Association of pre-ablation level of potential blood markers with atrial fibrillation recurrence after catheter ablation: a meta-analysis

Conventional and Novel Inflammatory Biomarkers in Chronic Heart Failure Patients with Atrial Fibrillation

(1) Background and Objectives: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased morbidity and mortality both in the general population and heart failure patients. Inflammation may promote the initiation, maintenance and perpetuation of AF, but the impact of inflammatory molecular signaling on the association between AF and heart failure remains elusive. (2) Materials and Methods: In 111 patients with chronic stable heart failure, baseline values of conventional (IL-6 and hsCRP) and selected novel inflammatory biomarkers (IL-10, IL-6/IL-10 ratio, orosomucoid and endocan) were determined. Inflammatory biomarkers were compared with respect to the presenting cardiac rhythm. (3) Results: Patients aged below 75 years with AF had significantly higher values of IL-6 and IL-6/IL-10 ratio; IL-6 levels were a significant predictor of AF in both univariate (OR 1.175; 95%CI 1.013-1.363; p = 0.034) and multivariate logistic regression analysis when accounting for other inflammatory biomarkers (OR 1.327; 95% CI 1.068-1.650; p = 0.011). Conversely, there was no association between other novel inflammatory biomarkers and AF. (4) Conclusions: IL-6 levels and the IL-6/IL-10 ratio are associated with AF in patients with chronic stable heart failure under the age of 75 years, suggesting that inflammatory molecular signaling may play a role in the development of AF in the heart failure population.

Pathophysiology and clinical relevance of atrial myopathy

Atrial myopathy is a condition that consists of electrical, structural, contractile, and autonomic remodeling of the atria and is the substrate for development of atrial fibrillation, the most common arrhythmia. Pathophysiologic mechanisms driving atrial myopathy are inflammation, oxidative stress, atrial stretch, and neurohormonal signals, e.g., angiotensin-II and aldosterone. These mechanisms initiate the structural and functional remodeling of the atrial myocardium. Novel therapeutic strategies are being developed that target the pathophysiologic mechanisms of atrial myopathy. In this review, we will discuss the pathophysiology of atrial myopathy, as well as diagnostic and therapeutic strategies.

Association of Preablation Plasma Corin Levels With Atrial Fibrillation Recurrence After Catheter Ablation: A Prospective Observational Study

BACKGROUND

We assessed the impact of pre- and postprocedural plasma corin levels on the recurrence of atrial fibrillation (AF) after catheter ablation (CA).

METHODS AND RESULTS

This prospective, single-center, observational study included patients undergoing their first CA of AF. Corin was measured before and 1 day after CA. The primary end point was recurrent AF between 3 and 12 months after ablation. From April 2019 through May 2021, we analyzed 616 patients with AF (59.09% men) with a mean age of 62.86±9.42 years. Overall, 153 patients (24.84%) experienced recurrent AF. In the recurrence group, the pre- and postprocedure corin concentrations were 539.14 (329.24-702.08) and 607.37 (364.50-753.80) pg/mL, respectively, which were significantly higher than the nonrecurrence group's respective concentrations of 369.05 (186.36-489.28) and 489.12 (315.66-629.05) pg/mL (both P<0.0001). A multivariate Cox regression analysis with confounders found that elevated preablation corin levels were significantly associated with an increased risk of AF recurrence after CA. Receiver operating characteristic curve analysis identified that a preablation corin threshold of >494.85 pg/mL predicted AF recurrence at 1 year. An increase of 1 SD in corin concentrations before CA (264.94 pg/mL) increased the risk of recurrent AF by 54.3% after adjusting for confounding variables (hazard ratio, 1.465 [95% CI, 1.282-1.655]; P<0.0001).

CONCLUSIONS

Plasma corin levels at baseline is a valuable predictor of AF recurrence after CA, independent of established conventional risk factors. Risk stratification before ablation for AF may be useful in selecting treatment regimens for patients.

Obesity, Cardiovascular Disease, and the Promising Role of Semaglutide: Insights from the SELECT Trial

Cardiovascular disease (CVD) is a leading global cause of death, with preventable risk factors like obesity contributing most to it. Obesity's association with CVD originate from factors like inflammation, insulin resistance, and altered lipid profiles. Obesity also raises the risk of atrial fibrillation (AF) and sudden cardiac death. Semaglutide, a GLP-1 receptor agonist, initially used for weight loss and diabetes, emerged as a breakthrough in CVD prevention. The SELECT trial assessed semaglutide's impact on major adverse cardiovascular events (MACE). In this double-blind, placebo-controlled trial, 17,604 adults with CVD and obesity were given a weekly 2.4 mg dose of semaglutide or placebo. The trial observed a significant 20% reduction in MACE risk for those receiving semaglutide, demonstrating its potential in obesity-associated CVD prevention. This shift marks a transformative approach to obesity management and CVD prevention. However, further research is needed to fully comprehend semaglutide's cardiovascular benefits and potential risks.

Prognostic Importance of B-Type Natriuretic Peptide Level in Patients Undergoing Catheter Ablation for Atrial Fibrillation

BACKGROUND

This study assessed the prognostic importance of B-type natriuretic peptide (BNP) concentrations for clinical events after catheter ablation for atrial fibrillation (AF).

METHODS AND RESULTS

We enrolled 1,750 consecutive patients undergoing initial AF ablation whose baseline BNP data were available from a large-scale multicenter observational cohort (TRANQUILIZE-AF Registry). The prognostic impact of BNP concentration on clinical outcomes, including recurrent tachyarrhythmias and a composite of heart failure (HF) hospitalization or cardiac death, was evaluated. Median baseline BNP was 94.2 pg/mL. During a median follow-up of 2.4 years, low BNP (<38.3 pg/mL) was associated with lower rates of recurrent atrial tachyarrhythmias than BNP concentrations ≥38.3 pg/mL (19.9% vs. 30.6% at 3 years; P<0.001) and HF (0.8% vs. 5.3% at 3 years; P<0.001). Multivariable Cox regression analyses revealed that low BNP was independently associated with lower risks of arrhythmia recurrence (hazard ratio [HR] 0.63; 95% confidence interval [CI] 0.47-0.82; P<0.001) and HF (HR 0.17; 95% CI 0.04-0.71; P=0.002). The favorable impact of low BNP on arrhythmia recurrence was prominent in patients with paroxysmal, but not non-paroxysmal, AF, particularly among those with long-standing AF.

CONCLUSIONS

Low BNP concentrations had a favorable impact on clinical outcomes after AF ablation. The heterogeneous impact of baseline BNP concentrations on arrhythmia recurrence for the subgroups of patients divided by AF type warrants future larger studies with longer follow-up periods.

Prevalence, Associated Factors, and Echocardiographic Estimation of Left Atrial Hypertension in Patients With Atrial Fibrillation

Background Elevated left atrial (LA) pressure predisposes individuals to the initiation and persistence of atrial fibrillation (AF), and LA hypertension is associated with AF recurrence after catheter ablation (CA). However, the exact frequency and factors associated with LA hypertension are unknown, and its noninvasive estimation is challenging. This study aimed to investigate the prevalence and determinants of LA hypertension in patients with AF who underwent first CA. Methods and Results We examined 183 patients with AF who underwent conventional and speckle-tracking echocardiography before CA to assess LA size, reservoir strain, and stiffness. Direct LA pressure was measured at the time of CA, and LA hypertension was defined as mean LA pressure >15 mm Hg. Thirty-three (18.0%) patients exhibited LA hypertension. Patients with LA hypertension had a significantly larger LA volume index (40.2 [28.4-52.1] versus 34.1 [26.9-42.4] mL/m2, P=0.025), reduced LA reservoir strain (15.1 [10.4-21.7] versus 22.7 [14.4-32.3] %, P=0.002) and increased LA stiffness (0.69 [0.34-0.99] versus 0.36 [0.24-0.54], P<0.001). Multivariable analyses showed that waist circumference, C-reactive protein level, LA reservoir strain, and LA stiffness were independently associated with LA hypertension (all P<0.05), while LA volume and E/e' ratio were not. Among echocardiographic parameters, receiver operating characteristic curve analysis identified LA stiffness as the best predictor of LA hypertension. Conclusions Approximately 20% of patients with AF who underwent CA had LA hypertension. Central obesity and inflammation might be involved in the pathophysiological mechanisms of LA hypertension, and echocardiography-derived LA stiffness may have clinical utility for the detection of LA hypertension before CA.

Atrial Natriuretic Peptides as a Bridge between Atrial Fibrillation, Heart Failure, and Amyloidosis of the Atria

ANP is mainly synthesized by the atria, and upon excretion, it serves two primary purposes: vasodilation and increasing the renal excretion of sodium and water. The understanding of ANP's role in cardiac systems has improved considerably in recent decades. This review focuses on several studies demonstrating the importance of analyzing the regulations between the endocrine and mechanical function of the heart and emphasizes the effect of ANP, as the primary hormone of the atria, on atrial fibrillation (AF) and related diseases. The review first discusses the available data on the diagnostic and therapeutic applications of ANP and then explains effect of ANP on heart failure (HF) and atrial fibrillation (AF) and vice versa, where tracking ANP levels could lead to understanding the pathophysiological mechanisms operating in these diseases. Second, it focuses on conventional treatments for AF, such as cardioversion and catheter ablation, and their effects on cardiac endocrine and mechanical function. Finally, it provides a point of view about the delayed recovery of cardiac mechanical and endocrine function after cardioversion, which can contribute to the occurrence of acute heart failure, and the potential impact of restoration of the sinus rhythm by extensive ablation or surgery in losing ANP-producing sites. Overall, ANP plays a key role in heart failure through its effects on vasodilation and natriuresis, leading to a decrease in the activity of the renin-angiotensin-aldosterone system, but it is crucial to understand the intimate role of ANP in HF and AF to improve their diagnosis and personalizing the patients' treatment.

Biomarkers as predictors of recurrence of atrial fibrillation post ablation: an updated and expanded systematic review and meta-analysis

Background

A high proportion of patients undergoing catheter ablation (CA) for atrial fibrillation (AF) experience recurrence of arrhythmia. This meta-analysis aims to identify pre-ablation serum biomarker(s) associated with arrhythmia recurrence to improve patient selection before CA.

Methods

A systematic approach following PRISMA reporting guidelines was utilised in libraries (Pubmed/Medline, Embase, Web of Science, Scopus) and supplemented by scanning through bibliographies of articles. Biomarker levels were compared using a random-effects model and presented as odds ratio (OR). Heterogeneity was examined by meta-regression and subgroup analysis.

Results

In total, 73 studies were identified after inclusion and exclusion criteria were applied. Nine out of 22 biomarkers showed association with recurrence of AF after CA. High levels of N-Terminal-pro-B-type-Natriuretic Peptide [OR (95% CI), 3.11 (1.80–5.36)], B-type Natriuretic Peptide [BNP, 2.91 (1.74–4.88)], high-sensitivity C-Reactive Protein [2.04 (1.28–3.23)], Carboxy-terminal telopeptide of collagen type I [1.89 (1.16–3.08)] and Interleukin-6 [1.83 (1.18–2.84)] were strongly associated with identifying patients with AF recurrence. Meta-regression highlighted that AF type had a significant impact on BNP levels (heterogeneity R² = 55%). Subgroup analysis showed that high BNP levels were more strongly associated with AF recurrence in paroxysmal AF (PAF) cohorts compared to the addition of non-PAF patients. Egger’s test ruled out the presence of publication bias from small-study effects.

Conclusion

Ranking biomarkers based on the strength of association with outcome provides each biomarker relative capacity to predict AF recurrence. This will provide randomised controlled trials, a guide to choosing a priori tool for identifying patients likely to revert to AF, which are required to substantiate these findings.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01978-w.

Biomarkers in the clinical management of patients with atrial fibrillation and heart failure

Atrial fibrillation (AF) and heart failure (HF) are two cardiovascular diseases with an increasing prevalence worldwide. These conditions share common pathophysiologiesand frequently co-exit. In fact, the occurrence of either condition can 'cause' the development of the other, creating a new patient group that demands different management strategies to that if they occur in isolation. Regardless of the temproral association of the two conditions, their presence is linked with adverse cardiovascular outcomes, increased rate of hospitalizations, and increased economic burden on healthcare systems. The use of low-cost, easily accessible and applicable biomarkers may hasten the correct diagnosis and the effective treatment of AF and HF. Both AF and HF effect multiple physiological pathways and thus a great number of biomarkers can be measured that potentially give the clinician important diagnostic and prognostic information. These will then guide patient centred therapeutic management. The current biomarkers that offer potential for guiding therapy, focus on the physiological pathways of miRNA, myocardial stretch and injury, oxidative stress, inflammation, fibrosis, coagulation and renal impairment. Each of these has different utility in current clinincal practice.

The role of brain natriuretic peptide in atrial fibrillation: a substudy of the Substrate Modification with Aggressive Blood Pressure Control for Atrial Fibrillation (SMAC-AF) trial

BACKGROUND

Catheter ablation is an established therapy for atrial fibrillation but is limited by recurrence; efforts have been made to identify biomarkers that predict recurrence. We investigated the effect of baseline NT-proBNP on AF recurrence following catheter ablation in patients randomized to aggressive (< 120/80 mmHg) or standard blood pressure management (< 140/90 mmHg) in the Substrate Modification with Aggressive Blood Pressure Control trial (SMAC-AF).

METHODS

The SMAC-AF study included 173 patients resistant or intolerant to at least one class I or III antiarrhythmic drug. We studied the effect of baseline NT-proBNP on the primary outcome of AF recurrence > 3 months post-ablation.

RESULTS

Of the 173 patients, 88 were randomized to the aggressive cohort, and 85 into the standard group. The primary outcome occurred in 61.4% of those in the aggressive arm, versus 61.2% in the standard arm. In the aggressive group, logNT-proBNP predicted recurrence (HR 1.28, p = 0.04, adjusted HR 1.43, p = 0.03), while in the standard cohort, it did not (HR 0.94, p = 0.62, adjusted HR 0.83, p = 0.22). NT-proBNP ≥ 280 pg/mL also predicted occurrence in the aggressive (HR 1.98, p = 0.02) but not the standard cohort (HR 1.00, p = 1.00).

CONCLUSION

We conclude that pre-ablation NT-proBNP may be useful in predicting recurrence in hypertensive patients and identifying patients who benefit from aggressive blood control and upstream therapies.

TRIAL REGISTRATION

NCT00438113, registered February 21, 2007.

Association between pericoronary adipose tissue attenuation and outcome after second-generation cryoballoon ablation for atrial fibrillation

OBJECTIVES

Previous studies reported the association between inflammation and atrial fibrillation (AF). Pericoronary adipose tissue (PCAT) attenuation, PCATA, on cardiac CT angiography (CTA) reflects pericoronary inflammation. We hypothesized that the PCATA predicts AF recurrence after cryoballoon ablation (CBA) for paroxysmal and persistent AF.

METHODS

We studied 364 patients (median age, 65 years) with persistent (n = 41) and paroxysmal (n = 323) AF undergoing successful first-session second-generation CBA with pre-ablation cardiac CTA. Three-vessel (3V)-PCATA was defined as the mean CT attenuation value of PCAT of all three major coronary arteries. Predictors of AF recurrence during follow-up were evaluated.

RESULTS

AF recurrence after the 3-month blanking period was detected in 90 patients (24.7%) during the median follow-up of 26 (interquartile range, 19-42) months. AF recurrence was associated with prior stroke and statin use, NT-proBNP and high-sensitivity cardiac troponin-I levels, left ventricular dimension, left atrial volume index (LAVI), 3V-PCATA, and early AF recurrence during the blanking period. On multivariable Cox proportional hazard analysis, prior stroke (hazard ratio [HR], 2.208, 95% confidence interval [CI], 1.166-4.180, p = 0.015), LAVI (HR, 1.030, 95% CI, 1.010-1.051, p = 0.003), 3V-PCATA (HR, 1.034, 95% CI, 1.001-1.069, p = 0.046), and early AF recurrence (HR, 2.858, 95% CI, 1.855-4.405, p < 0.001) remained statistically significant.

CONCLUSION

Pre-ablation CTA-derived 3V-PCATA, representing pericoronary inflammation, was an independent predictor of recurrence after first-session AF ablation using a second-generation cryoballoon.

ADVANCES IN KNOWLEDGE

Assessment of 3V-PCATA may identify patients at high risk of AF recurrence after CBA for AF.

Atrial fibrillation: is there a role for cardiac troponin?

Atrial fibrillation (AF) is the most common sustained arrhythmia, and its prevalence rate is expected to be doubled over the next decades. Despite the wide use of biomarkers in the management of different cardiac diseases such as myocardial infarction and heart failure, utilization of biomarkers in AF management is not routinely recommended by current guidelines. There is also growing evidence that higher levels of cardiac-specific troponin, as an intracellular protein involved in cardiomyocyte contraction, may be associated with the risk of incident and recurrent AF and its complications. In the present paper, we review the association between troponin and AF and propose clinical suggestions for use of troponin in the management of AF patients.

Is There an Association between Epicardial Adipose Tissue and Outcomes after Paroxysmal Atrial Fibrillation Catheter Ablation?

Background: In patients undergoing paroxysmal atrial fibrillation (PAF) ablation, pulmonary vein isolation (PVI) alone fails in maintaining sinus rhythm in up to one third of patients after a first catheter ablation. Epicardial adipose tissue (EAT), as an endocrine-active organ, could play a role in the recurrence of AF after catheter ablation. Objective: To evaluate the predictive value of clinical, echocardiographic, biological parameters and epicardial fat density measured by computed tomography scan (CT-scan) on AF recurrence in PAF patients who underwent a first pulmonary vein isolation procedure using radiofrequency (RF). Methods: This monocentric retrospective study included all patients undergoing first-time RF PAF ablation at the Nancy University Hospital between March 2015 and December 2018 with one-year follow-up. Results: 389 patients were included, of whom 128 (32.9%) had AF recurrence at one-year follow-up. Neither total-EAT volume (88.6 ± 37.2 cm³ vs. 91.4 ± 40.5 cm³, p = 0.519), nor total-EAT radiodensity (−98.8 ± 4.1 HU vs. −98.8 ± 3.8 HU, p = 0.892) and left atrium-EAT radiodensity (−93.7 ± 4.3 HU vs. −93.4 ± 6.0 HU, p = 0.556) were significantly associated with AF recurrence after PAF ablation. In multivariate analysis, previous cavo-tricuspid isthmus (CTI) ablation, ablation procedure duration, BNP and triglyceride levels remained independently associated with AF recurrence after catheter ablation at 12-months follow-up. Conclusion: Contrary to persistent AF, EAT parameters are not associated with AF recurrence after paroxysmal AF ablation. Thus, the role of the metabolic atrial substrate in PAF pathophysiology appears less obvious than in persistent AF.

Are the atrial natriuretic peptides a missing link predicting low-voltage areas in atrial fibrillation? Introducing the novel biomarker-based atrial fibrillation substrate prediction (ANP) score

BACKGROUND

In patients with atrial fibrillation (AF), left atrial (LA) enlargement, and the presence of low-voltage areas (LVAs) indicate an advanced disease stage. NT-proANP is a biomarker, which is significantly higher in both phenotypes. Prediction of LVAs before catheter ablation could impact the prognosis and therapeutical management in AF patients.

OBJECTIVE

The aim of this study was to (a) analyze the predictive value of a novel biomarker-based AF substrate prediction score, and (b) compare it with DR-FLASH and APPLE scores.

METHODS

Patients undergoing first AF catheter ablation were included. LA volume (LAV) was analyzed prior to ablation using cardiovascular magnetic resonance imaging (CMR). Blood plasma samples from the femoral vein were collected before AF ablation. NT-proANP was analyzed using commercially available assays. LVAs were determined using high-density maps during catheter ablation and defined as <0.5 mV. The novel ANP score (one point for Age ≥ 65 years, NT-proANP > 17 ng/mL, and Persistent AF) was calculated at baseline.

RESULTS

The study population included 156 AF patients (64 ± 10 years, 65% males, 61% persistent AF, 28% LVAs). The cut-off ANP score ≥ 2 demonstrated 77% sensitivity and 70% specificity. On logistic regression (odds ratio [OR] 3.469) and receiver operating characteristic (ROC) analysis (area under the curve [AUC] 0.778, P < .001), the ANP score significantly predicted LVAs presence. There were no differences between novel ANP score - which is a new one - is described in the Abstract; with APPLE (AUC 0.718, P = .378) and DR-FLASH (AUC 0.766, P = .856) scores.

CONCLUSIONS

The novel biomarker-based ANP score demonstrates good prediction of LVAs.

Serum microRNA in patients undergoing atrial fibrillation ablation

MicroRNAs mediate posttranscriptional gene regulation. The aim of the study was to find a microRNA predictor of successful atrial fibrillation (AF) ablation. A total of 109 patients undergoing first-time AF ablation were included. Nineteen patients were selected to undergo serum microRNA sequencing (study group). The sequencing data were used to select several microRNAs that correlated with 12-month recurrences after AF ablation. Those microRNAs were validated by digital droplet PCR in samples from remaining 90 patients. All patients underwent pulmonary vein isolation (RF ablation, contact force catheter, electroanatomical system). The endpoint of the study was the 12-month AF recurrence rate; the overall recurrence rate was 42.5%. In total, levels of 34 miRNAs were significantly different in sera from patients with AF recurrence compared to patients without AF recurrence. Six microRNAs (miR-183-5p, miR-182-5p, miR-32-5p, miR-107, miR-574-3p, and miR-144-3p) were validated in the whole group. Data from the validation group did not confirm the observations from the study group, as no significant differences were found between miRNAs serum levels in patients with and without recurrences 12 months after AF ablation.

Relationship between plasma cancer antigen (CA)-125 level and one-year recurrence of atrial fibrillation after catheter ablation

BACKGROUND

Previous studies have shown that plasma cancer antigen-125 (CA-125) is closely related to heart failure and new-onset atrial fibrillation (AF), but no study reported the relationship between CA-125 concentrations and advanced recurrence of AF ablation. This research is the first to describe CA-125 as a biomarker for the recurrence of AF after ablation.

METHODS

A total of 422 AF patients undergoing catheter ablation were included in this study.

RESULTS

During the 1-y follow-up, 326 patients (77.25%) maintained a sinus rhythm, whereas 83 patients (20.44%) presented AF recurrence. The patients with AF recurrence showed higher CA-125 concentrations at baseline than those with maintained sinus rhythm (P = 0.0001). Multivariate Cox proportional hazards regression analyses revealed that persistent AF (HR 2.212; 95% CI: 1.396-3.504, P = 0.001) and CA-125 concentration (HR, 1.003; 95% (CI): 1.000-1.005, P = 0.019) were independent predictors of AF recurrence. According to the receiver operating characteristic (ROC) analysis, CA-125 yielded an optimal cut-off value of 11.05 U/ml, and its sensitivity and specificity reached 65.6% and 85.0%, respectively. In addition, the area under the curve (AUC) value spanned 80.3% (95% CI: 0.750-0.857, P < 0.0001). Moreover, the results of the subgroup analysis indicated that patients with persistent atrial fibrillation have higher concentrations of CA-125 and have an increased risk of the recurrence of AF.

CONCLUSIONS

High CA-125 concentration is an independent predictor of AF recurrence after 1 y of AF ablation, especially in patients with persistent AF.

Individualised Approaches for Catheter Ablation of AF: Patient Selection and Procedural Endpoints

Pulmonary vein isolation (PVI) is the cornerstone of AF ablation, but studies have reported improved efficacy with high rates of repeat procedures. Because of the large interindividual variability in the underlying electrical and anatomical substrate, achieving optimal outcomes requires an individualised approach. This includes optimal candidate selection as well as defined ablation strategies with objective procedure endpoints beyond PVI. Candidate selection is traditionally based on coarse and sometimes arbitrary clinical stratification such as AF type, but finer predictors of treatment efficacy including biomarkers, advanced imaging and electrocardiographic parameters have shown promise. Numerous ancillary ablation strategies beyond PVI have been investigated, but the absence of a clear mechanistic and evidence-based endpoint, unlike in other arrhythmias, has remained a universal limitation. Potential endpoints include functional ones such as AF termination or non-inducibility and substrate-based endpoints such as isolation of low-voltage areas. This review summarises the relevant literature and proposes guidance for clinical practice and future research.

Association between reactive hyperemia peripheral arterial tonometry index and atrial fibrillation recurrence after catheter ablation

Background

Vascular endothelial function has recently been recognized as an independent predictor of cardiovascular events. However, studies investigating its association with atrial fibrillation (AF) are lacking. This study aimed to examine association with AF recurrence and vascular endothelial function as assessed using natural logarithmic transformation of reactive hyperemia peripheral arterial tonometry index (LnRHI).

Methods

Ninety-nine consecutive AF patients who underwent catheter ablation (CA) at Shinshu University Hospital between September 2015 and April 2017 were enrolled. LnRHI was measured 48 to 72 h before CA using the EndoPAT system. The primary outcome was AF recurrence beyond 3 months post-ablation.

Results

A total of 30 (30.3%) patients experienced AF recurrence after CA over a median follow-up period of 210 days (range: 93–764 days). Female sex and low LnRHI were significantly associated with AF recurrence. In multivariate analysis, LnRHI was an independent predictor of AF recurrence (hazard ratio: 0.087, 95% confidence interval 0.015–0.51, p = 0.007). In comparison in Kaplan-Meier analysis of high LnRHI (LnRHI ≥0.52, n = 52) and low LnRHI (LnRHI ≪0.52, n = 47) groups, AF recurrence rate was significantly higher in the low LnRHI group (log-rank test, p = 0.043). A negative correlation was observed between LnRHI and AF duration, whereby LnRHI was significantly decreased when the duration of AF events exceeded 1 year.

Conclusion

Decreased LnRHI was associated with AF recurrence after CA and prolonged AF duration.

Clinical Applications of Natriuretic Peptides in Heart Failure and Atrial Fibrillation

Natriuretic peptides (NPs) have become important diagnostic and prognostic biomarkers in cardiovascular diseases, particularly in heart failure (HF). Diagnosis and management of coronary artery disease and atrial fibrillation (AF) can also be guided by NP levels. When interpreting NP levels, however, the caveat is that age, sex, body mass index, renal dysfunction, and race affect the clearance of NPs, resulting in different cut-off values in clinical practice. In AF, NP levels have been associated with incident AF in the general population, recurrences after catheter ablation, prediction of clinical prognosis, and the risk of stroke. In this article, we first review and summarize the current evidence and the roles of B-type NP and atrial NP in HF and coronary artery disease and then focus on the increasing utility of NPs in the diagnosis and management of and the research into AF.

Influence of Left Atrial Appendage Amputation on Natriuretic Peptides-A Randomized Controlled Trial

BACKGROUND

Closure or amputation of the left atrial appendage (LAA) is a common therapy for atrial fibrillation (AF). As the LAA is a hormone-producing organ, however, amputation is still somewhat controversial. We examined patients after surgical AF therapy with or without LAA amputation to determine the influence of LAA amputation on pro-atrial natriuretic peptide (proANP) and B-type natriuretic peptide (BNP) plasma levels and on clinical severity of heart failure.

METHODS

Twenty-one consecutive patients were prospectively randomized to either undergo LAA amputation (n = 10) or no LAA amputation (n = 11) between 05/2015 and 10/2015. All patients underwent coronary and/or valve surgery and concomitant AF surgery with either cryoablation (n = 3) or radio frequency ablation (n = 17). ProANP and BNP levels were measured preoperatively and until 800 days postoperatively.

RESULTS

Baseline proANP values were comparable between the groups (without LAA amputation: 4.2 ± 2.1 nmol/L, with LAA amputation: 5.6 ± 3.6 nmol/L). Postoperatively, proANP levels rose markedly in both groups. Even after LAA amputation, proANP levels remained elevated for 7 days postoperatively but fell to baseline levels at day 31 and remained on baseline level at 800 days postoperatively. ProANP levels in the LAA amputation group (5.8-9.7 nmol/L) were not significantly lower than in the group without LAA amputation (9.2-14.1 nmol/L; p = 0.357). BNP levels also rose after surgery in both groups until day 7. At 800 days after surgery, BNP levels were back at baseline levels in both groups. Clinical follow-up at 2 years postoperatively showed no difference in heart failure symptoms or need for heart failure medication between the groups.

CONCLUSION

In contrast to commonly held beliefs about the endocrine and reservoir functions of the LAA, there seems to be no clinically relevant detrimental effect of LAA amputation on natriuretic peptide levels and severity of heart failure until up to 2 years postoperatively.

Immunopathogenesis and biomarkers of recurrent atrial fibrillation following ablation therapy in patients with preexisting atrial fibrillation

INTRODUCTION

Recurrent atrial fibrillation (RAF) following ablation therapy occurs in about 50% of patients. The pathogenesis of RAF is unknown, but is believed to be driven by atrial remodeling in the setting of background inflammation. Structural, electrophysiological and mechanical remodeling has been associated with atrial fibrillation (AF). Inflammation and fibrotic remodeling are the major factors perpetuating AF, as mediators released from the atrial tissues and cardiomyocytes due to mechanical and surgical injury could initiate the inflammatory process. In this article, we have critically reviewed the key mediators that may serve as potential biomarkers to predict RAF. Areas covered: Damage associated molecular patterns, heat shock proteins, inflammatory cytokines, non-inflammatory markers, markers of inflammatory cell activity, and markers of collagen deposition and metabolism are evaluated as potential biomarkers with molecular treatment options in RAF. Expert commentary: Establishing biomarkers to predict RAF could be useful in reducing morbidity and mortality. Investigations into the role of DAMPs participating in a sterile immune response may provide greater insight into the pathogenesis of RAF. Markers evaluating immune cell activity, collagen deposition, and levels of heat shock proteins show the greatest promise as potential biomarkers to predict RAF and develop novel therapies.

Association Between Cardiovascular Magnetic Resonance-Derived Left Atrial Dimensions, Electroanatomical Substrate and NT-proANP Levels in Atrial Fibrillation

Background Enlargement of left atrial ( LA ) size indicates advanced disease stage in patients with atrial fibrillation ( AF ) and is associated with poor success of different AF therapies. Two dimensional echocardiographic LA measurements do not reliably reflect the true size of LA anatomy. The aim of the current study was: 1) to analyze cardiovascular magnetic resonance ( CMR )-derived LA dimensions and their association with low voltage areas ( LVA ); and 2) to investigate the association between these parameters and NT -pro ANP (N-terminal proatrial natriuretic peptide) levels. Methods and Results Patients undergoing first AF catheter ablation were included. All patients underwent CMR imaging (Ingenia 1.5T Philips) before intervention. CMR data ( LA volume, superior-inferior, transversal and anterior-posterior LA diameters) were measured in all patients. LVA were determined using high-density maps and a low voltage threshold <0.5 mV. Blood plasma samples from femoral vein were collected before catheter ablation. NT -pro ANP levels were studied using commercially available assays. There were 216 patients (65±11 years, 59% males, 56% persistent AF , 26% LVA ) included into analyses. NT -pro ANP levels in patients with LVA were significantly higher than in those without (median/interquartile range 22 [13-29] versus 15 [9-22] pg/mL, P=0.004). All CMR derived LA diameters correlated significantly with persistent AF ( r²=0.291-0.468, all P<0.001), LVA ( r²=0.187-0.306, all P<0.001), and NT -pro ANP levels ( r²=0.258-0.352, P<0.01). On logistic regression multivariable analysis, age (odds ratio=1.090, 95% confidence interval: 1.030-1.153, P=0.003), females (odds ratio=2.686, 95% confidence interval: 1.047-6.891, P=0.040), and LA volume (odds ratio=1.022, 95% confidence interval: 1.009-1.035, P=0.001) remained significant predictors for LVA . Conclusions Left atrial CMR parameters are associated with persistent AF , low voltage areas and NT -pro ANP levels. LA volume is the most significant predictor for LVA .

Pre-ablation levels of brain natriuretic peptide are independently associated with the recurrence of atrial fibrillation after radiofrequency catheter ablation in patients with nonvalvular atrial fibrillation

Association between pre-ablation levels of biomarkers of cardiac and endothelial dysfunctions, CHADS2, CHA2DS2-VASc, and APPLE scores and the recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation has not been fully studied. A total of 254 patients with nonvalvular AF were prospectively followed for AF recurrence after a single ablation procedure. During a two-year follow-up period, AF recurred in 65 (25.6%) patients. Patients with AF recurrence had significantly greater baseline ln brain natriuretic peptide (BNP) than those without AF recurrence (P < 0.01), whereas there were no significant differences in the levels of biomarkers of endothelial dysfunction and points of scoring systems. In the Cox regression analyses, the baseline ln BNP was significantly independently associated with AF recurrence (adjusted HR =1.286, 95% CI =1.000–1.655, P < 0.05). The baseline levels of ln BNP were significantly associated with rhythm at blood collection, age, sex, and left atrial diameter, and left ventricular ejection fraction (P < 0.05).The subgroup analysis showed a significant interaction on the risk of AF recurrence between ln BNP, sex difference, and rhythm at blood collection (P for interaction < 0.05). In conclusion, the results suggest that the pre-ablation levels of ln BNP are useful to evaluate the risk of AF recurrence after ablation therapy; however, there is a need to be careful while using BNP as a biomarker for the risk of AF recurrence by taking account of the effects of rhythm status at blood collection and sex difference.

Influence of Inflammation and Atherosclerosis in Atrial Fibrillation

BACKGROUND

Inflammation markers have been associated with cardiovascular diseases including atrial fibrillation. This arrhythmia is the most frequent, with an incidence of 38/1000 person-years.

PURPOSE OF REVIEW

The aims of this study are to discuss the association between inflammation, atherosclerosis and atrial fibrillation and its clinical implications. Atherosclerosis is a chronic inflammatory disease and inflammation is a triggering factor of atherosclerotic plaque rupture. In addition to coronary artery disease, clinical conditions identified as risk factors for atrial fibrillation (AF) are also associated with the inflammatory state such as obesity, diabetes mellitus, hypertension, heart failure, metabolic syndrome and sedentary lifestyle. Biomarkers of inflammation, oxidative stress, coagulation, and myocardial necrosis have been identified in patients with atrial fibrillation and these traditional risk factors. Some markers of inflammation were identified as predictors of recurrence of this arrhythmia, subsequent myocardial infarction, stroke by embolism, and death. Thus, approaches to manipulate the inflammatory pathways may be therapeutic interventions, benefiting patients with AF and increased inflammatory markers.

Reduced P-wave Voltage in Lead I is Associated with Development of Atrial Fibrillation in Patients with Coronary Artery Disease

Background

Reduced P-wave voltage in lead 1 (PVL1) has been associated with atrial fibrillation (AF) recurrence.This study sought to determine the association between reduced PVL1 and AF in the NSTEMI population and the correlation between reduced PVL1 and interatrial block (IAB)/coronary artery disease (CAD).

Methods

Data were recorded for clinical, echocardiographic, angiographic, electrocardiographic and outcome variables. Patients were followed for a minimum of one year. Chi-square tests, independent samples t-tests and one-way ANOVA were used for the analysis, which was done using IBM SPSSResults:: A total of 322 consecutive patients were included in the analysis. Patients with new-onset AF had a significantly lower PVL1 (0.085 ± 0.030mV vs. 0.103 ± 0.037mV; p=0.007). There was a significant difference in mean PVL1 between those with no IAB, partial IAB and advanced IAB (p = <0.001). Those with any type of IAB had a significantly lower mean PVL1 than those without (0.094 ± 0.032 mV vs. 0.106 ± 0.038 mV; p=0.005). Patients who developed AF had a significantly longer P-wave duration (126 ± 20ms vs. 119 ± 17ms; p=0.022). Patients with IAB were more likely to develop new-onset AF (15.4% versus 7.5%, p=0.025). There were significant co-linear associations between reduced PVL1 and IAB (p=0.005); reduced PVL1 and diffuse CAD (p=0.031) and IAB and diffuse CAD (p=0.022).