverse cardiovascular events than usual rate control in patients with recent AF (diagnosed within 1 year). Within 1 year after the AF diagnosis, early initiation of rhythm control led to more favorable cardiovascular outcomes than rate control. Early rhythm control reduced the risks of stroke and heart failure-related admission than rate control. Moreover, rhythm control was associated with lower dementia risk than rate control. Finally, early rhythm control treatment was also effective in patients with asymptomatic AF but less effective in older adults. Therefore, in patients with AF, rhythm control should be considered at earlier stages, regardless of symptom.

Detection of the origin of atrial tachycardia by 3D electro-anatomical mapping and treatment by radiofrequency catheter ablation in horses

BACKGROUND

Atrial tachycardia (AT) can be treated by medical or electrical cardioversion but the recurrence rate is high. Three-dimensional electro-anatomical mapping, recently described in horses, might be used to map AT to identify a focal source or reentry mechanism and to guide treatment by radiofrequency ablation.

OBJECTIVES

To describe the feasibility of 3D electro-anatomical mapping and radiofrequency catheter ablation to characterize and treat sustained AT in horses.

ANIMALS

Nine horses with sustained AT.

METHODS

Records from horses with sustained AT referred for radiofrequency ablation at Ghent University were reviewed.

RESULTS

The AT was drug resistant in 4 out of 9 horses. In 8 out of 9 horses, AT originated from a localized macro-reentrant circuit (n = 5) or a focal source (n = 3) located at the transition between the right atrium and the caudal vena cava. In these 8 horses, local radiofrequency catheter ablation resulted in the termination of AT. At follow-up, 6 out of 8 horses remained free of recurrence.

CONCLUSIONS AND CLINICAL IMPORTANCE

Differentiation between focal and macro-reentrant AT in horses is possible using 3D electro-anatomical mapping. In this study, the source of right atrial AT in horses was safely treated by radiofrequency catheter ablation.

Outcomes in patients experiencing complications associated with atrial fibrillation ablation: Data from the German Ablation Registry

BACKGROUND

This study aims to report on the clinical and patient-reported outcomes in patients undergoing atrial fibrillation (AF) ablation with moderate or severe complications.

METHODS

The prospective, multicentre German Ablation Registry of patients undergoing catheter ablation was studied to compare outcomes of patients with moderate or severe complications (group I) and patients without or minor complications (group II).

RESULTS

A total of 3865 patients (group I = 158, group II = 3707) were included in this analysis. Procedural success (92.4% vs 96.1%, p = 0.019) was lower and arrhythmia recurrence before discharge significantly higher in group I (15.8% vs 6.5%, p < 0.001). Hospital stays were longer in in group I (6 days vs 3 days, p < 0.001). The in-hospital rate of death, myocardial infarction (MI) or stroke was 6.4% in group I. Age was an independent predictor of in-hospital complications (HR1.43, 95% CI 1.18-1.72). In the 1-year follow-up, the composite outcome of death, MI, stroke, or major bleeding (8.5% vs 1.5%, p < 0.001) was significantly higher in group I. The majority of patients were still feeling safe during treatment regardless of occurred complications (88.4% vs 94.0%, p = 0.14) and would choose the same centre again in most cases (90.7% vs 92.9%, p = 0.59). Patients reported no or improved symptoms in both cohorts (77.3% vs 78.6%) without significant differences.

CONCLUSION

Cardiovascular events in patients with severe complications are more common but patient satisfaction and symptomatic relief are high and comparable to those without complications.

Efficacy and safety of same-day discharge after atrial fibrillation ablation compared with post-procedural overnight stay: a systematic review and meta-analysis

AIMS

Catheter ablation for atrial fibrillation (AF) has historically required inpatient admission post-procedure, but same-day discharge (SDD) has recently been reported. We aimed to assess the efficacy and safety of SDD compared with overnight stay (OS) post-ablation.

METHODS AND RESULTS

We performed a systematic search of the PubMed database. Random-effects meta-analysis was performed to assess the efficacy (successful SDD) and safety (24 h complications, 30-day complications, 30-day re-admissions, and 30-day mortality) of a SDD AF ablation strategy. Fourteen non-randomized observational studies met criteria for inclusion, encompassing 26488 patients undergoing AF ablation, of whom 9766 were SDD. The mean age of participants was 61.9 years, and 67.9% were male. Around 61.7% underwent ablation for paroxysmal AF. The pooled success rate of SDD was 83.2% [95% confidence intervals (CIs): 61.5-97.0%, I2 100%]. The risk of bias was severe for all effect estimates due to confounding, as most cohorts were retrospectively identified without appropriately matched comparators. There was no significant difference in 30-day complications [odds ratio (OR): 0.95, 95% CI: 0.65-1.40, I2 53%] or 30-day re-admission (OR 0.96, 95% CI: 0.49-1.89, I2 82%) between groups. There were insufficient data for meta-analysis of 24 h complications and 30-day mortality. Where reported, no re-admissions occurred due to 24 h complications after SDD. Two deaths (0.04%) were reported in both SDD and OS groups.

CONCLUSION

Same-day discharge after AF ablation appears to be an effective and safe strategy in selected patients. However, the available evidence is of low quality, and more robust prospective studies comparing SDD to OS are needed.

Atrial fibrillation ablation with advanced radiofrequency catheter versus second-generation cryoballoon catheter

Aim: To compare cost and readmissions among atrial fibrillation (AF) patients undergoing ablation using the THERMOCOOL SMARTTOUCH™ SF (STSF) radiofrequency catheter versus the Arctic Front Advance™ (AFA) cryoballoon catheter. Patients & methods: The Premier Healthcare Database was used for the study purposes. Propensity score matching was used to match patients in the two groups. Costs and readmissions were assessed. A regression model was used for outcome assessment. Results: After propensity matching, 2767 patients were identified in each of the STSF and AFA cohorts. In the matched cohort, STSF patients had significantly lower supply costs than AFA patients. STSF patients had significantly lower 4-12-month AF-related inpatient readmissions compared with AFA patients (2.58% vs 3.99%; p = 0.0402). Costs of care summing index procedure and readmission costs were also lower for the STSF patients versus AFA patients. Conclusions: Patients who underwent AF ablation using the STSF catheter versus the AFA catheter had lower cost and AF-related readmissions.

Age and Outcomes of Early Rhythm Control in Patients With Atrial Fibrillation: Nationwide Cohort Study

OBJECTIVES

This study sought to investigate whether the effects of early rhythm control differ according to age.

BACKGROUND

Rhythm control, compared with usual care among patients recently diagnosed with atrial fibrillation (AF), was found to be associated with a lower risk of adverse cardiovascular outcomes. It is unclear whether the results can be generalized for older adults.

METHODS

This retrospective population-based cohort study included 31,220 patients with AF, from the Korean National Health Insurance Service database, undergoing rhythm control (antiarrhythmic drugs or ablation) or rate control therapy, initiated within 1 year of AF diagnosis. A composite outcome of cardiovascular death, ischemic stroke, hospitalization for heart failure, or myocardial infarction was compared in subgroups stratified by age.

RESULTS

Compared with rate control, early rhythm control was associated with a lower risk of the primary composite outcome in patients <75 years of age (HR: 0.80; 95% CI: 0.72-0.88). The protective association between early rhythm control and cardiovascular outcomes exhibited a linear decrease with advancing age, with declined benefits in patients ≥75 years of age (HR: 0.94; 95% CI: 0.87-1.03; P_interaction = 0.045). Trends toward lower risks of ischemic stroke (HR: 0.78; 95% CI: 0.67-0.90) and acute myocardial infarction (HR: 0.63; 95% CI: 0.41-0.97) were observed in the older adults. No significant differences in safety outcomes were found across different ages.

CONCLUSIONS

The beneficial association of early rhythm control with cardiovascular outcomes was attenuated with increasing age, with the larger benefits in younger patients <75 years of age. No differences were found by age in treatment-related safety outcomes.

The impact of hospital case volume on the outcomes after catheter ablation for atrial fibrillation according to the ablation technology

INTRODUCTION

The appropriate hospital case volume for catheter ablation (CA) in patients with atrial fibrillation (AF) according to the ablation technology has not been fully examined. This study aimed to investigate the association between the hospital case volume for AF and periprocedural complications and AF recurrence.

METHODS

In this retrospective cohort study, we used data from the National Database of Health Insurance Claims and Specific Health Checkups, which covers almost all healthcare insurance claims data in Japan. We included patients with AF who underwent first-time CA from April 2014 to March 2020. Using mixed-effect logistic regression, we analyzed the effect of the annual case volume for AF ablation on acute periprocedural complications and 1-year success rate off antiarrhythmic drugs according to the ablation technology (radiofrequency ablation or cryoballoon ablation).

RESULTS

Among 270 116 patients, 207 839 (77%) patients underwent radiofrequency ablation and 56 648 (21%) patients underwent cryoballoon ablation. Of all patients, acute complications occurred in 5411 (2.0%) patients, and the recurrence at 1 year was 71 511 (27%). In the radiofrequency ablation group, acute complications and 1-year AF recurrence according to case volume decreased as the annual case volume increased to up to 150-200 cases/year. However, in the cryoballoon ablation group, these outcomes were similar regardless of the case volumes.

CONCLUSION

The case-volume effect was noted in the radiofrequency ablation group, but not in the cryoballoon ablation group. Our results may affect the selection of ablation technology, especially in smaller case-volume hospitals.

Catheter Ablation for Hospitalized Atrial Fibrillation Patients with Reduced Systolic Function: Analysis of Inpatient Mortality, Resource Utilization and Complications

Background

Randomized trials have shown improvement in hard clinical end points when catheter ablation (CA) is employed as a management strategy for certain atrial fibrillation (AF) patients with heart failure and reduced ejection fraction (HFrEF). Limited data, however, exist in this realm outside the controlled clinical trial settings. We sought to determine real-world data on mortality and complications after utilization of CA in such patients.

Methods and Results

Data were derived from National Inpatient Sample from January 2008 to August 2015. Patients were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Baseline characteristics and outcomes were compared among HFrEF and AF patients undergoing CA or not. Propensity matching was done to mitigate selection bias and balance confounding variables. Various CA related complications were assessed. Logistic regression was done to determine predictors of mortality in our study cohort. A total of 2,569,919 patients were analyzed and a total of 7773 patients underwent CA. Mortality was significantly better in CA group in both unmatched (1.2% vs. 4.9%, p < 0.01) and propensity matched cohorts (1.2% vs. 3.6%, p < 0.01). Overall complication rate was 10.2% in CA cohort and primarily driven by cardiac and neurological etiologies. In regression analysis, CA remained a strong predictor of reduced mortality (OR 0.301, 95% CI 0.184-0.494).

Conclusions

CA is associated with improved mortality in admitted AF patients with concomitant HFrEF. Overall complication rate after CA was modest at 10.2%. Consideration can be given to the utilization of this therapeutic modality in hospitalized AF patients with concomitant HFrEF.

Same-Day Versus Next-Day Discharge Strategies for Left Atrial Ablation Procedures: A Parallel, Intra-Institutional Comparison of Safety and Feasibility

Background

Head-to-head comparative data for the postoperative care of patients undergoing left atrial ablation procedures are lacking.

Objective

We sought to investigate complication and readmission rates between patients undergoing same-day (SD) or next-day (ND) discharges for ablative procedures in the left atrium, primarily atrial fibrillation (AF).

Methods

Two electrophysiology centers simultaneously perform left atrial ablations with differing discharge strategies. We identified all patients who underwent left atrial ablation from August 2017 to August 2019 (n = 409) undergoing either SD (n = 210) or ND (n = 199) discharge protocols. We analyzed any clinical events that resulted in procedural abortion, extended hospitalization, or readmission within 72 hours.

Results

The primary endpoint of complication and readmission rate was similar between SD and ND discharge (14.3% vs 12.6%, p = 0.665). Rates of complications categorized as major (2.4% vs 3.0%, p = 0. 776) and minor (11.9% vs 9.5%, p = 0.524) were also similar.Multivariable regression modeling revealed no significant correlation between discharge strategy and complication/readmission occurrence (OR 1.565 [0.754 - 3.248], p = 0.23), but a positive association of hypertension and procedure duration (OR 3.428 [1.436 - 8.184], p = 0.006) and (OR 1.01 [1 - 1.019], p = 0.046) respectively.

Conclusions

Left atrial ablation complication and readmission rates were similar between SD and ND discharge practices. Hypertension and procedural duration were associated with increased complication rates irrespective of discharge strategy. These data, which represent the first side-by-side comparison of discharge strategy, suggests same-day discharge is safe and feasible for left atrial ablation procedures.

The 30-day readmission rate of same-day discharge protocol following catheter ablation for atrial fibrillation: a propensity score-matched analysis from National Readmission Database

AIMS

The effectiveness and safety of same-day discharge (SDD) for catheter ablation (CA) for atrial fibrillation (AF) has not been fully elucidated using a large nationwide database. This study aimed to evaluate the all-cause readmission rates within 30-days among patients receiving CA for AF with an SDD protocol compared with a conventional overnight stay (ONS).

METHODS AND RESULTS

We performed a retrospective cohort study using the US Nationwide Readmission Database. The primary outcome was all-cause 30-day readmission following discharge in patients receiving CA and a secondary outcome was requiring total healthcare cost. A 1 : 3 propensity score matching was conducted to compare the safety and efficacy within both SDD and ONS group. Among 30 776 patients [mean 67.2 ± 11.4 years, 12 590 female (41.5%)] who received CA from 2016 through 2018, 440 (1.42%) patients were discharged on the same-day following CA (SDD group), and the remaining 30 336 patients stayed at least one night in the hospital (ONS group). A propensity score analysis generated 1751 matched pairs (440 in the SDD group; 1311 in the ONS group). The 30-day readmission following discharge was not significantly higher in the SDD group than the ONS group (SDD vs. ONS: 12.7% vs. 9.7%; hazard ratio: 1.17, 95% confidence interval: 0.76-1.81, P = 0.47). Healthcare cost was significantly higher in the ONS group ($25 237 ± 14 036 vs. $30 749 ± 16 383; P < 0.01).

CONCLUSION

In this nationwide database study, there was no significant difference in the all-cause 30-day readmission following SDD for CA compared with ONS.

Efficacy and Safety of Nepcell STM in Achieving Hemostasis After Removal of a 15-Fr Femoral Venous Sheath in Patients Undergoing Cryoballoon Ablation for Atrial Fibrillation

Background: Hemostasis at the femoral venous access site after cryoballoon ablation (CA) for atrial fibrillation (AF) is often prolonged because of aggressive anticoagulation and the use of 15-Fr-caliber sheaths. The Nepcell S^TM (NC) is a newly developed hemostatic pad made of fibrosed calcium alginate extracted from natural seaweed. The calcium ions from the NC accelerate the clotting cascade. This single-center randomized clinical trial assessed the efficacy and safety of the NC in patients undergoing CA for AF.

Methods and Results: In all, 62 patients undergoing CA for non-valvular paroxysmal AF were randomly assigned to either the NC or control group. The primary endpoints of this study were time to hemostasis, internal hemorrhage, and rebleeding. Secondary endpoints were the length of hospital stay (LOS) and vascular complications at 1 month. The time to hemostasis was significantly shorter in NC than control group (mean [±SD] 377±216 vs. 505±241 s; P=0.031). The frequency of internal hemorrhaging (6% vs. 37%; P=0.003) and rebleeding (0% vs. 13%; P=0.033) was lower in the NC than control group, contributing to a decreased LOS in the NC group (3.56±0.67 vs. 4.23±0.73 days; P<0.001). There were no NC-related vascular complications at the 1-month echographic examination.

Conclusions: The use of NC was associated with a shorter hemostasis time and fewer bleeding complications in patients undergoing CA for AF, leading to a shorter LOS.

Antiarrhythmic drug therapy after catheter ablation for atrial fibrillation-Insights from the German Ablation Registry

Data on the optimal treatment strategy for antiarrhythmic drug therapy (AAD) after catheter ablation for atrial fibrillation (AF) are inconsistent. The present study investigates whether postinterventional AAD leads to an improved long-term outcome. Patients from the prospective German Ablation Registry (n = 3275) discharged with or without AAD after catheter ablation for AF were compared regarding the rates of recurrences, reablations and cardiovascular events as well as patient reported outcomes during 12 months follow-up. In patients with paroxysmal AF (n = 2138) the recurrence rate did not differ when discharged with (n = 1051) or without (n = 1087) AAD (adjusted odds ratio (OR) 1.13, 95% confidence interval (CI) [0.95-1.35]). The reablation rate was higher and reduced treatment satisfaction was reported more often in those discharged with AAD (reablation: OR 1.30, 95% CI [1.05-1.61]; reduced treatment satisfaction: OR 1.76, 95% CI [1.20-2.58]). Similar rates of recurrences, reablations and treatment satisfaction were found in patients with persistent AF (n = 1137) discharged with (n = 641) or without (n = 496) AAD (recurrence: OR 1.22, 95% CI [0.95-1.56]; reablation: OR 1.21, 95% CI [0.91-1.61]; treatment satisfaction: OR 1.24, 95% CI [0.74-2.08]). The incidence of cardiovascular events and mortality did not differ at follow-up in patients discharged with or without AAD. In conclusion, the rates of recurrences, cardiovascular events and mortality did not differ between patients discharged with or without AAD after AF catheter ablation. However, AAD should be considered carefully in patients with paroxysmal AF, in whom it was associated with a higher reablation rate and reduced treatment satisfaction. Clinical trial registration: The trial has been registered under the number NCT01197638.

Sex Differences in Ablation Strategy, Lesion Sets, and Complications of Catheter Ablation for Atrial Fibrillation: An Analysis From the GWTG-AFIB Registry

BACKGROUND

When presenting for atrial fibrillation (AF) ablation, women, compared with men, tend to have more nonpulmonary vein triggers and advanced atrial disease. Whether this informs differences in AF ablation strategy is not well described. We aimed to characterize ablation strategy and complications by sex, using the Get With The Guidelines-AF registry.

METHODS

From the Get With The Guidelines-AF registry ablation feature, we included patients who underwent initial AF ablation procedure between January 7, 2016, and December 27, 2019. Patients were stratified based on AF type (paroxysmal versus nonparoxysmal) and sex. We compared patient demographics, ablation strategy, and complications by sex.

RESULTS

Among 5356 patients from 31 sites who underwent AF ablation, 1969 were women (36.8%). Women, compared with men, were older (66.8±9.6 versus 63.4±10.6, P<0.0001) and were more likely to have paroxysmal AF (59.4% versus 49.5%, P<0.0001). In women with nonparoxysmal AF, left atrial linear ablation was more frequent (roof line: 53.9% versus 45.3%, P=0.0002; inferior mitral isthmus line: 10.2% versus 7.0%, P=0.01; floor line: 46.1% versus 40.6%, P=0.02) than in men. In multivariable analysis, the association between patient sex and complications from ablation was not statistically significant.

CONCLUSIONS

In this US wide AF ablation quality improvement registry, women with nonparoxysmal AF were more likely to receive adjunctive lesion sets compared with men. These findings suggest that patient sex may inform ablation strategy in ways that may not be strongly supported by evidence and emphasize the need to clarify optimal ablation strategies by sex.

Relationship between procedural volume and complication rates for catheter ablation of atrial fibrillation: a systematic review and meta-analysis

AIMS

There are conflicting data as to the impact of procedural volume on outcomes with specific reference to the incidence of major complications after catheter ablation for atrial fibrillation. Questions regarding minimum volume requirements and whether these should be per centre or per operator remain unclear. Studies have reported divergent results. We performed a systematic review and meta-analysis of studies reporting the relationship between either operator or hospital atrial fibrillation (AF) ablation volumes and incidence of complications.

METHODS AND RESULTS

Databases were searched for studies describing the relationship between operator or hospital AF ablation volumes and incidence of complications which were published prior to 12 June 2020. Of 1593 articles identified, 14 (315 120 patients) were included in the meta-analysis. Almost two-thirds of the procedures were performed in low-volume centres. Both hospital volume of ≥50 and ≥100 procedures/year were associated with a significantly lower incidence of complications compared to <50/year (4.2% vs. 5.5%, OR = 0.58, 95% CI 0.50-0.66, P < 0.001) or <100/year (5.5% vs. 6.2%, OR = 0.62, 95% CI 0.53-0.73, P < 0.001), respectively. Hospitals performing ≥50 procedures/year demonstrated significantly lower mortality compared with those performing <50 procedures/year (0.16% vs. 0.55%, OR = 0.33, 95% CI 0.26-0.43, P < 0.001). A similar relationship existed between proceduralist volume of <50/year and incidence of complications [3.75% vs. 12.73%, P < 0.001; OR = 0.27 (0.23-0.32)].

CONCLUSION

There is an inverse relationship between both hospital and proceduralist AF ablation volume and the incidence of complications. Implementation of minimum hospital and operator AF ablation volume standards should be considered in the context of a broader strategy to identify AF ablation Centers of Excellence.

Contemporary trends and in-hospital outcomes of catheter and stand-alone surgical ablation of atrial fibrillation

AIMS

The contemporary trends in catheter ablation (CA) and surgical ablation (SA) utilization and surgical techniques [open vs. thoracoscopic, with or without left atrial appendage closure (LAAC)] are unclear. In addition, the in-hospital outcomes of stand-alone SA compared with CA are not well-described.

METHODS AND RESULTS

The National Inpatient Sample 2010-18 was queried for atrial fibrillation (AF) hospitalizations with CA or stand-alone SA. Complex samples multivariable logistic and linear regression models were used to compare the association between stand-alone SA vs. CA and the primary outcomes of in-hospital mortality and stroke. Of 180 243 hospitalizations included within the study, 167 242 were for CA and 13 000 were for stand-alone SA. Catheter ablation and stand-alone SA hospitalizations decreased throughout the study period (Ptrend < 0.001). Surgical ablation had higher rates of in-hospital mortality [adjusted odds ratio (aOR) 2.26; 95% confidence interval (CI) 1.41-3.61; P = 0.001] and stroke (aOR 4.64; 95% CI 3.25-6.64; P < 0.001) compared with CA. When examining different surgical approaches, thoracoscopic SA was associated with similar in-hospital mortality (aOR 1.53; 95% CI 0.60-3.89; P = 0.369) and similar risk of stroke (aOR 1.75; 95% CI 1.00-3.07; P = 0.051) compared with CA.

CONCLUSION

Stand-alone SA comprises a minority of AF ablation procedures and is associated with increased risk of mortality, stroke, and other in-hospital complications compared to CA. However, when a thoracoscopic approach was utilized, the risks of mortality and stroke appear to be reduced.

Cost-Utility of Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure: An Economic Evaluation

Background Recent trials comparing catheter ablation to medical therapy in patients with heart failure (HF) with symptomatic atrial fibrillation despite first-line management have demonstrated a reduction in adverse outcomes. We performed an economic evaluation to estimate the cost-utility of catheter ablation as second line therapy in patients with HF with reduced ejection fraction. Methods and Results A Markov model with health states of alive, dead, and alive with amiodarone toxicity was constructed, using the perspective of the Canadian healthcare payer. Patients in the alive states were at risk of HF and non-HF hospitalizations. Parameters were obtained from randomized trials and Alberta health system data for costs and outcomes. A lifetime time horizon was adopted, with discounting at 3.0% annually. Probabilistic and 1-way sensitivity analyses were performed. Costs are reported in 2018 Canadian dollars. A patient treated with catheter ablation experienced lifetime costs of $64 960 and 5.63 quality-adjusted life-years (QALY), compared with $49 865 and 5.18 QALYs for medical treatment. The incremental cost-effectiveness ratio was $35 360/QALY (95% CI, $21 518-77 419), with a 90% chance of being cost-effective at a willingness-to-pay threshold of $50 000/QALY. A minimum mortality reduction of 28%, or a minimum duration of benefit of >1 to 2 years was required for catheter ablation to be attractive at this threshold. Conclusions Catheter ablation is likely to be cost-effective as a second line intervention for patients with HF with symptomatic atrial fibrillation, with incremental cost-effectiveness ratio $35 360/QALY, as long as over half of the relative mortality benefit observed in extant trials is borne out in future studies.

Standard versus strict stability criteria in radiofrequency paroxysmal atrial fibrillation ablation using ablation index

PURPOSE

To compare the outcome of paroxysmal atrial fibrillation (AF) ablation via pulmonary vein isolation using Ablation Index (AI) with strict or standard stability criteria.

METHODS

We enrolled 130 consecutive naive patients affected by paroxysmal AF who underwent PVI at two high-volume centers. AI target was ≥380 at the posterior wall and ≥500 at the anterior wall. Strict versus standard stability criteria were set for Group 1 (65 patients) and Group 2 (65 patients), respectively. We compared those strategies with a historical cohort of 72 consecutive patients treated at same centers in the VISITALY study, using average force ≥10 g and strict stability criteria as target parameters. Interlesion distance target was <6 mm. Recurrence was defined as any AF, atrial tachycardia (AT) or atrial flutter (AFL) during the 12 months after ablation, excluding a 90-days blanking period.

RESULTS

Procedure duration (224.05 ± 47.21 vs. 175.61 ± 51.29 min; p < .001), fluoroscopy time (11.85 ± 4.38 vs. 10.46 ± 6.49 min; p = .019) and pericardial effusion rate (9.23% vs. 0%; p = .01) were higher in Group 1 than in Group 2. Freedom from AF/AT/AFL at 12 months was not significantly different (Group 1: 86.15%; Group 2: 90.77%; p = .42). Compared to VISITALY study, there were not significant differences in terms of recurrences.

CONCLUSION

A strategy of PVI using AI with standard stability criteria performed the best in terms of procedure efficiency and safety. Twelve-months arrhythmia-free survival rate was comparable with other strategies pursuing an interlesion distance target <6 mm, regardless of the use of AI.

Impact of proton pump inhibitors on mortality and severe esophageal injury after catheter ablation for atrial fibrillation: a nationwide retrospective study using propensity score matching

Studies on the protective effects of proton pump inhibitors (PPIs) on mortality and severe esophageal injury after catheter ablation for atrial fibrillation are lacking. However, some reports have recommended use of PPIs for prophylaxis against esophageal injury. We investigated the effects of PPIs on mortality and severe esophageal injury after ablation. We retrospectively extracted data for adult in-patients who received catheter ablation with a diagnosis of atrial fibrillation from July 2010 to March 2018. The patients were divided into two groups: with PPI (PPI group) and without PPI (non-PPI group) administration before or on the day of ablation. The primary composite outcome was all-cause 30-day mortality and incidence of severe esophageal injury with complication (cardiac tamponade, ischemic stroke, or sepsis) within 30 days of ablation. Secondary outcomes included incidence of cardiac tamponade, ischemic stroke, and sepsis within 30 days of ablation. Propensity score matching was performed to compare the primary and secondary outcomes between the two groups. We identified 141,649 eligible patients, comprising 62,558 in the PPI group and 79,091 in the non-PPI group. Propensity score-matching analysis showed that PPI use was not associated with reduced proportion of the primary outcome (adjusted odds ratio 1.02; 95% confidence interval 0.71-1.47). PPI use may not be beneficial for reducing mortality or severe complications.

Gender differences in major vascular complications of catheter ablation for atrial fibrillation

AIMS

Catheter ablation (CA) for atrial fibrillation (AF) has a considerable risk of procedural complications. Major vascular complications (MVCs) appear to be the most frequent. This study investigated gender differences in MVCs in patients undergoing CA for AF in a high-volume tertiary center.

METHODS

A total of 4734 CAs for AF (65% paroxysmal, 26% repeated procedures) were performed at our center between January 2006 and August 2018. Patients (71% males) aged 60 ± 10 years and had a body mass index of 29 ± 4 kg/m² at the time of the procedure. Radiofrequency point-by-point ablation was employed in 96.3% of procedures with the use of three-dimensional navigation systems and facilitated by intracardiac echocardiography. Pulmonary vein isolation was mandatory; cavotricuspid isthmus and left atrial substrate ablation were performed in 22% and 38% procedures, respectively. MVCs were defined as those that resulted in permanent injury, required intervention, or prolonged hospitalization. Their rates and risk factors were compared between genders.

RESULTS

A total of 112 (2.4%) MVCs were detected: 54/1512 (3.5%) in females and 58/3222 (1.8%) in males (p < .0001). On multivariate analysis, lower body height was the only risk factor for MVCs in females (p = .0005). On the contrary, advanced age was associated with MVCs in males (p = .006).

CONCLUSION

Females have a higher risk of MVCs following CA for AF compared to males. This difference is driven by lower body size in females. Low body height in females and advanced age in males are independent predictors of MVCs. Ultrasound-guided venipuncture lowered the MVC rate in males.

Sex differences in mapping and rhythm outcomes of a repeat atrial fibrillation ablation

OBJECTIVE

The risk of procedure-related complications and rhythm outcomes differ between men and women after atrial fibrillation catheter ablation (AFCA). We evaluated whether consistent sex differences existed in mapping and rhythm outcomes in repeat ablation procedures.

METHODS

Among 3282 patients in the registry, we analysed 443 consecutive patients (24.6% female, 58.5±10.3 years old, 61.5% with paroxysmal atrial fibrillation) who underwent a second AFCA. We compared the clinical factors, mapping, left atrial (LA) pressure, complications and long-term clinical recurrences after propensity score matching.

RESULTS

LA volume index (43.1±18.6 vs 35.8±11.6 mL/m², p<0.001) was higher, but LA dimension (40.0±6.8 vs 41.6±6.3 mm, p=0.018), LA voltage (0.94±0.55 vs 1.20±0.68 mV, p=0.002) and pericardial fat volume (89.5±43.1 vs 122.1±53.9 cm³, p<0.001) were lower in women with repeat ablation than in their male counterparts. Pulmonary vein (PV) reconnections were lower (58.7% vs 74.9%, p=0.001), but the proportion of extra-PV triggers (27.5% vs 17.0%, p=0.026) and elevated LA pulse pressures (79.7% vs 63.7%, p=0.019) was significantly higher in women than in men. There was no significant sex difference in the rate of procedure-related complications (4.6% vs 4.2%, p=0.791). During a 31-month (8-60) median follow-up, clinical recurrences were significantly higher in women after both the de novo procedure (log-rank p=0.039, antiarrhythmic drug (AAD)-free log-rank p<0.001) and the second procedure (log-rank p=0.006, AAD-free log-rank p=0.093). Female sex (HR 1.51, 95% CI 1.06 to 2.15, p=0.023), non-paroxysmal atrial fibrillation (HR 1.78, 95% CI 1.30 to 2.34, p<0.010) and extra-PV triggers (HR 1.88, 95% CI 1.28 to 2.75, p=0.001) were independently associated with clinical recurrences after repeat procedures.

CONCLUSIONS

During repeat AFCA procedures, PV reconnections were lower in women than in men, and the existence of extra-PV triggers and an LA pressure elevation were more significant, which resulted in poor rhythm outcomes.

TRIAL REGISTRATION NUMBER

NCT02138695.

Importance of previous hospital stays on the risk of hospital re-admission in older adults: a real-life analysis of the PAERPA study population

BACKGROUND

consideration of the first hospital re-admission only and failure to take account of previous hospital stays, which are the two significant limitations when studying risk factors for hospital re-admission. The objective of the study was to use appropriate statistical models to analyse the impact of previous hospital stays on the risk of hospital re-admission among older patients.

METHODS

an exhaustive analysis of hospital discharge and health insurance data for a cohort of patients participating in the PAERPA ('Care Pathways for Elderly People at Risk of Loss of Personal Independence') project in the Hauts de France region of France. All patients aged 75 or over were included. All data on hospital re-admissions via the emergency department were extracted. The risk of unplanned hospital re-admission was estimated by applying a semiparametric frailty model, the risk of death by applying a time-dependent semiparametric Cox regression model.

RESULTS

a total of 24,500 patients (median [interquartile range] age: 81 [77-85]) were included between 1 January 2015 and 31 December 2017. In a multivariate analysis, the relative risk (95% confidence interval [CI]) of hospital re-admission rose progressively from 1.8 (1.7-1.9) after one previous hospital stay to 3.0 (2.6-3.5) after five previous hospital stays. The relative risk [95%CI] of death rose slowly from 1.1 (1.07-1.11) after one previous hospital stay to 1.3 (1.1-1.5) after five previous hospital stays.

CONCLUSION

analyses of the risk of hospital re-admission in older adults must take account of the number of previous hospital stays. The risk of death should also be analysed.

Differences in Healthcare Use Between Patients With Persistent and Paroxysmal Atrial Fibrillation Undergoing Catheter-Based Atrial Fibrillation Ablation: A Population-Based Cohort Study From Ontario, Canada

Background Patients with persistent atrial fibrillation (AF) undergoing catheter-based AF ablation have lower success rates than those with paroxysmal AF. We compared healthcare use and clinical outcomes between patients according to their AF subtypes. Methods and Results Consecutive patients undergoing AF ablation were prospectively identified from a population-based registry in Ontario, Canada. Via linkage with administrative databases, we performed a retrospective analysis comparing the following outcomes between patients with persistent and paroxysmal AF: healthcare use (defined as AF-related hospitalizations/emergency room visits), periprocedural complications, and mortality. Multivariable Poisson modeling was performed to compare the rates of AF-related and all-cause hospitalizations/emergency room visits in the year before versus after ablation. Between April 2012 and March 2016, there were 3768 consecutive patients who underwent first-time AF ablation, of whom 1040 (27.6%) had persistent AF. The mean follow-up was 1329 days. Patients with persistent AF had higher risk of AF-related hospitalization/emergency room visits (hazard ratio [HR], 1.21; 95% CI, 1.09-1.34), mortality (HR, 1.74; 95% CI, 1.15-2.63), and periprocedural complications (odds ratio, 1.36; 95% CI, 1.02-1.75) than those with paroxysmal AF. In the overall cohort, there was a 48% reduction in the rate of AF-related hospitalization/emergency room visits in the year after versus before ablation (rate ratio [RR], 0.52; 95% CI, 0.48-0.56). This reduction was observed for patients with paroxysmal (RR, 0.45; 95% CI, 0.41-0.50) and persistent (RR, 0.74; 95% CI, 0.63-0.87) AF. Conclusions Although patients with persistent AF had higher risk of adverse outcomes than those with paroxysmal AF, ablation was associated with a favorable reduction in downstream AF-related healthcare use, irrespective of AF type.

Women and atrial fibrillation

Atrial fibrillation (AF) remains a growing problem in the United States and worldwide, imposing a high individual and health system burden, including increased resource consumption due to repeated hospitalizations, stroke, dementia, heart failure, and death. This comprehensive review summarizes the most recent data on sex-related differences in risks associated with AF. Women with AF have increased risk of stroke and death compared to men, and possible reasons for this disparity are explored. Women also continue to have worse symptoms and quality of life, and poorer outcomes with stroke prevention, as well as with rate and rhythm control management strategies. Many current rhythm control treatment strategies for AF, including cardioversion and ablation, are used less frequently in women as compared to men, whereas women are more likely to be treated with rate control strategies or antiarrhythmic drugs. Sex differences should be considered in treating women with AF to improve outcomes and women and men should be offered the same interventions for AF. We need to improve the evidence base to understand if variation in utilization of rate and rhythm control management between men and women represents health inequities or appropriate clinical judgement.

Catheter ablation for atrial fibrillation in a low-volume center using contemporary technology

BACKGROUND

Catheter ablation is increasingly being performed worldwide for atrial fibrillation (AF). However, there are concerns of lower success rates and higher complications of AF ablations performed in low-volume centers. Thus, we sought to evaluate the safety and efficacy of AF catheter ablation in a low-volume center using contemporary technologies.

METHODS AND RESULTS

71 consecutive patients (50 paroxysmal AF [pAF] vs 21 persistent AF) who underwent first catheter ablation were studied. Primary outcome was AF recurrence rate. Secondary outcomes included periprocedural complications, hospitalization for symptomatic tachy-arrhythmias post-ablation and number of repeat ablations. Mean age of our cohort was 59.1 ± 9.7 years, of which 56 (78.9%) were males. 1-year AF recurrence was 19.5% in pAF and 23.8% in persistent AF (p = 0.694). Ablation in persistent AF group required longer procedural (197.76 ± 48.60 min [pAF] vs 238.67 ± 70.50 min [persistent AF], p = 0.006) and ablation duration (35.08 ± 15.84 min [pAF] vs 52.65 ± 28.46 min [persistent AF], p = 0.001). There were no significant differences in secondary outcomes. Major periprocedural complication rate was 2.8%.Subset analysis on (i) cryoablation vs radiofrequency, (ii) Ensite vs CARTO navigational system and (iii) circular vs high density mapping catheter did not yield significant differences in primary or secondary outcomes.

CONCLUSIONS

The AF ablation complication and recurrence free rates in both paroxysmal and persistent AF at one year were comparable to high-volume centers. Long-term follow up is needed. In addition, first AF catheter ablation in a low-volume center is realistic with comparable efficacy and safety outcomes to high-volume centers using contemporary ablation technologies.

Ultrasound guidance for femoral venous access in electrophysiology procedures-systematic review and meta-analysis

PURPOSE

The most common complications of electrophysiology (EP) procedures are related to vascular access. Our study aims to conduct a meta-analysis comparing ultrasound (US)-guided vs. palpation-based technique for femoral venous access in EP procedures.

METHODS

Electronic databases were searched and systematically reviewed for studies comparing femoral vein puncture with/without US in EP procedures. The primary outcome was the rate of major vascular complications; secondary outcomes were minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time. Predefined subgroup analysis was conducted separately for patients undergoing pulmonary vein isolation procedure (PVI). A random-effects model was used to derive risk ratios (RR) with 95% confidence interval (CI).

RESULTS

Nine studies involving 8232 patients met our inclusion criteria. Compared with the standard technique, the use of US reduced major vascular complications (from 2.01 to 0.71%, p < 0.0001). The rate of minor vascular complications (RR = 0.30, 95% CI, 0.14-0.62, p = 0.001) and inadvertent artery puncture were lower with US-guided puncture (RR = 0.31, 95% CI, 0.17-0.58, p = 0.0003). Puncture time was shorter (mean difference = - 92.1 s, 95% CI, - 142.12 - - 42.07 s, p = 0.0003) and postprocedural groin pain was less frequent (RR = 0.57, 95% CI, 0.41-0.79, p = 0.0008) in the US group. Subgroup analysis of patients undergoing PVI also showed significant reduction of major vascular complications (RR = 0.27, 95% CI, 0.12-0.64, p = 0.003) and inadvertent artery puncture (RR = 0.35, 95% CI, 0.21-0.59, p < 0.0001).

CONCLUSION

Real-time US-guidance of femoral vein puncture in EP procedures is beneficial: it reduces major and minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time.

Machine Learning Approach to Predict Risk of 90-Day Hospital Readmissions in Patients With Atrial Fibrillation: Implications for Quality Improvement in Healthcare

Background:

Atrial fibrillation (AF) in the elderly population is projected to increase over the next several decades. Catheter ablation shows promise as a treatment option and is becoming increasingly available. We examined 90-day hospital readmission for AF patients undergoing catheter ablation and utilized machine learning methods to explore the risk factors associated with these readmission trends.

Methods:

Data from the 2013 Nationwide Readmissions Database on AF cases were used to predict 90-day readmissions for AF with catheter ablation. Multiple machine learning methods such as k-Nearest Neighbors, Decision Tree, and Support Vector Machine were employed to determine variable importance and build risk prediction models. Accuracy, precision, sensitivity, specificity, and area under the curve were compared for each model.

Results:

The 90-day hospital readmission rate was 17.6%; the average age of the patients was 64.9 years; 62.9% of patients were male. Important variables in predicting 90-day hospital readmissions in patients with AF undergoing catheter ablation included the age of the patient, number of diagnoses on the patient’s record, and the total number of discharges from a hospital. The k-Nearest Neighbor had the best performance with a prediction accuracy of 85%. This was closely followed by Decision Tree, but Support Vector Machine was less ideal.

Conclusions:

Machine learning methods can produce accurate models in predicting hospital readmissions for patients with AF. The likelihood of readmission to the hospital increases as the patient age, total number of hospital discharges, and total number of patient diagnoses increase. Findings from this study can inform quality improvement in healthcare and in achieving patient-centered care.

Atrial fibrillation ablation in practice: assessing CABANA generalizability

AIMS

The Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial aimed to assess the impact of ablation on morbidity and mortality. This observational study was conducted in parallel to CABANA to assess trial generalizability.

METHODS AND RESULTS

Using a large US administrative database, we identified 183 760 patients with atrial fibrillation (AF) treated with ablation or medical therapy (antiarrhythmic or rate control drugs) between 1 August 2009 and 30 April 2016 (CABANA enrolment period). Propensity score weighting was used to balance patients treated with ablation (N = 12 032) or medical therapy alone (N = 171 728) on 90 dimensions. Ablation was associated with a reduction in the composite endpoint of all-cause mortality, stroke, major bleeding, and cardiac arrest [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.70-0.81; P < 0.001]. The majority of patients (73.8%) were potentially trial eligible; among whom the risk reduction associated with ablation was greatest (HR 0.70, 95% CI 0.63-0.77; P < 0.001). Among the 3.8% of patients who failed to meet the inclusion criterion, i.e. patients under 65 years without stroke risk factors, the event rates were low and there was no significant relationship with ablation (HR 0.67, 95% CI 0.29-1.56; P = 0.35). Among the 22.4% patients who met at least one of the trial exclusion criteria, there was a lesser but statistically significant reduction associated with ablation (HR 0.85, 95% CI 0.75-0.95; P = 0.01).

CONCLUSION

In routine clinical care, ablation was associated with a reduction in the primary CABANA composite endpoint of all-cause mortality, stroke, major bleeding, and cardiac arrest, particularly in patients who were eligible for the trial.

Using Machine Learning to Predict 30-Day Hospital Readmissions in Patients with Atrial Fibrillation Undergoing Catheter Ablation

Atrial fibrillation (AF) cases are expected to increase over the next several decades, due to the rise in the elderly population. One promising treatment option for AF is catheter ablation, which is increasing in use. We investigated the hospital readmissions data for AF patients undergoing catheter ablation, and used machine learning models to explore the risk factors behind these readmissions. We analyzed data from the 2013 Nationwide Readmissions Database on cases with AF, and determined the relative importance of factors in predicting 30-day readmissions for AF with catheter ablation. Various machine learning methods, such as k-nearest neighbors, decision tree, and support vector machine were utilized to develop predictive models with their accuracy, precision, sensitivity, specificity, and area under the curve computed and compared. We found that the most important variables in predicting 30-day hospital readmissions in patients with AF undergoing catheter ablation were the age of the patient, the total number of discharges from a hospital, and the number of diagnoses on the patient’s record, among others. Out of the methods used, k-nearest neighbor had the highest prediction accuracy of 85%, closely followed by decision tree, while support vector machine was less desirable for these data. Hospital readmissions for AF with catheter ablation can be predicted with relatively high accuracy, utilizing machine learning methods. As patient age, the total number of hospital discharges, and the total number of patient diagnoses increase, the risk of hospital readmissions increases.

Risk factors for venous bleeding complication at the femoral puncture site after catheter ablation of atrial fibrillation

BACKGROUND

Venous bleeding complication is often observed after catheter ablation of atrial fibrillation (AF), but the risk factors remain unclear.

METHODS

We retrospectively evaluated 570 consecutive patients who underwent catheter ablation of AF from April 2012 to March 2017. After the procedure, the sheaths were removed, and hemostasis was obtained by manual compression followed by application of rolled gauze with elastic bandage and continuous pressure to the puncture site. We evaluated the risk factors for venous bleeding complications defined as hemorrhage from the puncture site that needed recompression after removal of the elastic bandage and rolled gauze.

RESULTS

After excluding 11 patients because of missing data, 559 patients (395 [70.7%] men, mean age: 65.6 ± 8.7 years) were included for analysis. Venous bleeding complication was observed in 213 patients (38.1%). In the multivariate logistic regression analysis, low body mass index (BMI; odds ratio [OR] 0.95, 95% CI 0.90-1.00, P = .04), short compression time (OR 0.77, 95% CI 0.68-0.88, P < .001), and antiplatelet therapy (OR 1.86, 95% CI 1.09-3.16, P = .02) were independent risk factors for venous bleeding complication.

CONCLUSIONS

Low BMI, short compression time, and antiplatelet therapy were independent risk factors for venous bleeding complication after catheter ablation of AF. Longer compression time may be needed for patients with low BMI and/or those receiving antiplatelet therapy.

Treatment Complications of Atrial Fibrillation and Their Management

Atrial fibrillation (AF) is a rhythm disturbance defined by irregular, rapid electrical, and mechanical activation of the atria, which causes unsynchronized atrial contraction and promotes thromboembolism. AF is the most common sustained arrhythmia. Its prevalence and incidence are increasing due to aging and improved survival from acute heart diseases. This article is a review on AF management from both a surgical and catheter-based perspective. While both treatment approaches to AF have been shown to be successful in the management of AF, they are not without their own inherent complications. This article seeks to review some of these complications and help to guide treatment.

Variations in follow-up after atrial fibrillation ablation

BACKGROUND

A multidisciplinary patient-centered approach using evidence-based care is recommended in recent atrial fibrillation (AF) guidelines to achieve quality patient outcomes. Professional society guidelines are conflicting and vague in recommendations on timing of follow-up after AF ablation.

PURPOSE

The aim of this secondary analysis was to examine whether the type and timing of follow-up care after AF ablation affected patient outcomes.

METHODS

A 2-year, longitudinal, pilot study to explore patient experiences during the first 6 months following an AF ablation was conducted. Patients completed surveys and phone interviews before ablation, and at 1, 3, and 6 months after the ablation. Pearson correlations and repeated-measures analysis of variance were used for comparison of outcomes over time.

RESULTS

The sample (N = 20) had a mean age of 65 (± 7) years, was 55% female, 35% paroxysmal AF, and 65% persistent AF pre-ablation. Timing of follow-up visits following AF ablation varied widely. Patients reported many concerns and difficulties reflecting the lack of knowledge and unrealistic expectations of post-ablation recovery. Better outcomes were noted in those who were seen at 1-week post-ablation by a nurse practitioner (NP) compared with those who were not seen until 1 or 3 months after ablation by a physician.

IMPLICATIONS FOR PRACTICE

Atrial fibrillation ablation is routinely performed in the United States, yet there seems to be a lack of standardization concerning the type and timing of follow-up care after AF ablation. These preliminary findings support a standardized approach to include an NP visit at one week after AF ablation to achieve quality AF patient outcomes.