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Chang S, Zhang X, Ge C, Zhong Y, Zeng D, Cai Y, Huang T, Wu J. Automatic Echocardiographic Assessment of Left Atrial Function for Prediction of Low-Voltage Areas in Non-Valvular Atrial Fibrillation. Int J Gen Med 2024; 17:4493-4506. [PMID: 39372132 PMCID: PMC11456279 DOI: 10.2147/ijgm.s477499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 09/23/2024] [Indexed: 10/08/2024] Open
Abstract
Purpose Left atrial low-voltage areas (LA-LVAs) identified by 3D-electroanatomical mapping are crucial for determining treatment strategies and prognosis in patients with atrial fibrillation (AF). However, convenient and accurate prediction of LA-LVAs remains challenging. This study aimed to assess the viability of utilizing automatically obtained echocardiographic parameters to predict the presence of LA-LVAs in patients with non-valvular atrial fibrillation (NVAF). Patients and Methods This retrospective study included 190 NVAF patients who underwent initial catheter ablation. Before ablation, echocardiographic data were obtained, left atrial volume and strain were automatically calculated using advanced software (Dynamic-HeartModel and AutoStrain). Electroanatomic mapping (EAM) was also performed. Results were compared between patients with LA-LVAs ≥5% (LVAs group) and <5% (non-LVAs group). Results LA-LVAs were observed in 81 patients (42.6%), with a significantly higher incidence in those with persistent AF than paroxysmal AF (55.6% vs 19.3%, P <0.001). Compared with the non-LVAs group, the LVAs group included significantly older patients, lower left ventricular ejection fraction, higher heart rate, and higher E/e' ratio (P <0.05). The LVAs group exhibited higher left atrial volumemax index (LAVimax) and lower left atrial reservoir strain (LASr) (P <0.001). In multivariate analysis, both LAVimax and LASr emerged as independent indicators of LVAs (OR 0.85; 95% CI 0.80-0.90, P<0.001) and (OR 1.15, 95% CI 1.02-1.29, P =0.021). ROC analysis demonstrated good predictive capacity for LA-LVAs, with an AUC of 0.733 (95% CI 0.650-0.794, P <0.001) for LAVimax and 0.839 (95% CI 0.779-0.898, P <0.001) for LASr. Conclusion Automatic assessment of LAVimax and LASr presents a promising non-invasive modality for predicting the presence of LA-LVAs and evaluating significant atrial remodeling in NVAF patients. This approach holds potential for aiding in risk stratification and treatment decision-making, ultimately improving clinical outcomes in patients.
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Affiliation(s)
- Shuai Chang
- Department of Ultrasonic Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Xiaofeng Zhang
- Department of Ultrasonic Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Chenliang Ge
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yanfen Zhong
- Department of Ultrasonic Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Decai Zeng
- Department of Ultrasonic Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yongzhi Cai
- Department of Ultrasonic Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Tongtong Huang
- Department of Ultrasonic Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Ji Wu
- Department of Ultrasonic Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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Bregasi A, Freeman JV, Curtis JP, Akar JG, Ortiz-Leon XA, Maia JH, Higgins AY, Matthews RV, Sinusas AJ, McNamara RL, Sugeng L, Lin BA. Abnormal left atrial body stiffness is predicted by appendage size: impact of appendage occlusion on left atrial mechanics assessed by pressure-volume analysis. Am J Physiol Heart Circ Physiol 2022; 323:H559-H568. [PMID: 35960632 PMCID: PMC9576173 DOI: 10.1152/ajpheart.00083.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Atrial cardiomyopathy has been recognized as having important consequences for cardiac performance and clinical outcomes. The pathophysiological role of the left atrial (LA) appendage and the effect of percutaneous left atrial appendage occlusion (LAAO) upon LA mechanics is incompletely understood. We evaluated if changes in LA stiffness due to endocardial LAAO can be detected by LA pressure-volume (PV) analysis and whether stiffness parameters are associated with baseline characteristics. Patients undergoing percutaneous endocardial LAAO (n = 25) were studied using a novel PV analysis using near-simultaneous three-dimensional LA volume measurements by transesophageal echocardiography (TEE) and direct invasive LA pressure measurements. LA stiffness (dP/dV, change in pressure with change in volume) was calculated before and after LAAO. Overall LA stiffness significantly increased after LAAO compared with baseline (median, 0.41-0.64 mmHg/mL; P ≪ 0.001). LA body stiffness after LAAO correlated with baseline LA appendage size by indexed maximum depth (Spearman's rank correlation coefficient Rs = 0.61; P < 0.01). LA stiffness change showed an even stronger correlation with baseline LA appendage size by indexed maximum depth (Rs = 0.70; P < 0.001). We found that overall LA stiffness increases after endocardial LAAO. Baseline LA appendage size correlates with the magnitude of increase and LA body stiffness. These findings document alteration of LA mechanics after endocardial LAAO and suggest that the LA appendage modulates overall LA compliance.NEW & NOTEWORTHY Our study documents a correlation of LA appendage remodeling with the degree of chronically abnormal LA body stiffness. In addition, we found that LA appendage size was the baseline parameter that best correlated with the magnitude of a further increase in overall LA stiffness after appendage occlusion. These findings offer insights about the LA appendage and LA mechanics that are relevant to patients at risk for adverse atrial remodeling, especially candidates for LA appendage occlusion.
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Affiliation(s)
- Alda Bregasi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - James V Freeman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Joseph G Akar
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Julia H Maia
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Angela Y Higgins
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ray V Matthews
- Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Albert J Sinusas
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
- Department of Biomedical Engineering, Yale University School of Engineering and Applied Science, New Haven, Connecticut
| | - Robert L McNamara
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ben A Lin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
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Kim DY, Kim YG, Choi HY, Choi YY, Boo KY, Lee KN, Roh SY, Shim J, Choi JI, Kim YH. Sex-Related Differences in Left Atrial Low-Voltage Areas According to CHA 2DS 2-VA Scores among Patients with Atrial Fibrillation. J Clin Med 2022; 11:jcm11113111. [PMID: 35683498 PMCID: PMC9181075 DOI: 10.3390/jcm11113111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
(1) Background: We hypothesized that female sex would have a differential impact on left atrial (LA) low-voltage areas (LVAs) according to CHA2DS2-VA scores. (2) Methods: This study included 553 patients who underwent radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). LVAs were defined as regions with bipolar peak-to-peak voltages of <0.5 mV. The proportion of LVAs was calculated by dividing the total LVA by the LA surface area. (3) Results: There was no sex-related difference in LA LVAs among patients with a CHA2DS2-VA scores ≤ 2. The proportion of LVAs was significantly higher in females among patients with CHA2DS2-VA scores of 3 or 4 (10.1 (4.7−15.1)% vs. 15.8 (9.2−32.1)%; p = 0.027). Female sex was significantly associated with extensive LVAs (LVA proportion ≥ 30%). Females had odd ratios of 27.82 (95% confidence interval (CI) 3.33−756.8, p = 0.01), and 1.53 (95% CI 0.81−2.83, p = 0.184) for extensive LAVs in patients with CHA2DS2-VA scores ≥ 3 and CHA2DS2-VA scores < 3, respectively. In the multiple regression model, female patients with a CHA2DS2-VA ≥3 were significantly associated with a higher proportion of LVAs (β = 8.52, p = 0.039). (4) Conclusions: Female sex was significantly associated with extensive LVAs, particularly when their CHA2DS2-VA scores were ≥3. This result suggests that female sex has a differential effect on the extent of LVAs based on the presence of additional risk factors.
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Affiliation(s)
- Do Young Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Korea; (D.Y.K.); (Y.G.K.); (Y.Y.C.); (S.-Y.R.); (J.-I.C.); (Y.-H.K.)
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea
| | - Yun Gi Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Korea; (D.Y.K.); (Y.G.K.); (Y.Y.C.); (S.-Y.R.); (J.-I.C.); (Y.-H.K.)
| | - Ha Young Choi
- Division of Cardiology, Soonchunhyang University Chonan Hospital, Chonan 31151, Korea;
| | - Yun Young Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Korea; (D.Y.K.); (Y.G.K.); (Y.Y.C.); (S.-Y.R.); (J.-I.C.); (Y.-H.K.)
| | - Ki Yung Boo
- Division of Cardiology, Jeju National University Hospital, Jeju 63241, Korea;
| | - Kwang-No Lee
- Department of Cardiology, Ajou University School of Medicine, Suwon 16499, Korea;
| | - Seung-Young Roh
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Korea; (D.Y.K.); (Y.G.K.); (Y.Y.C.); (S.-Y.R.); (J.-I.C.); (Y.-H.K.)
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Korea; (D.Y.K.); (Y.G.K.); (Y.Y.C.); (S.-Y.R.); (J.-I.C.); (Y.-H.K.)
- Correspondence:
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Korea; (D.Y.K.); (Y.G.K.); (Y.Y.C.); (S.-Y.R.); (J.-I.C.); (Y.-H.K.)
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Korea; (D.Y.K.); (Y.G.K.); (Y.Y.C.); (S.-Y.R.); (J.-I.C.); (Y.-H.K.)
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Qiu D, Peng L, Ghista DN, Wong KKL. Left Atrial Remodeling Mechanisms Associated with Atrial Fibrillation. Cardiovasc Eng Technol 2021; 12:361-372. [PMID: 33650086 DOI: 10.1007/s13239-021-00527-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/09/2021] [Indexed: 02/05/2023]
Abstract
Heart disease has always been one of the important diseases that endanger health and cause death. Therefore, it is particularly important to understand left atrium reconstruction and atrial fibrillation before heart image processing. The purpose of this paper is to provide an important review of the mechanisms of left atrial remodeling (LAR) associated with atrial fibrillation (AF). LAR refers to the spectrum of pathophysiological changes in (i) atrial structure and physiological function, and (ii) electric, ionic, and molecular milieu of the LA, in response to stresses imposed by conditions such as hypertension, myocardial ischemia, autonomic denervation and congestive heart failure. The main mechanisms of LAR include electrical remodeling, structural remodeling, metabolic remodeling, autonomic remodeling, neurohormones and inflammation, and other influencing factors. LAR is not only the basic mechanism of AF and heart failure, but also the pathophysiological basis of its progression. In clinical practice, AF is the most common persistent arrhythmia, and is believed to be the result of a combination of mechanisms that have triggers and maintenance mechanisms, including spontaneous ectopic pacing and multiple wavelet reentry. While LA electrophysiological, structural, and ultra-structural changes trigger AF, in turn, AF alters the LA electrical and structural properties that promote its maintenance and recurrence. Chronic AF leads to extensive changes in atrial cellular substructures, including loss of myofibrils, accumulation of glycogen, changes in mitochondrial shape and size, fragmentation of sarcoplasmic reticulum, and dispersion of nuclear chromatin. Electrical remodeling and structural remodeling of the atria during AF, involving structural changes and functional impairment of the left atrium, can lead to serious decline in left ventricular function and severe heart failure. Therefore, LAR and AF are inter-activating phenomena, and the resulting complications can cause serious disabling and fatal events. In this paper, we present (i) the mechanisms of LAR, in the form of structural, electrical, metabolic, and neurohormonal changes, and (ii) their interactive roles in initiating and maintaining AF. These in-depth understanding of the atrial remodeling mechanisms can in turn provide useful insights into the treatment of AF and heart failure.
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Affiliation(s)
- Defu Qiu
- School of Electrical and Electronic Engineering, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Liqing Peng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Dhanjoo N Ghista
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
- University 2020 Foundation, San Jose, CA, 95126, USA
| | - Kelvin K L Wong
- School of Electrical and Electronic Engineering, The University of Adelaide, Adelaide, SA, 5005, Australia.
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.
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A novel predictive model for late recurrence after catheter ablation for atrial fibrillation using left appendage volume measured by cardiac computed tomography. Int J Cardiovasc Imaging 2021; 37:2063-2070. [PMID: 33566262 DOI: 10.1007/s10554-021-02169-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
Larger left atrial appendage (LAA) volume is associated with a higher risk of late recurrence (LR) in patients undergoing radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). However, it is unclear whether LAA volume predicts LR, independent of established risk factors. We sought to evaluate the value of LAA volume in predicting LR after RFCA for AF and to develop a score prediction model including LAA volume for these patients. We retrospectively studied 992 patients who underwent RFCA for AF and cardiac computed tomography before RFCA at a single center. At 3 years after RFCA, 362 patients (36.5 %) experienced recurrence. The multivariate Cox regression model showed that age ≥ 75 years (10 points), non-paroxysmal AF (9 points), diabetes mellitus (4 points), left atrial volume index (1 point per 10 ml/m2 rounded to the nearest integer), and the second (4.7 to < 7 ml/m2; 4 points) and third (≥ 7 ml/m2; 5 points) tertiles of the LAA volume index were independent risk factors LR. The above-mentioned risk factors were included in the integrated score model, and the C-index of the proposed score model was 0.715 (95 % confidence interval [CI] 0.679-0.752). LAA volume is an independent predictor of LR and the predictive model including LAA volume showed good discrimination power. These findings provide evidence for the inclusion of LAA volume in the risk stratification for AF recurrence in patients undergoing RFCA for AF.
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Kim YG, Min K, Hwang SH, Shim J, Choi YY, Choi HY, Choi JI, Oh YW, Kim YH. Blood flow volume of left atrial appendage measured by magnetic resonance imaging is improved after radiofrequency catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:669-677. [PMID: 33428249 DOI: 10.1111/jce.14879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/21/2020] [Accepted: 12/29/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Hemodynamics of left atrial appendage (LAA) is an important factor for future risk of ischemic stroke in atrial fibrillation (AF) patients. Velocity encoded cardiac magnetic resonance imaging (VENC-MRI) can evaluate blood flow volume of LAA without any invasive procedures. We aimed to evaluate the association between radiofrequency catheter ablation (RFCA) and LAA hemodynamics measured by MRI. METHODS AND RESULTS Consecutive RFCA cases in a single arrhythmia center were retrospectively analyzed. A total of 3120 AF patients who underwent first RFCA were analyzed. Among these patients 360 patients had both pre- and post-RFCA VENC-MRI evaluation. Atrial fibrillation was non-paroxysmal in 174 (48.3%) patients. Mean VENC-MRI (ml/sec) was significantly improved after RFCA with 49.93 ± 32.92 and 72.00 ± 34.82 for pre- and post-RFCA, respectively. Patients with non-paroxysmal AF (∆VENC-MRI = 14.63 ± 40.67 vs. 30.03 ± 35.37; p < .001) and low pre-RFCA VENC-MRI (∆VENC-MRI = 17.19 ± 38.35 vs. 50.35 ± 29.12; p < .001) had significantly higher improvement in VENC-MRI. Those who experienced late recurrence before post-RFCA MRI had significantly less improvement in LAA flow volume (∆VENC-MRI = 15.55 ± 41.41 vs. 26.18 ± 36.77; p = .011). Late recurrence and pre-RFCA VENC-MRI were significantly associated with ∆VENC-MRI after adjusting covariates. Patients who were AF before RFCA but maintained sinus rhythm after RFCA showed greatest improvement in VENC-MRI. CONCLUSION Effective rhythm control through RFCA can be associated with significant improvement in LAA hemodynamics. Low pre-RFCA VENC-MRI and absence of late recurrence were associated with greater improvement in LAA hemodynamics.
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Affiliation(s)
- Yun Gi Kim
- Arrhythmia Center, Department of Internal Medicine, Korea University Medicine, Seoul, Republic of Korea
| | - Kyongjin Min
- Arrhythmia Center, Department of Internal Medicine, Korea University Medicine, Seoul, Republic of Korea
| | - Sung Ho Hwang
- Arrhythmia Center, Department of Internal Medicine, Korea University Medicine, Seoul, Republic of Korea
| | - Jaemin Shim
- Arrhythmia Center, Department of Internal Medicine, Korea University Medicine, Seoul, Republic of Korea
| | - Yun Young Choi
- Arrhythmia Center, Department of Internal Medicine, Korea University Medicine, Seoul, Republic of Korea
| | - Ha Young Choi
- Arrhythmia Center, Department of Internal Medicine, Korea University Medicine, Seoul, Republic of Korea
| | - Jong-Il Choi
- Arrhythmia Center, Department of Internal Medicine, Korea University Medicine, Seoul, Republic of Korea
| | - Yu-Whan Oh
- Arrhythmia Center, Department of Internal Medicine, Korea University Medicine, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Arrhythmia Center, Department of Internal Medicine, Korea University Medicine, Seoul, Republic of Korea
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Zeljković I, Bulj N, Kordić K, Pavlović N, Radeljić V, Benko I, Zadro Kordić I, Đula K, Kos N, Delić Brkljačić D, Manola Š. Atrial appendages’ mechanics assessed by 3D transoesophageal echocardiography as predictors of atrial fibrillation recurrence after pulmonary vein isolation. IJC HEART & VASCULATURE 2020; 31:100642. [PMID: 33015318 PMCID: PMC7522341 DOI: 10.1016/j.ijcha.2020.100642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/05/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022]
Abstract
Data on atrial appendages' mechanics as predictors of AF recurrence after PVI is scarce. 3D and 2D-TEE have potential to provide additional data on LAA function. Patients with AFR had significantly lower LAA tissue velocity and ostium surface area. RAA tissue velocity and SVC ostium surface area were not correlated to AF recurrence.
Background Although there are numerous studies reflecting predictors of atrial fibrillation (AF) recurrence (AFR) after pulmonary vein isolation (PVI), data on atrial appendages' mechanics is scarce. This study aimed to assess atrial appendages' mechanics by 2-dimensional (2D) and 3-dimenssional (3D) transoesphageal echocardiography (TEE) and to explore its value to predict AFR after PVI. Methods Consecutive patients with paroxysmal AF undergoing first PVIwere analysed. 3D and 2D-TEE with tissue Doppler imaging (TDI) and strain analysis was obtained prior to the PVI, including: left atrial appendage (LAA) TDI and strain analysis, LAA ostium surface area, right atrial appendage’s TDI velocity and superior vena cava (SVC) ostium surface area. The primary end-point was freedom from any documented recurrence of atrial arrhythmia lasting > 30 s. Results This single-centre, prospective study included 74 patients with paroxysmal AF (median age 59 years; 36% female; BMI 27.4 ± 4.1 kg/m2, LA volume index 32 ± 11 mL/m2). After a median follow-up of 14 (IQR 10–22) months, 21 (28%) patients had AFR. In a univariate and multivariate Cox-regression analysis LAA TDI velocity (HR 1.48, 95%CI 1.28–1.62, p < 0.001) and LAA ostium surface area(HR 1.58, 95%CI 1.06–1.81, p = 0.033) both independently predicted AFR after single PVI. RAA TDI velocity and SVC ostium surface area were not correlated to AFR. Conclusion Paroxysmal AF patients with lower LAA TDI tissue velocity and LAA ostium surface area have higher risk of developing AFR after PVI. To our knowledge, this is the first study assessing atrial appendages’ mechanics in predicting AFR after PVI. Clinical trial registration: www.drks.de(Identifier: DRKS00010495)
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Affiliation(s)
- Ivan Zeljković
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
- Corresponding author at: Department of Cardiology, Sestre milosrdnice University Hospital Centre, Vinogradska cesta 29, 10 000 Zagreb, Croatia.
| | - Nikola Bulj
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Krešimir Kordić
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Nikola Pavlović
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Vjekoslav Radeljić
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivica Benko
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Ines Zadro Kordić
- Department of Internal Medicine, County Hospital “dr. Ivo Pedišić”, Sisak, Croatia
| | - Kristijan Đula
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Nikola Kos
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Diana Delić Brkljačić
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Šime Manola
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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Geng M, Lin A, Nguyen TP. Revisiting Antiarrhythmic Drug Therapy for Atrial Fibrillation: Reviewing Lessons Learned and Redefining Therapeutic Paradigms. Front Pharmacol 2020; 11:581837. [PMID: 33240090 PMCID: PMC7680856 DOI: 10.3389/fphar.2020.581837] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022] Open
Abstract
Since the clinical use of digitalis as the first pharmacological therapy for atrial fibrillation (AF) 235 years ago in 1785, antiarrhythmic drug therapy has advanced considerably and become a cornerstone of AF clinical management. Yet, a preventive or curative panacea for sustained AF does not exist despite the rise of AF global prevalence to epidemiological proportions. While multiple elevated risk factors for AF have been established, the natural history and etiology of AF remain incompletely understood. In the present article, the first section selectively highlights some disappointing shortcomings and current efforts in antiarrhythmic drug therapy to uncover reasons why AF is such a clinical challenge. The second section discusses some modern takes on the natural history of AF as a relentless, progressive fibro-inflammatory "atriomyopathy." The final section emphasizes the need to redefine therapeutic strategies on par with new insights of AF pathophysiology.
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Affiliation(s)
| | | | - Thao P. Nguyen
- Division of Cardiology, Department of Medicine, The Cardiovascular Research Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Baek YS, Choi JI, Kim YG, Lee KN, Roh SY, Ahn J, Kim DH, Lee DI, Hwang SH, Shim J, Kim JS, Kim DH, Park SW, Kim YH. Atrial Substrate Underlies the Recurrence after Catheter Ablation in Patients with Atrial Fibrillation. J Clin Med 2020; 9:E3164. [PMID: 33007810 PMCID: PMC7601892 DOI: 10.3390/jcm9103164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 11/16/2022] Open
Abstract
Prediction of recurrences after catheter ablation of atrial fibrillation (AF) remains challenging. We sought to investigate the long-term outcomes after AF catheter ablation. A total of 2221 consecutive patients who underwent catheter ablation for symptomatic AF were included in this study (mean age 55 ± 11 years, 20.3% women, and 59.0% paroxysmal AF). Extensive ablation, in addition to circumferential pulmonary vein isolation, was more often accomplished in patients with non-paroxysmal AF than in those with paroxysmal AF (87.4% vs. 25.3%, p < 0.001). During a median follow-up of 54 months, sinus rhythm (SR) was maintained in 67.1% after index procedure. After redo procedures in 418 patients, 83.3% exhibited SR maintenance. Recurrence rates were similar for single and multiple procedures (17.4% vs. 16.7%, p = 0.765). Subanalysis showed that the extent of late gadolinium enhancement (LGE), as assessed by cardiac magnetic resonance, is greater in patients with recurrence than in those without recurrence (36.2 ± 23.9% vs. 21.8 ± 13.7%, p < 0.001). Cox-regression analysis revealed that non-paroxysmal AF (hazard ratio (HR) 2.238, 95% confidence interval (CI) 1.905-2.629, p < 0.001), overweight (HR 1.314, 95% CI 1.107-1.559, p = 0.020), left atrium dimension ≥ 45 mm (HR 1.284, 95% CI 1.085-1.518, p = 0.004), AF duration (HR 1.020 per year, 95% CI 1.006-1.034, p = 0.004), and LGE ≥ 25% (HR 1.726, 95% CI 1.330-2.239, p < 0.001) are significantly associated with AF recurrence after catheter ablation. This study showed that repeated catheter ablation improves the clinical outcomes of patients with non-paroxysmal AF, suggesting that AF substrate based on LGE may underpin the mechanism of recurrence after catheter ablation.
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Affiliation(s)
- Yong-Soo Baek
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine and Inha University Hospital, Incheon 22212, Korea; (Y.-S.B.); (D.-H.K.)
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Yun Gi Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Kwang-No Lee
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Seung-Young Roh
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Jinhee Ahn
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Dong-Hyeok Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Dae In Lee
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Sung Ho Hwang
- Department of Radiology, Korea University Anam Hospital, Seoul 02841, Korea;
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Jin Seok Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Dae-Hyeok Kim
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine and Inha University Hospital, Incheon 22212, Korea; (Y.-S.B.); (D.-H.K.)
| | - Sang-Weon Park
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (Y.G.K.); (K.-N.L.); (S.-Y.R.); (J.A.); (D.-H.K.); (D.I.L.); (J.S.); (J.S.K.); (S.-W.P.); (Y.-H.K.)
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10
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Abstract
While AF most often occurs in the setting of atrial disease, current assessment and treatment of patients with AF does not focus on the extent of the atrial myopathy that serves as the substrate for this arrhythmia. Atrial myopathy, in particular atrial fibrosis, may initiate a vicious cycle in which atrial myopathy leads to AF, which in turn leads to a worsening myopathy. Various techniques, including ECG, plasma biomarkers, electroanatomical voltage mapping, echocardiography, and cardiac MRI, can help to identify and quantify aspects of the atrial myopathy. Current therapies, such as catheter ablation, do not directly address the underlying atrial myopathy. There is emerging research showing that by targeting this myopathy we can help decrease the occurrence and burden of AF.
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Affiliation(s)
- Harold Rivner
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, US
| | - Raul D Mitrani
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, US
| | - Jeffrey J Goldberger
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, US
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11
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Kim YG, Shim J, Lee KN, Lim JY, Chung JH, Jung JS, Choi JI, Lee SH, Son HS, Kim YH. Management of Atrio-esophageal Fistula Induced by Radiofrequency Catheter Ablation in Atrial Fibrillation Patients: a Case Series. Sci Rep 2020; 10:8202. [PMID: 32424298 PMCID: PMC7235255 DOI: 10.1038/s41598-020-65185-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 04/28/2020] [Indexed: 11/23/2022] Open
Abstract
Atrio-esophageal fistula (AEF) is one of the most devastating complication of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) and surgical repair is strongly recommended. However, optimal surgical approach remains to be elucidated. We retrospectively reviewed AEF cases that occurred after RFCA in a single center and evaluated the clinical results of different surgical approach. Surgical or endoscopic repair was attempted in five AF patients who underwent RFCA. Atrio-esophageal fistula and mediastinal infection was not controlled in the patient who underwent endoscopic repair eventually died. Lethal cerebral air embolism occurred two days after surgery in a patient who underwent esophageal repair only. Primary surgical repair of both the left atrium (LA) and esophagus was performed in the remaining three patients. Among these three patients, two underwent external LA repair and the remaining had internal LA repair via open-heart surgery. External repair of the LA was unsuccessful and one patient dies and another had to undergo second operation with internal repair of the LA. The patient who underwent internal LA repair during the first operation survived without additional surgery. Furthermore, we applied veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with artificial induction of ventricular fibrillation in this patient to prevent air and septic embolism and she had no neurologic sequelae. In summary, surgical correction can be considered preferentially to correct AEF. Open-heart surgical repair of LA from the internal side seems to be an acceptable surgical method. Application of VA-ECMO with artificial induction of ventricular fibrillation might be effective to prevent air and septic embolism.
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Affiliation(s)
- Yun Gi Kim
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Jaemin Shim
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea.
| | - Kwang-No Lee
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Ju Yong Lim
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Jae Ho Chung
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Jae Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Jong-Il Choi
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Sung Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Ho Sung Son
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine Anam Hospital, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Arrhythmia Center, Korea University Medicine Anam Hospital, Seoul, Republic of Korea.
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12
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Lee HG, Shim J, Choi JI, Kim YH, Oh YW, Hwang SH. Use of Cardiac Computed Tomography and Magnetic Resonance Imaging in Case Management of Atrial Fibrillation with Catheter Ablation. Korean J Radiol 2020; 20:695-708. [PMID: 30993921 PMCID: PMC6470091 DOI: 10.3348/kjr.2018.0774] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/21/2019] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia associated with the risk of morbidity and mortality in clinical patients. AF is considered as an arrhythmia type that develops and progresses through close connection with cardiac structural arrhythmogenic substrates. Since the introduction of catheter ablation-mediated electrical isolation of arrhythmogenic substrates, cardiac imaging indicates improved treatment outcome and prognosis with appropriate candidate selection, ablation catheter guidance, and post-ablation follow-up. Currently, cardiac computed tomography (CCT) and cardiovascular magnetic resonance (CMR) imaging are essential in the case management of AF at both pre-and post-procedural stages of catheter ablation. In this review, we discuss the roles and technical considerations of CCT and CMR imaging in the management of patients with AF undergoing catheter ablation.
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Affiliation(s)
- Hee Gone Lee
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jong Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Young Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Yu Whan Oh
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Sung Ho Hwang
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea.
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13
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Hwang J, Park HS, Han S, Jun SW, Kang NY, Jeon JH, Choi SW, Lee CH, Kim IC, Cho YK, Yoon HJ, Kim H, Nam CW, Hur SH. The impact of catheter ablation of atrial fibrillation on the left atrial volume and function: study using three-dimensional echocardiography. J Interv Card Electrophysiol 2019; 57:87-95. [PMID: 31889225 PMCID: PMC7036070 DOI: 10.1007/s10840-019-00696-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/23/2019] [Indexed: 11/25/2022]
Abstract
Purpose The exact correlation between the baseline left atrial (LA) volume (LAV) and atrial fibrillation (AF) radiofrequency catheter ablation (RFCA) outcomes and changes to the LA after AF RFCA has not yet been fully understood. We sought to evaluate the serial changes in the LAV and LA function after RFCA using 3D echocardiography. Methods Consecutive patients who received RFCA of paroxysmal (PAF) or persistent AF (PeAF) at our center between January 2013 and March 2016 were included. Real-time 3D apical full-volume images were acquired, and a 3D volumetric assessment was performed using an automated three-beat averaging method. The LAV index (LAVI) was calculated and the LA ejection fraction (LAEF) was calculated as [LAVmax − LAVmin]/LAVmax. Results Ninety-nine total patients were enrolled, and the mean age was 58.0 ± 8.2 years and 75 (74.7%) were male. There were 59 (59.6%) PAF patients and the remaining 40 (40.4%) had PeAF. AF recurred in 5 of 59 (8.5%) PAF and in 10 of 40 (25%) PeAF patients. The LAVImax increased on 1 day, decreased at 3 months, and then increased again at 1 year but was lower than that at baseline. The LAEF changes were similar to the volume changes but were more prominent in PeAF than PAF patients. The baseline 3D LAVImax was an independent predictor of AF recurrence after RFCA and the cut-off value was 44.13 ml/m2. Conclusion In our study, even after 3 months of scar formation due to ablation, structural remodeling of the LA continued. The changes were more prominent in the non-recurrent, PeAF patients. Electronic supplementary material The online version of this article (10.1007/s10840-019-00696-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jongmin Hwang
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Hyoung-Seob Park
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea.
| | - Seongwook Han
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Seung-Woon Jun
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Na-Young Kang
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Jin-Hwa Jeon
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Sang-Woong Choi
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Cheol Hyun Lee
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - In-Cheol Kim
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Yun-Kyeong Cho
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Hyuck-Jun Yoon
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Hyungseop Kim
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Chang-Wook Nam
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
| | - Seung-Ho Hur
- Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea
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14
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Blum S, Aeschbacher S, Meyre P, Zwimpfer L, Reichlin T, Beer JH, Ammann P, Auricchio A, Kobza R, Erne P, Moschovitis G, Di Valentino M, Shah D, Schläpfer J, Henz S, Meyer‐Zürn C, Roten L, Schwenkglenks M, Sticherling C, Kühne M, Osswald S, Conen D. Incidence and Predictors of Atrial Fibrillation Progression. J Am Heart Assoc 2019; 8:e012554. [PMID: 31590581 PMCID: PMC6818023 DOI: 10.1161/jaha.119.012554] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/21/2019] [Indexed: 11/16/2022]
Abstract
Background The incidence and predictors of atrial fibrillation (AF) progression are currently not well defined, and clinical AF progression partly overlaps with rhythm control interventions (RCIs). Methods and Results We assessed AF type and intercurrent RCIs during yearly follow-ups in 2869 prospectively followed patients with paroxysmal or persistent AF. Clinical AF progression was defined as progression from paroxysmal to nonparoxysmal or from persistent to permanent AF. An RCI was defined as pulmonary vein isolation, electrical cardioversion, or new treatment with amiodarone. During a median follow-up of 3 years, the incidence of clinical AF progression was 5.2 per 100 patient-years, and 10.9 per 100 patient-years for any RCI. Significant predictors for AF progression were body mass index (hazard ratio [HR], 1.03; 95% CI, 1.01-1.05), heart rate (HR per 5 beats/min increase, 1.05; 95% CI, 1.02-1.08), age (HR per 5-year increase 1.19; 95% CI, 1.13-1.27), systolic blood pressure (HR per 5 mm Hg increase, 1.03; 95% CI, 1.00-1.05), history of hyperthyroidism (HR, 1.71; 95% CI, 1.16-2.52), stroke (HR, 1.50; 95% CI, 1.19-1.88), and heart failure (HR, 1.69; 95% CI, 1.34-2.13). Regular physical activity (HR, 0.80; 95% CI, 0.66-0.98) and previous pulmonary vein isolation (HR, 0.69; 95% CI, 0.53-0.90) showed an inverse association. Significant predictive factors for RCIs were physical activity (HR, 1.42; 95% CI, 1.20-1.68), AF-related symptoms (HR, 1.84; 95% CI, 1.47-2.30), age (HR per 5-year increase, 0.88; 95% CI, 0.85-0.92), and paroxysmal AF (HR, 0.61; 95% CI, 0.51-0.73). Conclusions Cardiovascular risk factors and comorbidities were key predictors of clinical AF progression. A healthy lifestyle may therefore reduce the risk of AF progression.
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Affiliation(s)
- Steffen Blum
- Division of CardiologyDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Division of Internal MedicineDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
| | - Stefanie Aeschbacher
- Division of CardiologyDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
| | - Pascal Meyre
- Division of CardiologyDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
| | - Leon Zwimpfer
- Division of CardiologyDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Division of CardiologyDepartment of MedicineInselspitalBern University HospitalUniversity of BernSwitzerland
| | - Jürg H. Beer
- Department of MedicineCantonal Hospital of Baden and Molecular CardiologyUniversity Hospital of ZurichZurichSwitzerland
| | - Peter Ammann
- Division of CardiologyKantonsspital St. GallenSt. GallenSwitzerland
| | - Angelo Auricchio
- Division of CardiologyFondazione Cardiocentro TicinoLuganoSwitzerland
| | - Richard Kobza
- Division of CardiologyLuzerner KantonsspitalLuzernSwitzerland
| | - Paul Erne
- Laboratory for Signal TransductionDepartment of BiomedicineUniversity of BaselBaselSwitzerland
| | | | | | - Dipen Shah
- Division of CardiologyUniversity Hospital GenevaGenevaSwitzerland
| | - Jürg Schläpfer
- Service of CardiologyUniversity Hospital LausanneLausanneSwitzerland
| | - Selina Henz
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
| | - Christine Meyer‐Zürn
- Division of CardiologyDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
| | - Laurent Roten
- Division of CardiologyDepartment of MedicineInselspitalBern University HospitalUniversity of BernSwitzerland
| | | | - Christian Sticherling
- Division of CardiologyDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
| | - Michael Kühne
- Division of CardiologyDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
| | - Stefan Osswald
- Division of CardiologyDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
| | - David Conen
- Division of CardiologyDepartment of MedicineUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Cardiovascular Research Institute BaselUniversity Hospital BaselUniversity of BaselBaselSwitzerland
- Population Health Research InstituteMcMaster UniversityHamiltonOntarioCanada
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15
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Risk Factors for Ischemic Stroke in Atrial Fibrillation Patients Undergoing Radiofrequency Catheter Ablation. Sci Rep 2019; 9:7051. [PMID: 31065030 PMCID: PMC6504925 DOI: 10.1038/s41598-019-43566-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 04/26/2019] [Indexed: 11/23/2022] Open
Abstract
Ischemic stroke after radiofrequency catheter ablation (RFCA) in atrial fibrillation (AF) patients is a great challenge for electrophysiologists. We performed this retrospective study to evaluate clinical and echocardiographic characteristics associated with increased risk of ischemic stroke following RFCA. A total of 2,352 consecutive patients with AF who underwent first-time RFCA were analyzed. Among 10,023 patient*year follow up, ischemic stroke occurred in 49 patients (0.49% per year). Late recurrence after last RFCA was significantly associated with ischemic stroke (3.8% vs. 12.9%, p < 0.001). Old age (≥60 years old) (3.2% vs. 15.4%, p = 0.001), non-paroxysmal AF (hazard ratio = 1.91, p = 0.024), left atrium (LA) size ≥45.0 mm (6.6% vs. 11.7%, p < 0.001), E over E’ ≥10 (4.3% vs. 20.1%, p < 0.001), dense spontaneous echo contrast (SEC) (5.2% vs. 19.0%, p = 0.006), and decreased left atrial appendage (LAA) flow velocity (≤40 cm/sec) (4.1% vs. 10.8%, p < 0.001) were also associated with increased risk of ischemic stroke. The REVEEAL score derived from the risk factors identified in this study was superior to CHA2DS2-VASc score (p < 0.001) for the prediction of ischemic stroke. In conclusion, the risk factors for ischemic stroke in post-RFCA AF patients are not identical to RFCA naive AF patients and different approach to stratify the risk of ischemic stroke is needed.
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16
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Kim YG, Shim J, Boo KY, Kim DY, Oh SK, Lee KN, Choi JI, Kim YH. Different influence of cardiac hemodynamics on thromboembolic events in patients with paroxysmal and non-paroxysmal atrial fibrillation. PLoS One 2019; 14:e0214743. [PMID: 30925176 PMCID: PMC6440630 DOI: 10.1371/journal.pone.0214743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/19/2019] [Indexed: 11/19/2022] Open
Abstract
Blood stasis in left atrium (LA) or LA appendage (LAA) is thought to be the main cause of thrombus formation and systemic embolism in atrial fibrillation (AF) patients. Paroxysmal and non-paroxysmal AF differ significantly in various aspects. Impact of cardiac hemodynamics on systemic embolism might also differ between the 2 distinct AF entities. This study was performed to evaluate the influence of cardiac hemodynamics on systemic embolism in both paroxysmal and non-paroxysmal AF. Consecutive AF patients undergoing radiofrequency catheter ablation (RFCA) in Korea University Medical Center Anam Hospital between June 1998 and February 2018 were analyzed. Among 2,801 patients who underwent first-time RFCA, a total of 231 patients had either previous ischemic stroke, transient ischemic attack, or arterial embolism. In paroxysmal AF, LA diameter, LA volume (measured with magnetic resonance imaging), left ventricular (LV) ejection fraction, E/e’, LAA flow velocity, and prevalence of spontaneous echocontrast (SEC) and dense SEC were significantly different between patients with and without thromboembolic events. However, only E/e’ was different between patients with and without thromboembolic events in non-paroxysmal AF. The influence of LA diameter, LA volume, LV EF, LAA flow velocity, and dense SEC on thromboembolic events was significantly moderated by the type of AF. In conclusion, paroxysmal and non-paroxysmal AF might have a different mechanism responsible for thrombus formation and consequent embolic events. Relative contribution of hemodynamic parameters and other factors such as atrial myopathy to thromboembolic events in paroxysmal versus non-paroxysmal AF needs further evaluation.
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Affiliation(s)
- Yun Gi Kim
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Jaemin Shim
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
- * E-mail: (JS); (YHK)
| | - Ki Yung Boo
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Do Young Kim
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Suk-Kyu Oh
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Kwang-No Lee
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Jong-Il Choi
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
- * E-mail: (JS); (YHK)
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17
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Electrical isolation of the left atrial appendage increases the risk of ischemic stroke and transient ischemic attack regardless of postisolation flow velocity. Heart Rhythm 2019; 15:1746-1753. [PMID: 30502771 DOI: 10.1016/j.hrthm.2018.09.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Electrical isolation of the left atrial appendage (LAA) is associated with a lower rate of atrial fibrillation (AF) recurrence in patients undergoing radiofrequency catheter ablation. However, LAA isolation can significantly impair LAA contractility. OBJECTIVE This study was performed to evaluate whether electrical isolation of the LAA is associated with an increased risk of ischemic stroke or transient ischemic attack (TIA). METHODS Consecutive patients with AF undergoing radiofrequency catheter ablation at Korea University Medical Center Anam Hospital were analyzed. RESULTS Of 2352 patients, 39 (1.7%) had LAA isolation. Patients with LAA isolation had a significantly higher rate of ischemic stroke or TIA than did those without LAA isolation (log-rank, P < .001; hazard ratio 23.6; P < .001). There were significant differences in the baseline characteristics of the 2 groups, including type of AF (34 [87.2%] and 911 [39.4%] patients with and without LAA isolation had nonparoxysmal AF, respectively). After multivariate adjustment, LAA isolation was found to be a significant risk factor for ischemic stroke or TIA (adjusted hazard ratio 11.3; P < .001). Propensity score-matched analysis also revealed an increased risk of ischemic stroke or TIA in patients with LAA isolation compared with those without LAA isolation (log-rank, P = .001). The LAA flow velocity of post-LAA isolation status was not significantly different between patients who did and did not experience ischemic stroke or TIA (30.3 ± 17.7 cm/s vs 33.9 ± 17.9 cm/s; P = .608). CONCLUSION A significantly increased risk of ischemic stroke or TIA was observed in patients with electrical isolation of the LAA. In addition, postisolation LAA flow velocity is not a reliable marker to predict future ischemic events.
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Domínguez H, Madsen CV, Westh ONH, Pallesen PA, Carrranza CL, Irmukhamedov A, Park-Hansen J. Does Left Atrial Appendage Amputation During Routine Cardiac Surgery Reduce Future Atrial Fibrillation and Stroke? Curr Cardiol Rep 2018; 20:99. [PMID: 30171381 PMCID: PMC6132740 DOI: 10.1007/s11886-018-1033-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Purpose of Review Stroke is the most feared complication of atrial fibrillation. To prevent stroke, left atrial appendage exclusion has been targeted, as it is the prevalent site for formation of heart thrombi during atrial fibrillation. We review the historic development of methods for exclusion of the left atrial appendage and the evidence to support its amputation during routine cardiac surgery. Recent Findings Evidence is not yet sufficient to routinely recommend left atrial exclusion during heart surgery, despite a high prevalence of postoperative atrial fibrillation. Observational studies indicate that electrical isolation of scarring from clip or suture techniques reduces the arrhythmogenic substrate. Summary Randomized studies comparing different methods of closure of the left atrial appendage before amputation do not exist. Such studies are therefore warranted, as well as studies that can elucidate whether amputation is superior to leaving the left atrial appendage stump. Potentially, thrombogenic remaining pouch after closure should be addressed.
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Affiliation(s)
- Helena Domínguez
- Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Nordre Fasanvej 57, vej 4, Building 3, 3rd Floor, DK-2000, Frederiksberg, Denmark. .,Department of Biomedicine, University of Copenhagen, Blegdamsvej 3B, Panum Building 10.5, DK-2400, Copenhagen, Denmark.
| | - Christoffer Valdorff Madsen
- Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Nordre Fasanvej 57, vej 4, Building 3, 3rd Floor, DK-2000, Frederiksberg, Denmark
| | - Oliver Nøhr Hjorth Westh
- Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Nordre Fasanvej 57, vej 4, Building 3, 3rd Floor, DK-2000, Frederiksberg, Denmark
| | - Peter Appel Pallesen
- Department of Heart, Lung and Vascular Surgery, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense, Denmark
| | - Christian Lildal Carrranza
- Department of Cardio-thoracic Surgery, Blegdamsvej 9, 2100 København, Copenhagen, Rigshospitalet, Denmark
| | - Akhmadjon Irmukhamedov
- Department of Heart, Lung and Vascular Surgery, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense, Denmark
| | - Jesper Park-Hansen
- Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Nordre Fasanvej 57, vej 4, Building 3, 3rd Floor, DK-2000, Frederiksberg, Denmark.,Department of Biomedicine, University of Copenhagen, Blegdamsvej 3B, Panum Building 10.5, DK-2400, Copenhagen, Denmark
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