A prediction model based on functional mitral regurgitation for the recurrence of paroxysmal atrial fibrillation (PAF) after post-circular pulmonary vein radiofrequency ablation (CPVA)

AIM

To construct a prediction model based on functional mitral regurgitation (FMR) in patients with paroxysmal atrial fibrillation (PAF) to predict atrial fibrillation recurrence after the post-circular pulmonary vein radiofrequency ablation (CPVA).

METHODS

We retrospectively analyzed 289 patients with PAF who underwent CPVA for the first time. The patients were randomly divided into modeling group and verification group at the ratio of 75:25. In the modeling group, the multivariate logistic regression was used to analyze and construct a prediction model for post-CPVA recurrence in PAF patients, which was then validated in the verification group.

RESULTS

(1) After 3-6 months of follow-up, the patients were divided into sinus rhythm group (252 cases) and recurrence group (24 cases); (2) In the modeling group, the age, left atrial diameter (LAD), and the degree of MR (mild, moderate, severe) were higher in recurrence group than that of the sinus rhythm group, and the left atrial appendage emptying velocity (LAAV) was lower in recurrence group (all p < .05). (3) A model for predicting the recurrence of PAF after radiofrequency ablation was constructed in the modeling group. The equation was: Logit(P) = -3.253 + .092 × age + 1.263 × mild MR + 2.325 × moderate MR + 5.111 × severe MR -.113 × LAAV. The area under the curve (AUC) of the model was .889 in modeling group and .866 in verification group, and the difference was not statistically significant (p > .05).

CONCLUSION

The prediction model of atrial fibrillation (AF) recurrence after CPVA in PAF patients has good predictive efficacy, specificity, and accuracy.

Assessment of Left Atrial Structure and Function by Echocardiography in Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia with significant morbidity and mortality. Exacerbated by the aging population, the prevalence of AF is gradually increasing. Accurate evaluation of structure and function of left atrium (LA) has important prognostic significance in patients with AF. Echocardiography is the imaging technique of first choice to assess LA structure and function due to its better availability, accessibility and safety over cardiac computed tomography and cardiac magnetic resonance. Therefore, the aim of this review is to summarize the recent research progress of evaluating LA size by three-dimensional echocardiography and LA function by speckle tracking echocardiography (STE) in predicting the occurrence and recurrence of AF and determining the risk of stroke in AF. In addition, we summarized the role of traditional echocardiography in detecting AF patients that are at high risk of heart failure or cardiovascular death.

Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial

AIMS

Clinical practice guidelines restrict rhythm control therapy to patients with symptomatic atrial fibrillation (AF). The EAST-AFNET 4 trial demonstrated that early, systematic rhythm control improves clinical outcomes compared to symptom-directed rhythm control.

METHODS AND RESULTS

This prespecified EAST-AFNET 4 analysis compared the effect of early rhythm control therapy in asymptomatic patients (EHRA score I) to symptomatic patients. Primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome, analyzed in a time-to-event analysis. At baseline, 801/2633 (30.4%) patients were asymptomatic [mean age 71.3 years, 37.5% women, mean CHA2DS2-VASc score 3.4, 169/801 (21.1%) heart failure]. Asymptomatic patients randomized to early rhythm control (395/801) received similar rhythm control therapies compared to symptomatic patients [e.g. AF ablation at 24 months: 75/395 (19.0%) in asymptomatic; 176/910 (19.3%) symptomatic patients, P = 0.672]. Anticoagulation and treatment of concomitant cardiovascular conditions was not different between symptomatic and asymptomatic patients. The primary outcome occurred in 79/395 asymptomatic patients randomized to early rhythm control and in 97/406 patients randomized to usual care (hazard ratio 0.76, 95% confidence interval [0.6; 1.03]), almost identical to symptomatic patients. At 24 months follow-up, change in symptom status was not different between randomized groups (P = 0.19).

CONCLUSION

The clinical benefit of early, systematic rhythm control was not different between asymptomatic and symptomatic patients in EAST-AFNET 4. These results call for a shared decision discussing the benefits of rhythm control therapy in all patients with recently diagnosed AF and concomitant cardiovascular conditions (EAST-AFNET 4; ISRCTN04708680; NCT01288352; EudraCT2010-021258-20).

A predictive model using left atrial function and B-type natriuretic peptide level in predicting the recurrence of early persistent atrial fibrillation after radiofrequency ablation

Aim

A predictive model using left atrial function indexes obtained by real‐time three‐dimensional echocardiography (RT‐3DE) and the blood B‐type natriuretic peptide (BNP) level was constructed, and its value in predicting recurrence in patients with early persistent atrial fibrillation (AF) after radiofrequency ablation was explored.

Methods

A total of 228 patients with early persistent AF who were scheduled to receive the first circular pulmonary vein ablation (CPVA) were enrolled. Clinical data of patients were collected: (1) The blood BNP level was measured before radiofrequency ablation; (2) RT‐3DE was used to obtain the left atrial (LA) time‐volume curve; (3) The clinical characteristics, BNP level and LA function parameters were compared, and logistic regression was used to construct a prediction model with combined parameters; (4) The receiver operating characteristic (ROC) curve was used to examine the diagnostic efficacy of the model.

Results

(1) 215 patients with early persistent AF completed CPVA and the follow‐up. After 3–6 months of follow‐up, the patients were divided into sinus rhythm group (160 cases) and recurrence group (55 cases); (2) The recurrence group showed higher minimum LA volume index, diastolic ejection index, and preoperative BNP (all p ≤ .001), while the sinus rhythm group exhibited higher expansion index (PI) and left atrial appendage peak emptying velocity (p ≤ .001); (3) In univariate analysis, BNP level had the best diagnostic performance in predicting the recurrence of AF(AUC = 0.703). We constructed a model based on LA function and BNP level to predict the recurrence of persistent AF after CPVA. This combined model was better than BNP alone in predicting the recurrence of persistent AF after CPVA (AUC: 0.814 vs. 0.703, z = 2.224, p = .026).

Conclusion

The combined model of LA function and blood BNP level has good predictive value for the recurrence of early persistent AF after CPVA.

Atrial fibrillation in the elderly: a risk factor beyond stroke

Atrial fibrillation (AF) represents the most common arrhythmia worldwide and its prevalence exponentially increases with age. It is related to increased risk of ischemic stroke or systemic embolism, which determines a significant burden of morbidity and mortality, as widely documented in the literature. AF also constitutes a risk factor for other less investigated conditions, such as heart failure, pulmonary embolism, impairment in physical performance, reduced quality of life, development of disability, mood disorders and cognitive impairment up to dementia. In the elderly population, the management of AF and its complications is particularly complex due to the heterogeneity of the ageing process, the lack of specific evidence-based recommendations, as well as the high grade of comorbidity and disability characterizing the over 65 years aged people. In the present review, we aim to summarize the pieces of the most updated evidence on AF complications beyond stoke, mainly focusing on the elderly population.

CAABL-AF (California Study of Ablation for Atrial Fibrillation): Mortality and Stroke, 2005 to 2013

BACKGROUND

Ablation for atrial fibrillation (AF) is superior to medical therapy for rhythm control. We compared stroke and mortality among patients undergoing ablation for AF to matched controls in a large multiethnic population.

METHODS

Using discharge and surgical records from California nonfederal hospitals, we identified patients who had ablation and principal diagnosis of AF with at least 1 prior hospitalization for AF. We excluded cases with valve disease, open maze, other arrhythmias, or implantable devices. Matched controls were selected based on years of AF diagnosis, age, sex, and being alive the same number of days from the initial AF encounter to the ablation date. Clinical outcomes, including mortality, ischemic stroke, or hemorrhagic stroke, were assessed using a weighted proportional hazard model, adjusting for demographics, prior admissions with AF before the ablation, calendar year, and presence of chronic comorbidities.

RESULTS

There were 4169 ablation cases and 4169 weighted-matched controls; 39% percent of the ablation group was >65 years, 72% men, 84% white; mean follow-up was up to 3.6±0.9 years. In adjusted models, ablation was associated with significantly lower mortality (per patient-years) 0.9% versus 1.9%, hazard ratio=0.59 (P<0.0001; confidence interval: 0.45-0.77); ischemic stroke (>30 days post-ablation ≤5 years), 0.37% versus 0.59%, hazard ratio=0.68 (P=0.04; confidence interval: 0.47-0.97); hemorrhagic stroke 0.11% versus 0.35%, hazard ratio=0.36 (P=0.001; confidence interval: 0.20-0.64) compared with controls.

CONCLUSIONS

In this large population-based study of hospitalized patients with nonvalvular AF, ablation was associated with lower mortality, ischemic stroke, and hemorrhagic stroke compared with controls.

Who Needs Catheter Ablation And Which Approach?

Catheter ablation therapy for atrial fibrillation (AF) has gained a significant role during maintenance of sinus rhythm compared to anti-arrhythmic medication. Catheter ablation techniques are also improved and progressed over years in parallel to better understanding of disease mechanisms and technological advancements. However, due to invasive nature of the therapy with its pertinent procedural risks, both appropriate patient selection and use of relevant approach should be considered by all electrophysiologists before decide to perform catheter ablation.