Restoring Sinus Rhythm Reverses Cardiac Remodeling and Reduces Valvular Regurgitation in Patients With Atrial Fibrillation

Heart failure with preserved ejection fraction in atrial functional mitral regurgitation - Insight from the REVEAL-AFMR

BACKGROUND

Atrial functional mitral regurgitation (AFMR) and heart failure with a preserved ejection fraction (HFpEF) often coexist. However, the clinical impact of HFpEF in patients with AFMR has not been well characterized. This study aimed to determine clinical outcomes and response to mitral valve (MV) intervention or rhythm control therapy in patients with HFpEF and moderate AFMR (HFpEF-AFMR).

METHODS

This was a post-hoc analysis of the REVEAL-AFMR, a retrospective observational study involving patients with ≥ moderate AFMR. After excluding patients with severe MR, the presence of HFpEF was defined by the Universal definition.

RESULTS

Of 438 patients with moderate AFMR, 352 met the criteria of HFpEF (prevalence: 80 %). Compared to non-HFpEF-AFMR (n = 86), patients with HFpEF-AFMR were older and had greater symptom burden and a higher prevalence of severe tricuspid regurgitation (19 %). During a median follow-up of 33.2 months, a composite outcome of all-cause mortality or HF hospitalization occurred in 130 patients. Patients with HFpEF-AFMR had a 3.6-fold increased risk of the composite outcome compared to non-HFpEF-AFMR. While MV intervention was not associated with outcomes in HFpEF-AFMR, concomitant tricuspid valve (TV) procedures were associated with a better outcome than isolated MV intervention (HR 0.15, 95 %CI 0.04-0.54, p = 0.009). Catheter or surgical rhythm control showed a favorable outcome in HFpEF-AFMR and atrial fibrillation (HR 0.38, 95 %CI 0.17-0.87, p = 0.008).

CONCLUSION

HFpEF was substantially common in moderate AFMR and was associated with worse clinical outcomes. Simultaneous MV and TV intervention procedures or rhythm control therapy were associated with better clinical outcomes in HFpEF-AFMR.

Effects of Rhythm Control for Atrial Fibrillation on Cardiac Remodeling and Valvular Regurgitation in Patients with Heart Failure

PURPOSE

Previous studies investigating cardiac remodeling and functional regurgitation of rhythm control for atrial fibrillation (AF) in heart failure (HF) are limited. Therefore, this study aimed to evaluate the impact of rhythm control for AF on cardiac remodeling and functional regurgitation in the spectrum of HF. Its effect on prognosis was explored.

METHODS

According to the treatment strategies of AF, the cohort was classified into the rhythm control and rate control groups. To further detect the implications of rhythm control on cardiac remodeling, functional regurgitation, and outcomes in HF subtypes, patients were further divided into HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction, and HF with preserved ejection fraction (HFpEF) subgroups.

RESULTS

A total of 828 patients were enrolled, with 307 patients in the rhythm control group and 521 patients in the rate control group. Over a median follow-up time of 3.8 years, patients with rhythm control treatments experienced improvements in biatrial structure parameters, left ventricular ejection fraction, and functional regurgitation (mitral and tricuspid regurgitation) compared with rate control treatment (p < 0.05). Cox regression analysis demonstrated that rhythm control reduced the risks of all-cause mortality (HR 0.436 [95% CI, 0.218-0.871], p = 0.019) in HFpEF and HF-related admissions in HFrEF (HR 0.500 [95% CI, 0.330-0.757], p = 0.001) and HFpEF (HR 0.541 [95% CI, 0.407-0.720], p < 0.001); these associations were similar after adjusting for multiple confounders.

CONCLUSIONS

Rhythm control therapy can be considered an appropriate treatment strategy for the management of AF in HF to improve cardiac remodeling, functional regurgitation, and prognosis.

Identifying left atrium and left atrial appendage prone to thrombus formation in patients with atrial fibrillation using statistical shape modeling

BACKGROUND

The morphology of the left atrium (LA) and left atrial appendage (LAA) is associated with LAA thrombus formation (LAAT) in patients with atrial fibrillation (AF). Statistical shape modeling (SSM) could be a comprehensive and objective method for evaluating LA/LAA shape, thereby improving LAAT risk assessment.

METHODS AND RESULTS

In this individual-matched case-control study, 110 pairs of AF patients with or without LAAT were compared. Using SSM of cardiac computed tomography angiography images, we developed a LA/LAA shape deformation score (LADS). LADS was significantly higher in the LAAT group (4.0 ± 5.0 vs. -4.0 ± 6.5, P < 0.01) and independently associated with LAAT (odds ratio for each point increase in LADS: 1.31, 95 % confidence interval: 1.21-1.42, P < 0.01). LAAT risk assessment was significantly improved by the addition of LADS to clinical characteristics plus traditional structural parameters, evaluated by the area under the receiver-operating characteristic curve (0.879 vs 0.788, P < 0.01), net reclassification improvement (30.9 %, 95 % CI: 23.6-38.1 %, P < 0.05) and integrated discrimination improvement (18.5 %, 95 %CI: 16.8-20.3 %, P < 0.05). The predictive role of LADS in LAAT was confirmed by an unmatched external validation study including 406 patients with AF (19 cases with LAAT). Computational fluid dynamics analysis of 20 patients showed a significant association between LADS and endothelial cell activation potential, time-averaged wall shear stress, relative residence time, and blood velocity in the LAA.

CONCLUSION

SSM-derived LADS was significantly associated with LAAT and improved LAAT risk assessment. The relationship between LAAT and LADS may be attributed to mechanisms involving endothelial dysfunction and blood stasis.

How Would You Manage This Patient With Recent-Onset Atrial Fibrillation? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Atrial fibrillation (AF) is the most common arrhythmia. Risk factors for AF include obstructive sleep apnea, physical inactivity, obesity, cigarette use, and alcohol misuse. Atrial fibrillation substantially increases the risk for stroke and is associated with higher rates of mortality than for individuals without AF. Strategies to prevent these risk factors and to optimize those that already exist reduce the risk for subsequent AF. Physicians play an important role in proposing strategies to reduce the risk for AF among patients. Decision making regarding management of AF is often complex and requires consideration of symptoms, burden of AF (the percentage of time in AF), comorbid conditions that increase stroke risk, and the risk for bleeding. In particular, novel risk scoring systems to predict stroke risk, and consideration of factors beyond those in these tools, refine the ability to identify patients with AF who are most likely to benefit from anticoagulation to reduce stroke risk. Early use of catheter ablation of AF in selected patients improves symptoms and reduces the potential for progression from intermittent to persistent AF. A 2023 collaborative guideline from the American College of Cardiology, American Heart Association, American College of Chest Physicians, and the Heart Rhythm Society addressed multiple aspects of care of patients with AF. Here, a general cardiologist and a cardiac electrophysiologist discuss recommendations derived from this guideline and how to apply them to the care of a particular patient.

Transcatheter Tricuspid Valve Replacement

Transcatheter tricuspid valve replacement (TTVR) has emerged as a promising intervention for the treatment of severe tricuspid regurgitation with complex valve morphology. This consensus document provides a comprehensive overview of the current state of orthotopic TTVR, focusing on patient selection, procedural details, and follow-up care. Clinical outcomes from initial studies and compassionate use cases are discussed, highlighting the effectiveness of TTVR in reducing tricuspid regurgitation, inducing reverse right ventricular remodeling, and enhancing patients' quality of life. This review paper also addresses potential complications and challenges associated with TTVR, such as new-onset conduction disturbances, bleeding complications, and afterload mismatch, and provides expert recommendations for the periprocedural management, anticoagulation strategies, and long-term follow-up. With the commercial approval of the first TTVR system in the United States and Europe, it intends to serve as a reference for clinicians and researchers involved in the evolving field of transcatheter tricuspid valve interventions.

Advance in the application of 4-dimensional flow MRI in atrial fibrillation

Atrial fibrillation (AF) is the most prevalent arrhythmia in world-wild places and is associated with the development of severe secondary complications such as heart failure and stroke. Emerging evidence shows that the modified hemodynamic environment associated with AF can cause altered flow patterns in left atrial and even systemic blood associated with left atrial appendage thrombosis. Recent advances in magnetic resonance imaging (MRI) allow for the comprehensive visualization and quantification of in vivo aortic flow pattern dynamics. In particular, the technique of 4- dimensional flow MRI (4D flow MRI) offers the opportunity to derive advanced hemodynamic measures such as velocity, vortex, endothelial cell activation potential, and kinetic energy. This review introduces 4D flow MRI for blood flow visualization and quantification of hemodynamic metrics in the setting of AF, with a focus on AF and associated secondary complications.

Prognostic implications of baseline rhythm during catheter ablation for atrial tachycardia

BACKGROUND

Atrial tachycardias (AT) occurring in patients after previous atrial fibrillation (AF) ablation are increasingly observed in clinical practice. Catheter ablation is the treatment of choice but an optimal workflow to improve patient outcome has not been defined. The purpose of this study was to assess procedural and clinical outcome depending on baseline rhythm at the beginning of AT ablation.

METHODS

A total of 380 patients (69 (61-75) years, 56.6% male) who underwent catheter ablation for consecutive AT after previous AF ablation were studied.

RESULTS

At the beginning of the procedure, 140 patients (36.8%) presented in sinus rhythm (SR), 208 (54.7%) with AT and 32 (8.4%) with AF. Patients in SR or with AT underwent shorter procedures (173 (132-213) minutes vs. 161 (120-203) minutes vs. 226 (154-249) minutes; p = 0.002) with more frequent termination to SR (87.9% vs. 81.3% vs. 56.3%; p < 0.001) than patients with AF. Acute procedural success did not differ between patients in SR or with AT but was higher compared to those with AF (96.4% vs. 97.1% vs. 87.5%; p = 0.033). During a follow-up of 290 (181-680) days, patients in baseline SR experienced arrhythmia recurrences less often (36.4% vs. 49.5% vs. 68.8%; p = 0.002) than patients with AT or AF.

CONCLUSION

Baseline rhythm during AT ablation predicts procedural and clinical outcome. Whereas acute procedural success does not differ between patients in SR or with AT, patients presenting in SR have a more favorable mid-term success rate.

Transcatheter Approaches to Atrial Functional Mitral Regurgitation: How Far Have We Come?

Functional mitral regurgitation (MR) is associated with increased cardiovascular morbidity and mortality and over the past decade, the diagnosis of atrial functional mitral regurgitation (aFMR) has been increasingly observed in the elderly, especially in those with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). Annular enlargement, perturbations of annular contraction, and atriogenic leaflet tethering distinguish the pathophysiology of aFMR from the one of ventricular origin. However, no consensus provides recommendations regarding the differential diagnosis and the subsequent management of aFMR. The advent of transcatheter mitral valve repair has paved the way for various treatments including edge-to-edge repair (TEER), mitral annuloplasty, and replacement, with optimistic results on short-medium-term outcome provided by preliminary studies. In parallel, rhythm control of AF for paroxysmal and persistent types, should be pursued to induce reverse remodeling and restoring the normal leaflet coaptation. In this setting, catheter ablation aiming for electrical isolation of the pulmonary veins is the most widely recognized and effective strategy for maintaining sinus rhythm. Nevertheless, arrhythmia-free survival is lower in patients with persistent and long-term persistent AF, leading to the adoption of hybrid strategies combining transcatheter endocardial ablation and thoracoscopic epicardial surgical ablation. This review provides an update on the diagnosis and treatment of aFMR, focusing on available transcatheter approaches that can be performed in the catheterization lab and electrophysiology lab.

Metabolomics in Atrial Fibrillation: Unlocking Novel Biomarkers and Pathways for Diagnosis, Prognosis, and Personalized Treatment

BACKGROUND/OBJECTIVES

Atrial fibrillation (AF) is the most frequent arrhythmia in the adult population associated with a high rate of severe consequences leading to significant morbidity and mortality worldwide. Therefore, its prompt recognition is of high clinical importance. AF detection often remains challenging due to unspecific symptoms and a lack of reliable biomarkers for its prediction. Herein, novel bioanalytical methodologies, such as metabolomics, offer new opportunities for a better understanding of the underlying pathological mechanisms of cardiovascular diseases, including AF. The metabolome, considered a complete set of small molecules present in the organism, directly reflects the current phenotype of the studied system and is highly sensitive to any changes, including arrhythmia's onset. A growing body of evidence suggests that metabolite profiling has prognostic value in AF prediction, highlighting its potential role not only in early diagnosis but also in guiding therapeutic interventions. By identifying specific metabolites as a disease biomarker or recognising particular metabolomic pathways involved in the AF pathomechanisms, metabolomics could be of great clinical value for further clinical decision-making, risk stratification, and an individual personalised approach. The presented narrative review aims to summarise the current state of knowledge on metabolomics in AF with a special emphasis on its implications for clinical practice and personalised medicine.

Utility of the Ratio Between the Size of the Right Atrium and the Right Ventricle at End-Systole to Diagnose Atrial Secondary Tricuspid Regurgitation

BACKGROUND

In the multiparametric framework for diagnosing atrial secondary tricuspid regurgitation (A-STR), an end-systolic (ES) right atrial (RA)-to-right ventricular (RV) volume or area ratio ≥1.5 supports the diagnosis of A-STR over the ventricular secondary tricuspid regurgitation phenotype (V-STR). However, this threshold value has never been tested.

METHODS

A single-center study was conducted, prospectively enrolling consecutive patients with secondary tricuspid regurgitation who underwent two- and three-dimensional echocardiography.

RESULTS

A total of 350 patients were enrolled (mean age, 75 ± 13 years; 65% women). Although patients with A-STR and V-STR presented similar degrees of secondary tricuspid regurgitation and comparable RA size, the ES RA/RV volume ratio was significantly larger in A-STR than in V-STR (1.75 [interquartile range, 1.35-2.45] vs 1.18 [interquartile range, 0.81-1.66], respectively; P < .001). On receiver operating characteristic analysis, the ES RA/RV volume ratio showed a significantly higher predictive power for A-STR (area under the curve [AUC], 0.73; 95% CI, 0.68-0.78) compared with RA maximum volume (AUC, 0.6; 95% CI, 0.54-0.66; P = .01), RA minimum volume (AUC, 0.59; 95% CI, 0.53-0.65; P = .007), and ratio of RA minimum volume to RV end-diastolic volume (AUC, 0.57; 95% CI, 0.51-0.63; P < .001). However, the predictive power of the ES RA/RV volume ratio (AUC, 0.73; 95% CI, 0.68-0.78) and the ES RA/RV area ratio (AUC, 0.76; 95% CI, 0.71-0.81) for the diagnosis of A-STR was similar (P = .58). The threshold value for ES RA/RV volume ratio that best distinguished between A-STR and V-STR was 1.40 (AUC, 0.68; 95% CI, 0.63-0.73), whereas for ES RA/RV area ratio, it was 1.6 (AUC, 0.64; 95% CI, 0.59-0.69). A multivariable model that included either ES RA/RV volume ratio or ES RA/RV area ratio, along with LV ejection fraction, RV ejection fraction, RV ES volume, and pulmonary artery systolic pressure, resulted in an AUC of 0.97 for differentiating between A-STR and V-STR.

CONCLUSIONS

ES RA/RV volume ratio ≥ 1.4 and ES RA/RV area ratio ≥ 1.6 support the diagnosis of A-STR over V-STR.

Atrial Functional Tricuspid Regurgitation: A Comprehensive Review of Pathophysiology, Diagnosis, and Management Strategies

Atrial fibrillation (AF), the most prevalent sustained cardiac arrhythmia, is intricately linked with atrial functional tricuspid regurgitation (AFTR), a condition distinguished from ventricular functional tricuspid regurgitation by its unique pathophysiological mechanisms and clinical implications. This review article delves into the multifaceted aspects of AFTR, exploring its epidemiology, pathophysiology, diagnostic evaluation, and management strategies. Further, we elucidate the mechanisms underlying AFTR, including tricuspid annular dilatation, right atrial enlargement, and dysfunction, which collectively contribute to the development of tricuspid regurgitation in the absence of significant pulmonary hypertension or left-sided heart disease. The section on diagnostic evaluation highlights the pivotal role of echocardiography, supplemented by cardiac magnetic resonance (CMR) imaging and computed tomography (CT), in assessing disease severity and guiding treatment decisions. Management strategies for AFTR are explored, ranging from medical therapy and rhythm control to surgical and percutaneous interventions, underscoring the importance of a tailored, multidisciplinary approach. Furthermore, the article identifies gaps in current knowledge and proposes future research directions to enhance our understanding and management of AFTR. By providing a comprehensive overview of AFTR, this review aims to raise awareness among healthcare professionals and stimulate further research to improve patient care and outcomes in this increasingly recognized condition.

[Atrial fibrillation in combination with severe mitral regurgitation : Which should be treated first, the atrial fibrillation or the mitral valve?]

BACKGROUND

The primary therapeutic approach for severe secondary mitral regurgitation (MR) in combination with atrial fibrillation is often not clear.

OBJECTIVES/METHODS

To create a therapeutic guideline for daily clinical practice based on a case report as well as basic literature.

RESULTS

If a functional component is suspected, restoration of sinus rhythm may lead to a significant improvement in MR. The extent of the improvement and the time required to achieve this improvement are often difficult to predict.

CONCLUSIONS

The involvement of an electrophysiologist is recommended in order to assess the likelihood of successful long-term rhythm control aimed at improving MR. In unclear cases, cardioversion combined with short-term administration of antiarrhythmic medication may be useful to demonstrate potential improvement of MR in sinus rhythm.

Assessing right atrial size in patients with tricuspid regurgitation: importance of the right ventricular-focused view

AIMS

To assess the accuracy of measuring the right atrial volume (RAV) using two-dimensional echocardiography (2DE) in a right ventricular focused (RVF) view compared to the conventional apical four-chamber (4Ch) view in patients with secondary tricuspid regurgitation (STR). We also compared the clinical correlates of the measures obtained using different methods.

METHODS AND RESULTS

The accuracy of RAV measurements obtained between 2DE-4Ch and RVF views in 384 patients with STR were compared using three-dimensional echocardiography (3DE) as a reference. We used the analysis of variance to test the differences among RAVs obtained from the different 2DE and 3DE acquisitions and the receiving operating characteristics (ROC) curves to evaluate the association with the composite endpoint of hospitalization for heart failure or death. Compared to 3DE, RAV was significantly more underestimated when measurements were obtained from 4Ch rather than RVF (-24 vs. -14%, respectively, P < 0.001 for both). RAV underestimation in 4Ch and RVF view was relatively larger in lower grades of STR (-28 vs. -17% in mild, -23 vs. -14% in moderate, and -19 vs. -11% in severe STR, P = 0.001), and in the atrial compared to ventricular (-28 vs. -22%; P = 0.002) STR. RAV measured by 3DE and RVF showed the highest area under the curve (AUC = 0.67 for 3DE vs. 0.64 for RVF, P = 0.05), while 4Ch was significantly less related to the outcomes (AUC: 0.61, P = 0.021 vs. 3DE RAV).

CONCLUSION

In patients with STR, the use of RVF view improved the accuracy of 2DE RAV measurement as compared to the conventional 4Ch-derived measurements.

Impact of Non-Valvular Atrial Fibrillation on Mitral Valve Anatomic Features: A Study of Three-Dimensional Mitral Valve by Transesophageal Echocardiography and Automatic Analysis Software

BACKGROUND/AIM

Mitral regurgitation (MR) is frequently observed in non-valvular atrial fibrillation (NVAF) patients and is a significant risk factor for its progression. This study aims to investigate the three-dimensional anatomical characteristics of the mitral valve (MV) in patients with different types of NVAF to elucidate the underlying mechanisms of MR.

METHODS

A retrospective analysis was conducted on 82 paroxysmal atrial fibrillation patients (PAF group) and 66 persistent atrial fibrillation patients (PerAF group) who underwent real-time three-dimensional transesophageal echocardiography (RT 3D-TEE) before initial ablation. Additionally, 30 patients undergoing RT 3D-TEE for the assessment of patent foramen ovale were selected as the control group. Basic echocardiographic variables were measured, left atrioventricular volume and strain parameters were calculated using automated software (Dynamic-HeartModel and AutoStrain). MV anatomic features were analyzed using the 4D-MV Assessment software (TomTec Imaging Systems).

RESULTS

The maximum left atrial volume (LAVmax) was highest in the PerAF group, followed by the PAF and control groups, with statistically significant differences (p < 0.01). Left atrial reservoir strain (LASr) showed an opposite trend, being the lowest in the PerAF group (p < 0.01). The proportion of moderate to severe MR was significantly higher in the PerAF group (27.3%) compared to the PAF group (11.0%) (p < 0.01). Compared to controls, the AF groups exhibited mitral annular (MA) dilation, flattening of the MA plane, and increased leaflet area (all p < 0.05). Correlation analysis between effective regurgitant orifice area (EROA) and left atrioventricular structure and function parameters, as well as various annular parameters, showed that EROA was significantly correlated with left ventricular end-diastolic volume (LVEDV), LAVmax, LASr, anterior and posterior diameter, annular area, ratio of annular height to commissural diameter (AH/CD ratio), posterior leaflet area, posterior leaflet length, and the C-shaped annulus length (all p < 0.05).

CONCLUSIONS

Significant remodeling of the MV apparatus occurs in NVAF patients, with more pronounced changes in PerAF patients, contributing to a higher incidence of moderate to severe MR. RT 3D-TEE-based MV automated assessment offers significant advantages in accurately diagnosing MV remodeling and supporting the evaluation of MR in NVAF patients.

Predictors of functional mitral regurgitation improvement in patients with left bundle branch block treated with left bundle branch area pacing

BACKGROUND

Functional mitral regurgitation (FMR) and its severity are associated with adverse outcomes in heart failure patients. This study aims to analyze the predictors of FMR improvement after successful left bundle branch area pacing (LBBAP) in patients with LVEF < 50% and complete left bundle branch block (CLBBB).

METHODS

Consecutive patients with LVEF < 50% and CLBBB who underwent successful LBBAP from July 2018 to July 2023 were retrospectively identified. Significant MR was defined as regurgitation of moderate severity or greater. Patients with significant FMR were included in the analysis. FMR improvement (FMRI) was defined as a reduction of at least one grade in regurgitation severity compared to baseline at 3 months or longer follow-up.

RESULTS

Among the 81 identified patients, 42 patients with significant FMR preoperatively were included. After LBBAP, QRS duration significantly shortened from 170.6 ± 18.8 ms to 114.5 ± 20.2 ms (p < .001). Significant FMR improves in approximately 76.2%, and the patients were divided into an FMRI group (n = 32) and a non-FMRI group (n = 10). Univariate analysis showed that absence of persistent atrial fibrillation, typical CLBBB, and left atrium diameter at baseline were associated with improvement of FMR after LBBAP. Of these variables, only absence of persistent atrial fibrillation remains an independent predictor in the multivariate model (OR 12.436, p = .009).

CONCLUSION

LBBAP is able to improve FMR in heart failure patients who had CLBBB with LVEF < 50%. Meanwhile, the absence of persistent atrial fibrillation is an independent predictor of FMR improvement.

Atrial cardiomyopathy revisited-evolution of a concept: a clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asian Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS)

AIMS

The concept of "atrial cardiomyopathy" (AtCM) had been percolating through the literature since its first mention in 1972. Since then, publications using the term were sporadic until the decision was made to convene an expert working group with representation from four multinational arrhythmia organizations to prepare a consensus document on atrial cardiomyopathy in 2016 (EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication). Subsequently, publications on AtCM have increased progressively.

METHODS AND RESULTS

The present consensus document elaborates the 2016 AtCM document further to implement a simple AtCM staging system (AtCM stages 1-3) by integrating biomarkers, atrial geometry, and electrophysiological changes. However, the proposed AtCM staging needs clinical validation. Importantly, it is clearly stated that the presence of AtCM might serve as a substrate for the development of atrial fibrillation (AF) and AF may accelerates AtCM substantially, but AtCM per se needs to be viewed as a separate entity.

CONCLUSION

Thus, the present document serves as a clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asian Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS) to contribute to the evolution of the AtCM concept.

Atrial Functional Mitral Regurgitation: From Diagnosis to Current Interventional Therapies

Mitral regurgitation (MR) is one of the most common valvular pathologies worldwide, contributing to the morbidity and mortality of several cardiovascular pathologies, including heart failure (HF). Novel transcatheter treatment for MR has given the opportunity for a safe and feasible alternative, to surgery, in order to repair the valve and improve patient outcomes. However, after the results of early transcatheter edge-to-edge repair (TEER) trials, it has become evident that subcategorizing the mitral regurgitation etiology and the left ventricular function, in patients due to undergo TEER, is of the essence, in order to predict responsiveness to treatment and select the most appropriate patient phenotype. Thus, a novel MR phenotype, atrial functional MR (AFMR), has been recently recognized as a distinct pathophysiological entity, where the etiology of the regurgitation is secondary to annular dilatation, in a diseased left atrium, with preserved left ventricular function. Recent studies have evaluated and compared the outcomes of TEER in AFMR with ventricular functional MR (VFMR), with the results favoring the AFMR. In specific, TEER in this patient substrate has better echocardiographic and long-term outcomes. Thus, our review will provide a comprehensive pathogenesis and mechanistic overview of AFMR, insights into the echocardiographic approach of such patients and pre-procedural planning, discuss the most recent clinical trials and their implications for future treatment directions, as well as highlight future frontiers of research in the setting of TEER and transcatheter mitral valve replacement (TMVR) in AFMR patients.

The Diagnosis and Treatment of Tricuspid Regurgitation

BACKGROUND

It is estimated that 6% of persons over age 75 have clinically relevant tricuspid regurgitation (TR). This condition carries a high mortality and is of particular interest because of the recent development of new interventional treatments.

METHODS

This review is based on publications that were retrieved by a selective search in the PubMed database for randomized controlled trials (RCTs), observational studies, registry studies, expert recommendations, and current international guidelines.

RESULTS

The evidence reveals that TR is an independent cause of mortality. Mortality is correlated with the severity of TR: approximately 35% of patients with severe TR and right heart failure die within 1 year, and about 60% within 3 years. The clinical course varies depending on the etiology (primary TR, atrial/ventricular secondary TR, association with pacemaker systems). In the outpatient setting, timely diagnosis by transthoracic echocardiography is crucial. The options for pharmacotherapy are essentially limited to diuretic treatment (grade 2a recommendation). Early referral to a specialized heart valve center is essential for the prevention of irreversible damage of the right heart and secondary end-organ damage, including cardiohepatic and cardiorenal syndromes. In the heart valve center, an extended diagnostic evaluation with multimodal imaging is followed by a case discussion by the interdisciplinary cardiac team, with individual evaluation of the treatment options. The first randomized controlled trial of treatment for TR yielded a win ratio of 1.48 (95% confidence interval, [1.06; 2.13]) for interventional treatment (edge-to-edge repair) compared to optimal medical therapy.

CONCLUSION

As the understanding of tricuspid regurgitation improves, strategies for its interventional treatment are undergoing steady development, with the aim of lowering the mortality of this condition.

Secondary tricuspid regurgitation: incidence, types, and outcomes in atrial fibrillation vs. sinus rhythm

BACKGROUND AND AIMS

Incidence and types of secondary tricuspid regurgitation (TR) are not well defined in atrial fibrillation (AFib) and sinus rhythm (SR). Atrial secondary TR (A-STR) is associated with pre-existing AFib; however, close to 50% of patients with A-STR do not have AFib. The aim of this study was to assess incidence, types, and outcomes of ≥ moderate TR in AFib vs. SR.

METHODS

Adults with and without new-onset AFib without structural heart disease or ≥ moderate TR at baseline were followed for the development of ≥ moderate TR. Tricuspid regurgitation types were pacemaker, left-sided valve disease, left ventricular (LV) dysfunction, pulmonary hypertension (PH), isolated ventricular, and A-STR.

RESULTS

Among 1359 patients with AFib and 20 438 in SR, 109 and 378 patients developed ≥ moderate TR, respectively. The individual types of TR occurred more frequently in AFib related to the higher pacemaker implantation rates (1.12 vs. 0.19 per 100 person-years, P < .001), larger right atrial size (median 78 vs. 53 mL, P < .001), and higher pulmonary pressures (median 30 vs. 28 mmHg, P < .001). The most common TR types irrespective of rhythm were LV dysfunction-TR and A-STR. Among patients in SR, those with A-STR were older, predominantly women with more diastolic abnormalities and higher pulmonary pressures. All types of secondary TR were associated with all-cause mortality, highest in PH-TR and LV dysfunction-TR.

CONCLUSIONS

New-onset AFib vs. SR conferred a higher risk of the individual TR types related to sequelae of AFib and higher pacemaker implantation rates, although the distribution of TR types was similar. Secondary TR was universally associated with increased mortality.

Effects of antiarrhythmic drug responsiveness and diagnosis-to-ablation time on outcomes after catheter ablation for persistent atrial fibrillation

Background

The impact of delaying atrial fibrillation catheter ablation (AFCA) for antiarrhythmic drug (AAD) management on the disease course remains unclear. This study investigated AFCA rhythm outcomes based on the diagnosis-to-ablation time (DAT) and AAD responsiveness in participants with persistent AF (PeAF).

Methods

We included data from 1038 AAD-resistant PeAF participants, all of whom had a clear time point for AF diagnosis, especially PeAF at diagnosis time, and had undergone an AFCA for the first time. Participants who experienced recurrences of paroxysmal type on AAD therapy were analyzed as a cohort of AAD-partial responders; those maintaining PeAF on AAD were AAD-non-responders. We determined the DAT cutoff for best discriminating long-term rhythm outcomes using a maximum log-likelihood estimation method based on the Cox proportional hazard regression model.

Results

Of the participants (79.8% male; median age 61), 806 (77.6%) were AAD-non-responders. AAD-non-responders had a higher body mass index and a larger left atrial diameter than AAD-partial-responders. They also had a higher incidence of AF recurrence after AFCA (adjusted hazard ratio 1.75, 95% confidence interval 1.33-2.30; log-rank p < .001) compared to AAD-partial-responders. The maximum log-likelihood estimation showed bimodal cutoffs at 22 and 40 months. The optimal DAT cutoff rhythm outcome was 22 months, which discriminated better in the AAD-partial-responders than in the AAD-non-responders.

Conclusions

Both DAT and AAD responsiveness influenced AFCA rhythm outcomes. Delaying AFCA to a DAT of longer than 22 months was inadvisable, particularly in the participants in whom PeAF was changed to paroxysmal AF during AAD therapy.

Tricuspid Regurgitation in Patients With Heart Failure and Preserved Ejection Fraction: JACC State-of-the-Art Review

Heart failure with preserved ejection fraction (HFpEF) is associated with high morbidity and mortality. Important risk factors for the development of HFpEF are similar to risk factors for the progression of tricuspid regurgitation (TR), and both conditions frequently coexist and thus is a distinct phenotype or a marker for advanced HF. Many patients with severe, symptomatic atrial secondary TR have been enrolled in current transcatheter device trials, and may represent patients at an advanced stage of HFpEF. Management of HFpEF thus may affect the pathophysiology of TR, and the physiologic changes that occur following transcatheter treatment of TR, may also impact symptoms and outcomes in patients with HFpEF. This review discusses these issues and suggests possible management strategies for these patients.

Sinus rhythm restoration reverses tricuspid regurgitation in patients with atrial fibrillation: a systematic review and meta-analysis

BACKGROUND

Tricuspid regurgitation (TR) is a common valvular heart disease worldwide, and current guidelines for TR treatment are relatively conservative, as well as with detrimental outcomes. Restoration of sinus rhythm was reported to improve the TR severity in those TR patients with atrial fibrillation (AF). However, relevant research was limited. The aim of this meta-analysis was to evaluate the clinical outcomes of restoration of sinus rhythm in TR patients with AF.

METHODS

In this study, PubMed, Web of Science, and Scopus databases were searched for study enrollment until July 2023. This study was designed under the guidance of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. These studies containing the patient's baseline characteristics, surgical procedure, and at least one of the clinical outcomes were included. The primary endpoint was TR grade during follow-up after restoration of sinus rhythm.

RESULTS

Out of 1074 records, 6 were enrolled. Restoration of sinus rhythm is associated with a reduction of TR severity (TR grade, odds ratio 0.11, 95% confidence interval (CI): 0.01 to 1.28, P = 0.08, I2 = 83%; TR area, mean difference (MD) -2.19 cm2, 95% CI: -4.17 to -0.21 cm2, P = 0.03, I2 = 96%). Additionally, remolding of right heart with a significant reduction of tricuspid valve annulus diameter (MD -0.36 cm, 95%CI: -0.47 to -0.26 cm, P < 0.00001, I2 = 29%) and right atrium volume index (MD -11.10 mL/m2, 95%CI: -16.81 to -5.39 mL/m2, P = 0.0001, I2 = 79%) was observed during follow-up.

CONCLUSIONS

In conclusion, rhythm-control therapy could reduce TR severity in AF patients with TR and is associated with right heart remodeling.

Functional Mitral Regurgitation and Heart Failure With Preserved Ejection Fraction: Clinical Implications and Management

Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and associated with worse cardiovascular outcomes. The pathophysiology of HFpEF mostly relies on the development of elevated left ventricle filling pressure, diastolic dysfunction, and atrial dilatation and impairment. This dynamic process may eventually lead to the development of functional mitral regurgitation (MR), characterized by mitral annular dilatation and consequent leaflet remodeling, in the context of preserved left ventricular ejection fraction. These observations highlight the possible common pathophysiology of MR and HFpEF. However, less is known about the prevalence and the clinical value of MR in the context of HFpEF. This review aims to provide an overview of the association and interplay between functional MR and HFpEF, discuss the underlying mechanisms that are common to these diseases, and summarize potential targeted pharmacological treatments.

Chinese guidelines for the diagnosis and management of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Body Fat Distribution and Left Atrial Reverse Remodeling After Catheter Ablation for Atrial Fibrillation

Background

Emerging evidence suggests a pathophysiological link between obesity and atrial fibrillation (AF). However, the contribution of body fat distribution to left atrial (LA) remodeling and its reversibility remain unclear in nonobese AF patients.

Objectives

The purpose of this study was to investigate the association of body fat distribution with LA size and reverse remodeling (LARR).

Methods

In total, 116 nonobese patients with AF (88 men, age 63 ± 11 years) who underwent first catheter ablation (CA) were included. Body fat distribution was assessed with bioelectrical impedance, and body fat percentage (BF%) and central fat percentage (CF%) were calculated. Patients were categorized by body size metrics (body mass index [BMI] and waist-to-hip [W/H] ratio) and fat parameters (BF% and CF%). Echocardiography was performed before and 6 months after CA. Multivariable logistic regression was used to examine the association between the 4 metrics (ie, BMI, W/H ratio, BF%, and CF%) and a lack of LARR (<15% reduction or increase in the LA volume index).

Results

Body size metrics and adiposity measures were not independently associated with baseline LA size. Six months after CA, the higher W/H ratio and CF% groups exhibited persistent LA enlargement compared to their counterparts (both P < 0.01). In the multivariable analysis, W/H ratio and CF% were associated with a lack of LARR (adjusted ORs of 3.86 and 2.81 per 0.10 and 10% increase, respectively, both P < 0.01). The combined assessment of CF% with W/H ratio provided complementary risk stratification for persistent LA enlargement.

Conclusions

Central adiposity was associated with a lack of LARR after CA, highlighting the importance of assessing body fat distribution even in nonobese patients.

A causal relationship between appendicular lean mass and atrial fibrillation: A two sample Mendelian randomization study

BACKGROUND AND AIM

The relationship between appendicular lean mass (ALM) and most cardiovascular events has been established, but the direct association between ALM and atrial fibrillation (AF) remains uncertain.

METHODS AND RESULTS

Herein, we identified 494 single-nucleotide polymorphisms (SNPs) strongly associated with ALM as instrumental variables (P < 5E-8) based on a genome-wide association study (GWAS) with 450,243 European participants. Then, we employed five Mendelian randomization (MR) analysis methods to investigate the causal relationship between ALM and AF. All results indicated a causal relationship between ALM and AF, among Inverse variance weighted (P = 8.44E-15, odds ratio [OR]: 1.16, 95 % confidence interval [CI]: 1.114-1.198). Furthermore, we performed a sensitivity analysis, which revealed no evidence of pleiotropy (egger_intercept = 0.000089, P = 0.965) or heterogeneity (MR Egger, Q Value = 0.980; Inverse variance weighted, Q Value = 0.927). The leave-one-out method demonstrates that individual SNPs have no driven impact on the whole causal relationship. Multivariable MR analysis indicates that, after excluding the influence of hypertension and coronary heart disease, a causal relationship between ALM and AF still exists (P = 7.74E-40, OR 95 %CI: 1.389 (1.323-1.458)). Importantly, the Radial MR framework analysis and Robust Adjusted Profile Score (RAPS) further exhibit the robustness of this causal relationship.

CONCLUSION

A strong association between ALM and AF was confirmed, and high ALM is a risk factor for AF.

Evaluation of the Effect of Conversion of Nonvalvular Atrial Fibrillation to Sinus Rhythm on Cardiac Remodeling

BACKGROUND

Atrial fibrillation (AF) represents the most prevalent cardiac arrhythmia globally, with a significant burden on mortality and morbidity. While rhythm control strategies, particularly electrical cardioversion (EC), have gained traction in recent years, the precise impact of sinus rhythm (SR) restoration on cardiac reverse remodeling remains a subject of debate.

METHODS

In this study, 23 AF patients underwent elective EC. AF diagnosis was made via ECG by a cardiologist, and candidates for cardioversion were selected by an electrophysiologist. Transthoracic echocardiography (TTE) by utilizing two-dimensional, three-dimensional, and tissue Doppler imaging modalities was performed before cardioversion. Patients who maintained SR after six months underwent a second TTE evaluation.

RESULTS

SR was restored successfully in all 23 patients and 15 patients (65.2%) maintained SR after six months. SR group had significantly lower baseline cardiac output (CO) and indexed left ventricular end-systolic volume (LVESVi), and better European Heart Rhythm Association (EHRA) scores after six months. Within the SR group, patients exhibited significant changes in mitral regurgitation, tricuspid regurgitation, EHRA score, LVESVi, stroke volume, left ventricle ejection fraction, left ventricle global longitudinal strain, indexed minimum left atrial volume, left atrial emptying fraction, and left and right atrial diameters. Reduced CO was associated with AF recurrence. Receiver operating curve analysis revealed that CO value can predict six-month AF recurrence with a cut-off point of 2.3.

CONCLUSION

Our study underscores the beneficial effects of SR restoration on cardiac parameters in AF patients post EC. Notably, CO value emerged as a predictor of AF recurrence, emphasizing the importance of comprehensive assessments for predicting long-term outcomes.

Valvular heart disease: from mechanisms to management

Valvular heart disease is common and its prevalence is rapidly increasing worldwide. Effective medical therapies are insufficient and treatment was historically limited to the surgical techniques of valve repair or replacement, resulting in systematic underprovision of care to older patients and those with substantial comorbidities, frailty, or left ventricular dysfunction. Advances in imaging and surgical techniques over the past 20 years have transformed the management of valvular heart disease. Better understanding of the mechanisms and causes of disease and an increasingly extensive and robust evidence base provide a platform for the delivery of individualised treatment by multidisciplinary heart teams working within networks of diagnostic facilities and specialist heart valve centres. In this Series paper, we aim to provide an overview of the current and future management of valvular heart disease and propose treatment approaches based on an understanding of the underlying pathophysiology and the application of multidisciplinary treatment strategies to individual patients.

New Approaches to Assessment and Management of Tricuspid Regurgitation Before Intervention

Severe tricuspid regurgitation (TR) is a progressive condition associated with substantial morbidity, poor quality of life, and increased mortality. Patients with TR commonly have coexisting conditions including congestive heart failure, pulmonary hypertension, chronic lung disease, atrial fibrillation, and cardiovascular implantable electronic devices, which can increase the complexity of medical and surgical TR management. As such, the optimal timing of referral for isolated tricuspid valve (TV) intervention is undefined, and TV surgery has been associated with elevated risk of morbidity and mortality. More recently, an unprecedented growth in TR treatment options, namely the development of a wide range of transcatheter TV interventions (TTVI) is stimulating increased interest and referral for TV intervention across the entire medical community. However, there are no stepwise algorithms for the optimal management of symptomatic severe TR before TTVI. This article reviews the contemporary assessment and management of TR with addition of a medical framework to optimize TR before referral for TTVI.

Functional tricuspid regurgitation and efficacy of electrical cardioversion in patients with atrial fibrillation and atrial functional mitral regurgitation

INTRODUCTION

Atrial functional mitral regurgitation (afMR) is common in patients with atrial fibrillation (AF). The presence of functional tricuspid regurgitation (fTR), which arises as a secondary effect of afMR, has the potential to impact the effectiveness of procedures aimed at restoring normal heart rhythm. In this study, we sought to evaluate the efficacy of electrical cardioversion (CVE) in AF regarding the presence and degree of fTR in patients with afMR.

MATERIAL AND METHODS

Retrospective analysis included 521 patients with persistent AF on optimal medical therapy undergoing CVE. 157 (30.1%) patients had afMR (characterized by left ventricle ejection fraction ≥ 50% and LA dilatation) and were divided into 2 groups: the group with fTR (107, 68.2%) and the group without fTR (50, 31.9%).

RESULTS

Patients with afMR and fTR had a higher prevalence of metabolic syndrome (p = 0.02) and greater right atrial area (p < 0.01) compared to patients without fTR. The efficacy of CVE was lower in the group with fTR in comparison to patients with isolated afMR (82.2% vs. 94%; p = 0.048) and it was unrelated to the degree of fTR (p = 0.15) and RVSP (p = 0.56). The energy required for successful CVE was comparable regardless of the presence (p = 0.26) or severity of fTR (p = 0.94).

CONCLUSIONS

The fTR frequently coexists with afMR and it significantly diminishes the effectiveness of CVE for treating AF. The degree of fTR does not appear to influence the efficacy of CVE.

Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Relationship between duration of atrial fibrillation and right heart structure remodeling as assessed by 3-dimensional transesophageal echocardiography

BACKGROUND

Tricuspid valve (TV) remodeling occurs in patients with atrial fibrillation (AF); however, the affecting factor related to TV remodeling in AF remains to be elucidated. We sought to explore whether the AF persistence itself affects right heart remodeling.

METHODS

A total of 372 lone AF patients (234 paroxysmal AF [paroxAF] and 138 persistent AF [persAF]) who underwent 3-dimensional transesophageal echocardiography (3D-TEE) was retrospectively reviewed. The duration from first-detected episode of AF to the TEE exam date was defined as AF duration.

RESULTS

PersAF patients had a larger TV area index (625.4 vs 719.0 mm2/m2; P < 0.001) and a higher right atrium area-to-right ventricle end-systolic area ratio (RA/RVESA ratio, 1.7 vs 1.9; P = 0.005) than paroxAF patients. The prevalence of AF-tricuspid regurgitation was higher in persAF than in paroxAF patients (1.3% vs 12.3%; P < 0.001). In persAF patients, AF duration was moderately correlated with TV diameter and 3D-TEE-derived TV annular area but not in paroxAF. On multivariable analysis, AF duration was independently associated with TV annular dilatation even after adjustment for RA/RVESA ratio and tricuspid regurgitation severity (β 0.37 [95% CI: 0.77-1.81]; P < 0.001). Additionally, AF duration with cutoff values of 20 months for predicting TV annular dilatation and 37 months for predicting RA/RVESA ratio > 2.1 had both high diagnostic accuracies among persAF patients (both P < 0.01).

CONCLUSIONS

AF duration itself is independently associated with right heart remodeling in persAF but not in paroxAF, such as TV annular dilatation and predominant RA remodeling which may lead to subsequent TR progression and adverse outcomes.

Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment

Atrial secondary tricuspid regurgitation (A-STR) is a distinct phenotype of secondary tricuspid regurgitation with predominant dilation of the right atrium and normal right and left ventricular function. Atrial secondary tricuspid regurgitation occurs most commonly in elderly women with atrial fibrillation and in heart failure with preserved ejection fraction in sinus rhythm. In A-STR, the main mechanism of leaflet malcoaptation is related to the presence of a significant dilation of the tricuspid annulus secondary to right atrial enlargement. In addition, there is an insufficient adaptive growth of tricuspid valve leaflets that become unable to cover the enlarged annular area. As opposed to the ventricular phenotype, in A-STR, the tricuspid valve leaflet tethering is typically trivial. The A-STR phenotype accounts for 10%-15% of clinically relevant tricuspid regurgitation and has better outcomes compared with the more prevalent ventricular phenotype. Recent data suggest that patients with A-STR may benefit from more aggressive rhythm control and timely valve interventions. However, little is mentioned in current guidelines on how to identify, evaluate, and manage these patients due to the lack of consistent evidence and variable definitions of this entity in recent investigations. This interdisciplinary expert opinion document focusing on A-STR is intended to help physicians understand this complex and rapidly evolving topic by reviewing its distinct pathophysiology, diagnosis, and multi-modality imaging characteristics. It first defines A-STR by proposing specific quantitative criteria for defining the atrial phenotype and for discriminating it from the ventricular phenotype, in order to facilitate standardization and consistency in research.

Reduction of moderate to severe tricuspid regurgitation after catheter ablation for atrial fibrillation

OBJECTIVE

Tricuspid regurgitation (TR) is a progressive disease with high mortality and limited medical treatment options, and its association with atrial fibrillation (AF) has been documented. This study aimed to investigate whether successful rhythm control through catheter ablation for AF could reduce TR severity.

METHODS

A total of 106 patients with drug-refractory AF with moderate to severe secondary TR who underwent AF ablation were screened from a single-centre ablation registry. Echocardiographic parameter changes (pre-procedure vs 1 day/1 year post-procedure) were analysed. Holter monitoring was performed at 3/6/12 months to assess AF recurrence. The primary outcome was at least one grade TR reduction with its main determinants evaluated.

RESULTS

After excluding 36 patients (prior tricuspid valve surgery, intracardiac devices or insufficient data), 70 patients (aged 63.8±9.7 years, 50% female) were analysed. Of these, 17 (24.3%) had severe TR, 55 (78.6%) persistent AF and all restored sinus rhythm with catheter ablation. The primary outcome was achieved in 53 (75.7%) at 1-year assessment (73.6% of moderate and 82.4% of severe TR). There were significant decreases of vena contracta (6.1→3.2 mm) and tricuspid annular diameter (37.3→32.6 mm) at 1 year. Although 25 patients experienced AF recurrence within 1 year, 56 (80%) patients finally maintained sinus rhythm with medical treatment (87% in patients with TR reduction and 59% without). From the multivariate analysis, sinus rhythm maintenance was the most significant determinant of TR reduction (OR 8.3, 95% CI 1.8 to 37.4).

CONCLUSION

In patients with AF with moderate to severe TR, more than two-thirds of patients experienced reduced TR severity, with notable improvements in echocardiographic parameters. Sinus rhythm maintenance was associated with significant TR reduction.

Does asymptomatic atrial fibrillation exist?

Atrial fibrillation (AF) is currently defined as symptomatic by asking patients if they are aware of when they are in AF and if they feel better in sinus rhythm. However, this approach of defining AF as symptomatic and asymptomatic fails to adequately consider the adverse effects of AF in patients who are unaware of their rhythm including progression from paroxysmal to persistent AF, and the development of dementia, stroke, sinus node dysfunction, valvular regurgitation, ventricular dysfunction, and heart failure. Labeling these patients as asymptomatic falsely suggests that their AF requires less intense therapy and puts into question the notion of truly asymptomatic AF. Because focusing on patient awareness ignores other important consequences of AF, clinical endpoints that are independent of symptoms are being developed. The concept of AF burden has more recently been used as a clinical endpoint in clinical trials as a more clinically relevant endpoint compared to AF-related symptoms or time to first recurrence, but its correlation with symptoms and other clinical outcomes remains unclear. This review will explore the impact of AF on apparently asymptomatic patients, the use of AF burden as an endpoint for AF management, and potential refinements to the AF burden metric. The review is based on a presentation by the senior author during the 2023 16th annual European Cardiac Arrhythmia Society (ECAS) congress in Paris, France.

Circulating exosome long non-coding RNAs are associated with atrial structural remodeling by increasing systemic inflammation in atrial fibrillation patients

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia with severe clinical sequelae, but its genetic characteristic implicated in pathogenesis has not been completely clarified. Accumulating evidence has indicated that circulating exosomes and their carried cargoes, such as long non-coding RNAs (lncRNAs), involve in the progress of multiple cardiovascular diseases. However, their potential role as clinical biomarkers in AF diagnosis and prognosis remains unknown.

Methods

Herein, we conducted the sequence and bioinformatic analysis of circulating exosomes harvested from AF and sinus rhythm patients.

Results

A total of 53 differentially expressed lncRNAs were identified, and a total of 6 significantly changed lncRNAs (fold change > 2.0), including NR0046235, NR003045, NONHSAT167247.1, NONHSAT202361.1, NONHSAT205820.1 and NONHSAT200958.1, were verified by qRT-PCR in 215 participants. Moreover, these circulating exosome lncRNA levels were different between paroxysmal and persistent AF patients, which were dramatically associated with abnormal hemodynamics and atrial diameter. Furthermore, we observed that the area under ROC curve (AUC) of six lncRNAs combination for diagnosis of persistent AF was 80.34%. Gene ontology (GO) and Kyoto encyclopedia of genes and genomes (KEGG) enrichment pathway analysis indicated these exosome lncRNAs mainly concerning response to chemokine-chemokine receptor interaction, which induced activated inflammation and structural remodeling. In addition, increased plasma levels of CXCR3 ligands, including CXCL4, CXCL9, CXCL10 and CXCL11, were accumulated in AF patient tissues.

Conclusion

Our study provides the transcriptome profile revealing pattern of circulating exosome lncRNAs in atrial structural remodeling, which bring valuable insights into improving prognosis and therapeutic targets for AF.

The effect of high-power short-duration pulmonary vein isolation on PWPT-a predictor of paroxysmal atrial fibrillation

BACKGROUND

The P wave peak time (PWPT) is a predictor of paroxysmal atrial fibrillation (PAF). High-power short-duration ablation has been associated with improved durability of circumferential pulmonary vein electrical isolation (PVI). We investigated the effect of high-power short-duration PVI on PWPT in patients with PAF.

METHODS

Out of 111 patients with PAF, 91 received radiofrequency ablation (ablation group) and 20 received medication treatment (control group). A VIZIGO sheath and an STSF catheter (Biosense Webster, CA, USA) were used together for high-power short-duration circumferential PVI at ablation index values of 500 and 400 for the anterior and posterior walls, respectively. The patients were followed up for 12 months.

RESULTS

The preoperative PWPT in the ablation group was similar to that in the control group: PWPT II = 54.38 ± 6.18 ms vs. 54.35 ± 6.12 ms (p > 0.05), PWPT V1 = 54.19 ± 6.21 ms vs. 54.31 ± 6.08 ms (p > 0.05), respectively. Circumferential PVI was achieved for all patients in the ablation group during the operation. At the 12-month follow-up, there were seven cases of AF recurrence. The PWPT in the ablation group 12 months postoperatively was shorter than the preoperative value: PWPT II = 49.39 ± 7.11 ms vs. 54.38 ± 6.18 ms (p < 0.001), PWPT V1 = 47.69 ± 7.01 ms vs. 54.19 ± 6.21 ms (p < 0.001). The PWPT in the patients with AF recurrence was significantly longer than that in the non-recurrence patients: PWPT II = 50.48 ± 7.12 ms vs. 47.33 ± 6.21 ms (p < 0.001), PWPT V1 = 50.84 ± 7.05 ms vs. 47.19 ± 6.27 ms, (p < 0.001). The PWPT of the control group at the 12-month follow-up was similar to the baseline level: PWPT II = 54.32 ± 6.20 ms vs. 54.35 ± 6.12 ms (p > 0.05), PWPT V1 = 53.89 ± 6.01 ms vs. 54.31 ± 6.08 ms (p > 0.05).

CONCLUSION

The results showed that high-power short-duration PVI had a positive effect on PWPT, which is a predictor of PAF.

Left atrial strain: A memory of the severity of atrial myocardial stress in atrial fibrillation

BACKGROUND

Left atrial (LA) strain is a simple marker of LA function. The aim of the study was to evaluate the determinants of atrial cardiomyopathy in AF.

METHODS

In this pilot study, we prospectively evaluated clinical, biological, metabolomic and echocardiographic parameters for 85 consecutive patients hospitalized for atrial fibrillation (AF) with restoration of sinus rhythm at 6 months. Eighty-one patients with an analysable LA strain at 6 months were divided into groups according to median reservoir strain:<23.3% (n=40) versus≥23.3% (n=41).

RESULTS

Compared to patients with the highest LA strain, patients with lowest LA strain had multiple differences at admission: clinical (older age; more frequent history of AF; more patterns of persistent AF); biological (higher fasting blood glucose levels, glycated haemoglobin, high-sensitivity C-reactive protein, and urea; lower glomerular filtration rate); metabolomic (higher levels of kynurenine, kynurenine/tryptophan, and urea/creatinine; lower levels of arginine and methionine/methionine sulfoxide); and echocardiographic (higher two-dimensional end-systolic LA volume [LAV] indexes; higher three-dimensional end-systolic and end-diastolic LAV and right atrial volume indexes; lower LA and right atrial emptying fractions and three-dimensional right ventricular ejection fraction) (all P<0.05). Area under the receiver operating characteristic curve to predict LA strain alteration at 6 months was highest for a combined score including clinical, biological, metabolomic and echocardiographic variables at admission (area under the receiver operating characteristic curve 0.871; P<0.0001).

CONCLUSIONS

LA reservoir strain could be a memory of initial atrial myocardial stress in AF. It can be predicted using a combination of clinical, biological, metabolomic and echocardiographic admission variables.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Clinical impact of left atrial remodeling pattern in patients with atrial fibrillation: Comparison of volumetric, electrical, and combined remodeling

INTRODUCTION

Atrial fibrillation (AF) is accompanied by various types of remodeling, including volumetric enlargement and histological degeneration. Electrical remodeling reportedly reflects histological degeneration.

PURPOSE

To clarify the differences in determinants and clinical impacts among types of remodeling.

METHODS

This observational study included 1118 consecutive patients undergoing initial ablation for AF. Patients were divided into four groups: minimal remodeling (left atrial volume index [LAVI] < mean value and no low-voltage area [LVA], n = 477); volumetric remodeling (LAVI ≥ mean value and no LVA, n = 361); electrical remodeling (LAVI < mean value and LVA presence, n = 96); and combined remodeling (LAVI ≥ mean value and LVA presence, n = 184). AF recurrence and other clinical outcomes were followed up for 2 and 5 years, respectively.

RESULTS

Major determinants of each remodeling pattern were high age for electrical (odds ratio = 2.32, 95% confidence interval = 1.68-3.25) and combined remodeling (2.57, 1.88-3.49); female for electrical (3.85, 2.21-6.71) and combined remodeling (4.92, 2.90-8.25); persistent AF for combined remodeling (7.09, 3.75-13.4); and heart failure for volumetric (1.71, 1.51-2.53) and combined remodeling (2.21, 1.30-3.75). Recurrence rate after initial ablation increased in the order of minimal remodeling (20.1%), volumetric (27.4%) or electrical remodeling (36.5%), and combined remodeling (50.0%, p < .0001). A composite endpoint of heart failure, stroke, and death occurred in the order of minimal (3.4%), volumetric (7.5%) or electrical (8.3%), and combined remodeling (15.2%, p < .0001).

CONCLUSION

Volumetric, electrical, and combined remodeling were each associated with a unique patient background, and defined rhythm and other clinical outcomes.

Epidemiology, pathophysiology, diagnosis and management of chronic right-sided heart failure and tricuspid regurgitation. A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Right-sided heart failure and tricuspid regurgitation are common and strongly associated with poor quality of life and an increased risk of heart failure hospitalizations and death. While medical therapy for right-sided heart failure is limited, treatment options for tricuspid regurgitation include surgery and, based on recent developments, several transcatheter interventions. However, the patients who might benefit from tricuspid valve interventions are yet unknown, as is the ideal time for these treatments given the paucity of clinical evidence. In this context, it is crucial to elucidate aetiology and pathophysiological mechanisms leading to right-sided heart failure and tricuspid regurgitation in order to recognize when tricuspid regurgitation is a mere bystander and when it can cause or contribute to heart failure progression. Notably, early identification of right heart failure and tricuspid regurgitation may be crucial and optimal management requires knowledge about the different mechanisms and causes, clinical course and presentation, as well as possible treatment options. The aim of this clinical consensus statement is to summarize current knowledge about epidemiology, pathophysiology and treatment of tricuspid regurgitation in right-sided heart failure providing practical suggestions for patient identification and management.