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Eppinger S, Piayda K, Galea R, Sandri M, Maarse M, Güner A, Karabay CY, Pershad A, Ding WY, Aminian A, Akin I, Davtyan KV, Chugunov IA, Marijon E, Rosseel L, Schmidt TR, Amabile N, Korsholm K, Lund J, Guerios E, Amat-Santos IJ, Boccuzzi G, Ellis CR, Sabbag A, Ebelt H, Clapp B, Assa HV, Levi A, Ledwoch J, Lehmann S, Lee OH, Mark G, Schell W, Della Rocca DG, Natale A, de Backer O, Kefer J, Esteban PP, Abelson M, Ram P, Moceri P, Galache Osuna JG, Alvarez XM, Cruz-Gonzalez I, de Potter T, Ghassan M, Osadchiy A, Chen W, Goyal SK, Giannini F, Rivero-Ayerza M, Afzal S, Jung C, Skurk C, Langel M, Spence M, Merkulov E, Lempereur M, Shin SY, Mesnier J, McKinney HL, Schuler BT, Armero S, Gheorghe L, Ancona MBM, Santos L, Mansourati J, Nombela-Franco L, Nappi F, Kühne M, Gaspardone A, van der Pals J, Montorfano M, Fernández-Armenta J, Harvey JE, Rodés-Cabau J, Klein N, Sabir SA, Kim JS, Cook S, Kornowski R, Saraste A, Nielsen-Kudsk JE, Gupta D, Boersma L, Räber L, Sievert K, Sievert H, Bertog S. Embolization of percutaneous left atrial appendage closure devices: Timing, management and clinical outcomes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 64:7-14. [PMID: 38448258 DOI: 10.1016/j.carrev.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/25/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Left atrial appendage (LAA) occluder embolization is an infrequent but serious complication. OBJECTIVES We aim to describe timing, management and clinical outcomes of device embolization in a multi-center registry. METHODS Patient characteristics, imaging findings and procedure and follow-up data were collected retrospectively. Device embolizations were categorized according to 1) timing 2) management and 3) clinical outcomes. RESULTS Sixty-seven centers contributed data. Device embolization occurred in 108 patients. In 70.4 % of cases, it happened within the first 24 h of the procedure. The device was purposefully left in the LA and the aorta in two (1.9 %) patients, an initial percutaneous retrieval was attempted in 81 (75.0 %) and surgery without prior percutaneous retrieval attempt was performed in 23 (21.3 %) patients. Two patients died before a retrieval attempt could be made. In 28/81 (34.6 %) patients with an initial percutaneous retrieval attempt a second, additional attempt was performed, which was associated with a high mortality (death in patients with one attempt: 2.9 % vs. second attempt: 21.4 %, p < 0.001). The primary outcome (bailout surgery, cardiogenic shock, stroke, TIA, and/or death) occurred in 47 (43.5 %) patients. Other major complications related to device embolization occurred in 21 (19.4 %) patients. CONCLUSIONS The majority of device embolizations after LAA closure occurs early. A percutaneous approach is often the preferred method for a first rescue attempt. Major adverse event rates, including death, are high particularly if the first retrieval attempt was unsuccessful. CONDENSED ABSTRACT This dedicated multicenter registry examined timing, management, and clinical outcome of device embolization. Early embolization (70.4 %) was most frequent. As a first rescue attempt, percutaneous retrieval was preferred in 75.0 %, followed by surgical removal (21.3 %). In patients with a second retrieval attempt a higher mortality (death first attempt: 2.9 % vs. death second attempt: 24.1 %, p < 0.001) was observed. Mortality (10.2 %) and the major complication rate after device embolization were high.
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Affiliation(s)
| | - Kerstin Piayda
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany; Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, Gießen, Germany
| | - Roberto Galea
- Department of Cardiology, Universitätsspital Bern, Bern, Switzerland
| | | | - Moniek Maarse
- Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Hospital, Istanbul, Turkey
| | - Can Y Karabay
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Education Research Hospital, Istanbul, Turkey
| | - Ashish Pershad
- Department of Cardiology, Banner Health, Phoenix, AZ, USA
| | - Wern Y Ding
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Adel Aminian
- Department of Cardiology, Centre hospitalier universitaire de Charleroi, Charleroi, Belgium
| | - Ibrahim Akin
- Department of Cardiology, Universitätsmedizin Mannheim, Germany
| | - Karapet V Davtyan
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Ivan A Chugunov
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Eloi Marijon
- Department of Cardiology, Hôpital Européen Georges-Pompidou HEGP, Paris, France
| | | | | | - Nicolas Amabile
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Juha Lund
- Heart Center, Turku University Hospital, Turku, Finland
| | - Enio Guerios
- Department of Cardiology, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | | | - Giacomo Boccuzzi
- Department of Cardiology, Ospedale san Giovanni Bosco, Torino, Italy
| | | | - Avi Sabbag
- Department of Cardiology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Henning Ebelt
- Department of Cardiology, Katholisches Krankenhaus St. Nepomuk, Erfurt, Germany
| | - Brian Clapp
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hana Vaknin Assa
- Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Amos Levi
- Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | | | - Sonja Lehmann
- Department of Cardiology, Hôpital Fribourgeois, Fribourg, Switzerland
| | - Oh-Hyun Lee
- Department of Cardiology, Yonsei University Hospital, Yongin, Republic of Korea
| | - George Mark
- The Heart House/Cooper University Camden, NJ, USA
| | - Wendy Schell
- Department of Cardiology, Cooper University Hospital, NJ, USA
| | | | - Andrea Natale
- Department of Cardiology, St David's Medical Center, Austin, TX, USA
| | - Ole de Backer
- Department of Cardiology, Rigshospitalet Copenhagen, Copenhagen, Denmark
| | - Joelle Kefer
- Department of Cardiology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Pablo P Esteban
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Mark Abelson
- Department of interventional Cardiology, Mediclinic Vergelegen, Cape Town, South Africa
| | - Pradhum Ram
- Department of Cardiology, Emory University, Atlanta, GA, USA
| | - Pamela Moceri
- Department of Cardiology, Hopital Pasteur 1, Nice, France
| | | | | | | | | | - Moubarak Ghassan
- Department of Cardiology, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Andrey Osadchiy
- Department of Cardiology, City Hospital #40, St. Petersburg, Russia
| | - Weita Chen
- Department of Cardiology, Taipei Municipal Wanfang Hospital, Taipei, Taiwan
| | | | | | | | - Shazia Afzal
- Department of Cardiology, Heinrich-Heine University, University Hospital, Duesseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Heinrich-Heine University, University Hospital, Duesseldorf, Germany
| | - Carsten Skurk
- Department of Cardiology, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Langel
- Department of Cardiology, Klinikum St. Georg, Leipzig, Germany
| | - Mark Spence
- Department of Cardiology, Royal Victoria Hospital, Belfast Trust, Belfast, UK
| | | | | | - Seung Y Shin
- Cardiovascular & Arrhythmia Center, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Brian T Schuler
- Department of Cardiology, WellSpan York Hospital, York, PA, USA
| | | | - Livia Gheorghe
- Department of Cardiology, Puerta del Mar University Hospital, Cadiz, Spain
| | - Marco B M Ancona
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lino Santos
- Department of Cardiology, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, Portugal
| | | | | | | | - Michael Kühne
- Department of Cardiology, University Hospital Basel, Switzerland
| | | | - Jesper van der Pals
- Department of Cardiology, Lund University and Skane University Hospital, Lund, Sweden
| | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - James E Harvey
- Department of Cardiology, WellSpan York Hospital, York, PA, USA
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Norbert Klein
- Department of Cardiology, Klinikum St. Georg, Leipzig, Germany
| | - Sajjad A Sabir
- Department of Cardiology, Cooper University Hospital, NJ, USA
| | - Jung-Sun Kim
- Department of Cardiology, Yonsei University Hospital, Yongin, Republic of Korea
| | - Stephane Cook
- Department of Cardiology, Hôpital Fribourgeois, Fribourg, Switzerland
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Antti Saraste
- Heart Center, Turku University Hospital, Turku, Finland
| | | | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Lucas Boersma
- Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Lorenz Räber
- Department of Cardiology, Universitätsspital Bern, Bern, Switzerland
| | - Kolja Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany.
| | - Stefan Bertog
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
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Xie F, Jiang Z, Zhu B, Li J, Wu Y, Su H. The heart rate response to the 6-min walk test in atrial fibrillation patients with or without beta-blockers: Referring to patients with sinus rhythm. Ann Noninvasive Electrocardiol 2024; 29:e13128. [PMID: 38872457 PMCID: PMC11176575 DOI: 10.1111/anec.13128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 11/04/2023] [Accepted: 05/21/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND The aim was to evaluate the effect of beta-blockers (BB) on the response of heart rate (HR) to 6-min walk test (6MWT) in atrial fibrillation (AF) and whether the AF patients treated with BB have a similar HR response to 6MWT as the AF and sinus rhythm (SR) patients without BB treatment at the same resting HR level. METHODS The before-after study involving 74 AF patients was to evaluate the effect of BB treatment (pre-BB and with BB). The comparison study included 74 BB-treated AF patients (with BB), 74 matched AF patients without BB (no BB), and 74 SR patients. The percentage increase amplitude of HR (HR-PIA) in 6MWT was calculated: [(the exercise HR - the resting HR)/(the resting HR)] × 100%. RESULTS The before-after study showed that BB treatment decreased the resting and mean exercise HR (98.6 ± 15.2 vs. 85.5 ± 11.2 bpm and 121.3 ± 17.3 vs. 109.0 ± 16.7 bpm) during 6MWT. The comparison study demonstrated that against the SR, the AF with BB and no BB groups have higher mean exercise HR-PIA (28.2 ± 17.1% and 22.0 ± 9.6%, vs. 6.9 ± 3.7%) when their resting HR is similar. Moreover, the mean exercise HR-PIA was also significantly higher in the with BB group than in the no BB group. CONCLUSION In AF patients with relatively higher resting HR, BB treatment could decrease the resting and exercise HR during 6MWT. However, BB treatment could not effectively attenuate the exercise HR rise as compared with AF without BB treatment, even with similar resting HR levels.
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Affiliation(s)
- Feng Xie
- Department of Cardiovascular Medicine, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Zhenzhen Jiang
- Department of Cardiovascular Medicine, Jiujiang University Affiliated Hospital, Jiujiang, Jiangxi, China
| | - Bo Zhu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Juxiang Li
- Department of Cardiovascular Medicine, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Yanqing Wu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Hai Su
- Department of Cardiovascular Medicine, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
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Kukendrarajah K, Ahmad M, Carrington M, Ioannou A, Taylor J, Razvi Y, Papageorgiou N, Mead GE, Nevis IF, D'Ascenzo F, Wilton SB, Lambiase PD, Morillo CA, Kwong JS, Providencia R. External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta-analysis. Cochrane Database Syst Rev 2024; 6:CD013255. [PMID: 38828867 PMCID: PMC11145740 DOI: 10.1002/14651858.cd013255.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). OBJECTIVES To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to collect data and performed a network meta-analysis using the standard frequentist graph-theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. MAIN RESULTS We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy-nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow-up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low-certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. AUTHORS' CONCLUSIONS Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method.
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Affiliation(s)
| | - Mahmood Ahmad
- Department of Cardiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | | | - Adam Ioannou
- Royal Free London NHS Foundation Trust, London, UK
| | - Julie Taylor
- Institute of Health Informatics Research, University College London, London, UK
| | - Yousuf Razvi
- Department of Cardiology, Royal Free Hospital, London, UK
| | | | - Gillian E Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Immaculate F Nevis
- Health Economics and Outcomes Research, ICON plc, Blue Bell, Philadelphia, USA
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Stephen B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Pier D Lambiase
- Centre for Cardiology in the Young, The Heart Hospital, University College London Hospitals, London, UK
| | - Carlos A Morillo
- Department of Cardiac Sciences, Cumming School of Medicine, Foothills Medical Centre, Calgary, Canada
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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Agarwal PP, Nasr LA, Ghoshhajra BB, Brown RKJ, Collier P, De Cecco CN, Fuss C, Goldstein JN, Kallianos K, Malik SB, Maroules CD, Meyersohn NM, Nazarian S, Scherer MD, Singh S, Tailor TD, Tong MS, Koweek LM. ACR Appropriateness Criteria® Preprocedural Planning for Left Atrial Procedures in Atrial Fibrillation. J Am Coll Radiol 2024; 21:S237-S248. [PMID: 38823947 DOI: 10.1016/j.jacr.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
This document summarizes the relevant literature for the selection of preprocedural imaging in three clinical scenarios in patients needing endovascular treatment or cardioversion of atrial fibrillation. These clinical scenarios include preprocedural imaging prior to radiofrequency ablation; prior to left atrial appendage occlusion; and prior to cardioversion. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Layla A Nasr
- Research Author, Allegheny Health Network Imaging Institute, Pittsburgh, Pennsylvania
| | | | - Richard K J Brown
- University of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | - Cristina Fuss
- Oregon Health & Science University, Portland, Oregon
| | - Jennifer N Goldstein
- ChristianaCare Health System, Newark, Delaware; Society of General Internal Medicine
| | | | - Sachin B Malik
- VA Palo Alto Health Care System, Palo Alto, California; Stanford University, Stanford, California
| | | | | | - Saman Nazarian
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Heart Rhythm Society
| | - Markus D Scherer
- Sanger Heart and Vascular Institute, Charlotte, North Carolina; Society of Cardiovascular Computed Tomography
| | - Simranjit Singh
- Indiana University School of Medicine, Indianapolis, Indiana; American College of Physicians
| | - Tina D Tailor
- Duke University Medical Center, Durham, North Carolina
| | - Matthew S Tong
- Ohio State University, Columbus, Ohio; Society for Cardiovascular Magnetic Resonance
| | - Lynne M Koweek
- Specialty Chair, Duke University Medical Center, Durham, North Carolina
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Binding C, Blanche P, Lip GYH, Kamper AL, Lee CJY, Staerk L, Gislason G, Torp-Pedersen C, Olesen JB, Bonde AN. Efficacy and safety of oral anticoagulants according to kidney function among patients with atrial fibrillation. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:210-218. [PMID: 38402466 DOI: 10.1093/ehjcvp/pvae016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/31/2024] [Accepted: 02/23/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND AND AIMS Patients with severely reduced kidney function have been excluded from randomized controlled trials and data on the safety and efficacy of direct oral anticoagulants (DOACs) according to kidney function remain sparse. The aim was to evaluate the safety and efficacy of the DOACs across subgroups of kidney function. METHODS Using multiple Danish nationwide registers and laboratory databases, we included patients initiated on oral anticoagulants (OACs) with atrial fibrillation and available creatinine level and followed patients for 2 years to evaluate occurrence of stroke/thromboembolism (TE) and major bleeding. RESULTS Among 26 686 included patients, 3667 (13.7%) had an estimated glomerular filtration rate (eGFR) of 30-49 mL/min/1.73 m2 and 596 (2.2%) had an eGFR below 30 mL/min/1.73 m2. We found no evidence of differences regarding the risk of stroke/TE between the OACs (P-value interaction >0.05 for all). Apixaban was associated with a lower 2-year risk of major bleeding compared to vitamin K antagonists (VKA) [hazard ratio 0.79, 95% confidence interval (CI) 0.67-0.93], and the risk difference was significantly larger among patients with reduced kidney function (P-value interaction 0.018). Rivaroxaban was associated with a higher risk of bleeding compared to apixaban (hazard ratio 1.78, 95%CI 1.32-2.39) among patients with eGFR 30-49 mL/min/1.73 m2. CONCLUSIONS Overall, we found no differences regarding the risk of stroke/TE, but apixaban was associated with a 21% lower relative risk of major bleeding compared to VKA. This risk reduction was even greater when comparing apixaban to VKA among patients with eGFR 15-30 mL/min/1.73 m2, and when comparing apixaban to dabigatran and rivaroxaban among patients with eGFR 30-49 mL/min/1.73 m2.
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Affiliation(s)
- Casper Binding
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
- Department of Cardiology, Aalborg Universitetshospital, Aalborg, Denmark
| | - Paul Blanche
- Department of Public Health, Section of Biostatistics, University of Copenhagen, 1014 Copenhagen K, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christina J Y Lee
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
- Department of Cardiology, Nordsjællands Hospital, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
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6
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Zhuo W, Wang B, Fu G, Yu Y, Feng M, Liu J, Du X, Chu H. Impact of left atrial appendage orifice diameter on the safety and efficacy of left atrial appendage closure using the LAmbre device. J Formos Med Assoc 2024; 123:600-605. [PMID: 38238125 DOI: 10.1016/j.jfma.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 12/02/2023] [Accepted: 01/05/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND The diameter and shape of the left atrial appendage (LAA) orifices may influence occluder selection and the outcomes of left atrial appendage closure (LAAC) procedure. This study aimed to evaluate the impact of LAA orifice diameter on the safety and efficacy of LAAC using the LAmbre device. METHODS A total of 133 patients with nonvalvular atrial fibrillation (AF) who underwent LAAC with the LAmbre device between June 2018 and June 2020 were included in this study. The patients were categorized into two groups based on the maximal diameter of the LAA orifice: the large LAA group (n = 45) with a maximal orifice diameter of ≥31 mm, and the normal LAA group (n = 88) with a maximal orifice diameter of <31 mm. The study assessed periprocedural characteristics and long-term clinical follow-up. RESULTS Successful implantation of the LAmbre device was observed in all patients. The incidence of periprocedural peridevice leakage (PDL) was significantly higher in the large LAA group (P < 0.001), while the incidence of acute pericardial effusion (PE) during the procedure was comparable between the two groups (P = 1.000). After a mean follow-up period of 4.8 ± 1.7 years, three patients in the large LAA group developed delayed PE, while no patients in the normal LAA group did (P = 0.037). Additionally, a larger LAA maximal orifice diameter was associated with a higher prevalence of PDL (P = 0.001) and PE (including both acute and delayed PE) (P = 0.027). The optimal cutoff value of the LAA maximal orifice diameter for predicting PDL and PE after LAAC with the LAmbre device was determined to be 30 mm. CONCLUSION The findings suggest that the LAmbre device is a safe and feasible option for occluding the LAA, regardless of its orifice diameter. However, it is important to note that a larger LAA orifice diameter may increase the risk of PDL and delayed PE.
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Affiliation(s)
- Weidong Zhuo
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Binhao Wang
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Guohua Fu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Yibo Yu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Mingjun Feng
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Jing Liu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Xianfeng Du
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Huimin Chu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China.
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Gkarmiris KI, Lindbäck J, Alexander JH, Granger CB, Kastner P, Lopes RD, Ziegler A, Oldgren J, Siegbahn A, Wallentin L, Hijazi Z. Repeated Measurement of the Novel Atrial Biomarker BMP10 (Bone Morphogenetic Protein 10) Refines Risk Stratification in Anticoagulated Patients With Atrial Fibrillation: Insights From the ARISTOTLE Trial. J Am Heart Assoc 2024; 13:e033720. [PMID: 38529655 PMCID: PMC11179770 DOI: 10.1161/jaha.123.033720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/16/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND BMP10 (bone morphogenic protein 10) has emerged as a novel biomarker associated with the risk of ischemic stroke and other outcomes in patients with atrial fibrillation (AF). The study aimed to determine if repeated BMP10 measurements improve prognostication of cardiovascular events in patients with AF. METHODS AND RESULTS BMP10 was measured using a prototype Elecsys immunoassay in plasma samples collected at randomization and after 2 months in patients with AF randomized to apixaban or warfarin in the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial (n=2878). Adjusted Cox-regression models were used to evaluate the association between 2-month BMP10 levels and outcomes. BMP10 levels increased by 7.8% (P<0.001) over 2 months. The baseline variables most strongly associated with BMP10 levels at 2 months were baseline BMP10 levels, body mass index, sex, age, creatinine, diabetes, warfarin treatment, and AF-rhythm. During median 1.8 years follow-up, 34 ischemic strokes/systemic embolism, 155 deaths, and 99 heart failure hospitalizations occurred. Comparing the third with the first sample quartile, higher BMP10 levels at 2 months were associated with higher risk of ischemic stroke (hazard ratio [HR], 1.33 [95% CI, 0.67-2.63], P=0.037), heart failure (HR, 1.91 [95% CI, 1.17-3.12], P=0.012) and all-cause death (HR, 1.61 [95% CI, 1.17-2.21], P<0.001). Adding BMP10 levels at 2 months on top of established risk factors and baseline BMP10 levels improved the C-indices for ischemic stroke/systemic embolism (from 0.73 to 0.75), heart failure hospitalization (0.76-0.77), and all-cause mortality (0.70-0.72), all P<0.05. CONCLUSIONS Elevated levels of BMP10 at 2 months strengthened the associations with the risk of ischemic stroke, hospitalization for heart failure, and all-cause mortality. Repeated measurements of BMP10 may further refine risk stratification in patients with AF.
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Affiliation(s)
- Konstantinos I. Gkarmiris
- Department of Medical SciencesCardiology, Uppsala UniversityUppsalaSweden
- Uppsala Clinical Research Center, Uppsala UniversityUppsalaSweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala UniversityUppsalaSweden
| | - John H. Alexander
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
| | | | | | - Renato D. Lopes
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
| | | | - Jonas Oldgren
- Department of Medical SciencesCardiology, Uppsala UniversityUppsalaSweden
- Uppsala Clinical Research Center, Uppsala UniversityUppsalaSweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala UniversityUppsalaSweden
- Department of Medical SciencesClinical Chemistry, Uppsala UniversityUppsalaSweden
| | - Lars Wallentin
- Department of Medical SciencesCardiology, Uppsala UniversityUppsalaSweden
- Uppsala Clinical Research Center, Uppsala UniversityUppsalaSweden
| | - Ziad Hijazi
- Department of Medical SciencesCardiology, Uppsala UniversityUppsalaSweden
- Uppsala Clinical Research Center, Uppsala UniversityUppsalaSweden
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Doldi F, Geßler N, Anwar O, Kahle AK, Scherschel K, Rath B, Köbe J, Lange PS, Frommeyer G, Metzner A, Meyer C, Willems S, Kuck KH, Eckardt L. In-Hospital Pulmonary Arterial Embolism after Catheter Ablation of Over 45,000 Cardiac Arrhythmias: Individualized Case Analysis of Multicentric Data. Thromb Haemost 2024. [PMID: 38555641 DOI: 10.1055/s-0044-1785519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
OBJECTIVE AND BACKGROUND Data on incidence of in-hospital pulmonary embolisms (PE) after catheter ablation (CA) are scarce. To gain further insights, we sought to provide new findings through case-based analyses of administrative data. METHODS Incidences of PE after CA of supraventricular tachycardias (SVT), atrial fibrillation (AF), atrial flutter (AFlu), and ventricular tachycardias (VT) in three German tertiary centers between 2005 and 2020 were determined and coded by the G-DRG (German Diagnosis Related Groups System) and OPS (German Operation and Procedure Classification) systems. An administrative search was performed with a consecutive case-based analysis. RESULTS Overall, 47,344 ablations were analyzed (10,037 SVT; 28,048 AF; 6,252 AFlu; 3,007 VT). PE occurred in 14 (0.03%) predominantly female (n = 9; 64.3%) patients with a mean age of 55.3 ± 16.9 years, body mass index 26.2 ± 5.1 kg/m2, and left ventricular ejection fraction of 56 ± 13.6%. PE incidences were 0.05% (n = 5) for SVT, 0.02% (n = 5) for AF, and 0.13% (n = 4) for VT ablations. No patient suffered PE after AFlu ablation. Five patients (35.7%) with PE after CA had no prior indication for oral anticoagulation (OAC). Preprocedural international normalized ratio in PE patients was 1.2 ± 0.5. Most patients with PE following CA presented with symptoms the day after the procedure (n = 9) after intraprocedural heparin application of 12,943.2 ± 5,415.5 IU. PE treatment included anticoagulation with either phenprocoumon (n = 5) or non-vitamin K-dependent OAC (n = 9). Two patients with PE died after VT/AF ablation, respectively. The remaining patients were discharged without sequels. CONCLUSION Over a 15-year period, incidence of PE after ablation is low, particularly low in patients with ablation for AF/AFlu. This is most likely due to stricter anticoagulation management in these patients compared with those receiving SVT/VT ablation procedures and could argue for continuation of OAC prior to ablation. Optimizing periprocedural anticoagulation management should be subject of further prospective trials.
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Affiliation(s)
- Florian Doldi
- Department for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Nele Geßler
- Department of Cardiology and Intensive Care, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Omar Anwar
- Department of Cardiology and Intensive Care, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Ann-Kathrin Kahle
- Klinik für Kardiologie, Angiologie, Intensivmedizin, cNEP Research Consortium EVK, Düsseldorf, Germany
| | - Katharina Scherschel
- Klinik für Kardiologie, Angiologie, Intensivmedizin, cNEP Research Consortium EVK, Düsseldorf, Germany
| | - Benjamin Rath
- Department for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Julia Köbe
- Department for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Philipp Sebastian Lange
- Department for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Gerrit Frommeyer
- Department for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Andreas Metzner
- Klinik und Poliklinik für Kardiologie, Universitäres Herz- und Gefäßzentrum UKE Hamburg, Hamburg, Germany
| | - Christian Meyer
- Klinik für Kardiologie, Angiologie, Intensivmedizin, cNEP Research Consortium EVK, Düsseldorf, Germany
| | - Stephan Willems
- Department of Cardiology and Intensive Care, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology and Intensive Care, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Lars Eckardt
- Department for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
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AlTurki A, Essebag V. Atrial Fibrillation Burden: Impact on Stroke Risk and Beyond. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:536. [PMID: 38674182 PMCID: PMC11051719 DOI: 10.3390/medicina60040536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/07/2024] [Accepted: 03/14/2024] [Indexed: 04/28/2024]
Abstract
Atrial fibrillation (AF) is an important independent risk factor for stroke. Current guidelines handle AF as a binary entity with risk driven by the presence of clinical risk factors, which guides the decision to treat with an oral anticoagulant. Recent studies in the literature suggest a dose-response relationship between AF burden and stroke risk, in both clinical AF and subclinical atrial fibrillation (SCAF), which differs from current guidance to disregard burden and utilize clinical risk scores alone. Within clinical classification and at the same risk levels in various scores, the risk of stroke increases with AF burden. This opens the possibility of incorporating burden into risk profiles, which has already shown promise. Long-term rhythm monitoring is needed to elucidate SCAF in patients with stroke. Recent data from randomized trials are controversial regarding whether there is an independent risk from AF episodes with a duration of less than 24 h, including the duration of SCAF greater than six minutes but less than 24 h.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Montreal, QC H3G1A4, Canada
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriya 13110, Kuwait
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Montreal, QC H3G1A4, Canada
- Division of Cardiology, Hopital Sacre-Coeur de Montreal, Montreal, QC H4J 1C5, Canada
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Lin KJ, Singer DE, Avorn J, Heist EK, Sreedhara SK, Anand P, Zhang Y, Tsacogianis TN, Schneeweiss S. Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2024; 17:e010279. [PMID: 38440888 PMCID: PMC10950527 DOI: 10.1161/circoutcomes.123.010279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 11/30/2023] [Indexed: 03/06/2024]
Abstract
BACKGROUND Transcatheter left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation, but the predictors of LAAO use in routine care are unclear. We aimed to assess the utilization trends of LAAO and compare the change in characteristics of LAAO users versus OACs since its marketing. METHODS Using the US Medicare claims database (March 15, 2015, to December 31, 2020), we identified patients with atrial fibrillation, ≥65 years, and CHA2DS2-VASc score ≥2 (men) or ≥3 (women), with either first implantation of an LAAO device or initiation of OACs, including apixaban, dabigatran, rivaroxaban, edoxaban, or warfarin. Patient characteristics, measured 365 days before the first LAAO or OAC use date, were compared using logistic regression. RESULTS There were 30 058 LAAO recipients (mean age, 77.74 years; female, 42.1%) and 792 600 OAC initiators (mean age, 78.48; female, 53.3%). In 2020, patients had higher odds of initiating LAAO use than in 2015 (0.52 versus 9.32%; adjusted odds ratio [aOR], 13.64 [95% CI, 12.56-14.81]). Old age (ie, >85 versus 65-75 years; aOR, 0.84 [95% CI, 0.80-0.88]), female sex (aOR, 0.74 [95% CI, 0.71-0.76]), Black race (aOR, 0.63 [95% CI, 0.58-0.68]) versus White race, and Medicaid eligibility (aOR, 0.61 [95% CI, 0.58-0.64]) were associated with lower odds of receiving LAAO. Among clinical characteristics, frailty, cancer, fractures, and venous thromboembolism were associated with lower odds of LAAO use, while history of intracranial and extracranial bleeding, coagulopathy, and falls were associated with higher odds of receiving LAAO. CONCLUSIONS Among patients with atrial fibrillation receiving stroke-preventive therapy, LAAO use increased rapidly from 2015 to 2020 and was positively associated with the risk factors for OAC complications but negatively associated with old age, advanced frailty, and cancer. Black race and female sex were associated with a lower likelihood of receiving LAAO.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
| | - Daniel E Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - E. Kevin Heist
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
| | - Sushama Kattinakere Sreedhara
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Priyanka Anand
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Yichi Zhang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Theodore N. Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
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Luo J, Li Z, Qin X, Zhang X, Liu X, Zhang W, Xu W, Liu B, Wei Y. Association of stress hyperglycemia ratio with in-hospital new-onset atrial fibrillation and long-term outcomes in patients with acute myocardial infarction. Diabetes Metab Res Rev 2024; 40:e3726. [PMID: 37712510 DOI: 10.1002/dmrr.3726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/14/2023] [Accepted: 08/18/2023] [Indexed: 09/16/2023]
Abstract
AIMS To investigate the predictive value and prognostic impact of stress hyperglycemia ratio (SHR) for new-onset atrial fibrillation (NOAF) complicating acute myocardial infarction (AMI). MATERIALS AND METHODS This retrospective study included 2145 AMI patients without AF history between February 2014 and March 2018. SHR was calculated using fasting blood glucose (mmol/L)/[1.59*HbA1c (%)-2.59]. The association between SHR and post-MI NOAF was assessed with multivariable logistic regression analyses. The primary outcome was a composite of cardiac death, heart failure hospitalisation, recurrent MI, and ischaemic stroke (MACE). Cox regression-adjusted hazard ratios with 95% confidence intervals (CI) were estimated for MACE. RESULTS A total of 245 (11.4%) patients developed NOAF. In the multivariable logistic regression analyses, SHR (each 10% increase) was significantly associated with increased risks of NOAF in the whole population (OR: 1.05, 95% CI: 1.01-1.10), particularly in non-diabetic individuals (OR:1.08, 95% CI: 1.01-1.17). During a median follow-up of 2.7 years, 370 (18.5%) MACEs were recorded. The optimal cut-off value of SHR for MACE prediction was 1.119. Patients with both high SHR (≥1.119) and NOAF possessed the highest risk of MACE compared to those with neither high SHR nor NOAF after multivariable adjustment (HR: 2.18, 95% CI: 1.39-3.42), especially for diabetics (HR: 2.63, 95% CI: 1.41-4.91). Similar findings were observed using competing-risk models. CONCLUSIONS SHR is an independent predictor of post-MI NOAF in non-diabetic individuals. Diabetic patients with both high SHR and NOAF had the highest risk of MACE, suggesting that therapies targeting SHR may be considered in these patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT03533543.
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Affiliation(s)
- Jiachen Luo
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhiqiang Li
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoming Qin
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xingxu Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiangdong Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenming Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Baoxin Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yidong Wei
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
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Chen S, Wang Z, Xuan F, Liang M, Jin Z, Ding J, Sun M, Zhang P, Han Y. One-year outcomes of wide antral cryoballoon ablation guided by high-density mapping vs. conventional cryoballoon ablation for atrial fibrillation: a propensity score-matched study. Front Cardiovasc Med 2024; 11:1327639. [PMID: 38361587 PMCID: PMC10867262 DOI: 10.3389/fcvm.2024.1327639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/12/2024] [Indexed: 02/17/2024] Open
Abstract
Background Pulmonary vein isolation with wide antral ablation leads to better clinical outcomes for the treatment of atrial fibrillation, but the isolation lesion is invisible in conventional cryoballoon ablation. In this study, we aim to investigate the efficacy of the wide pulmonary vein isolation technique that includes the intervenous carina region, guided by high-density mapping, compared with pulmonary vein isolation alone without the mapping system. Methods We conducted a propensity score-matched comparison of 74 patients who underwent a wide cryoballoon ablation guided by high-density mapping (mapping group) and 74 controls who underwent conventional cryoballoon ablation in the same period (no-mapping group). The primary outcome was a clinical recurrence of documented atrial arrhythmias for >30 s during the 1-year follow-up. Results Of 74 patients in the mapping group, residual local potential in the pulmonary vein antrum was found in 30 (40.5%) patients, and additional cryothermal applications were performed to achieve a wide pulmonary vein isolation. Compared with the no-mapping group, the use of the mapping system in the mapping group was associated with a longer fluoroscopic time (26.97 ± 8.07 min vs. 23.76 ± 8.36 min, P = 0.023) and greater fluoroscopic exposure [339 (IQR181-586) mGy vs. 224 (IQR133-409) mGy, P = 0.012]. However, no significant differences between the two groups were found in terms of procedural duration and left atrial dwell time (104.10 ± 18.76 min vs. 102.45 ± 21.01 min, P = 0.619; 83.52 ± 17.01 min vs. 79.59 ± 17.96 min, P = 0.177). The rate of 12-month freedom from clinical atrial arrhythmia recurrence was 85.1% in the mapping group and 70.3% in the no-mapping group (log-rank P = 0.029). Conclusion Voltage and pulmonary vein potential mapping after cryoballoon pulmonary vein isolation can identify residual potential in the pulmonary vein antrum, and additional cryoablation guided by mapping leads to improved freedom from atrial arrhythmias compared with conventional pulmonary vein isolation without the mapping system. Clinical Trial Registration Number ChiCTR2200064383.
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Affiliation(s)
- Sanbao Chen
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
- Department of Cardiology, Beifang Hospital of China Medical University, Shenyang, China
| | - Zulu Wang
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Fengqi Xuan
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
- Department of Cardiology, Beifang Hospital of China Medical University, Shenyang, China
| | - Ming Liang
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Zhiqing Jin
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Jian Ding
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Mingyu Sun
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Ping Zhang
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
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Leung ANW, Bhat A. Use of Anticoagulation for Thromboembolic Prophylaxis in Patients With Atrial High-Rate Episodes on Device Monitoring: A Narrative Review. Am J Cardiol 2024; 211:183-190. [PMID: 37944778 DOI: 10.1016/j.amjcard.2023.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Abstract
Ischemic stroke and systemic thromboembolism are primary drivers of significant morbidity and mortality in patients with atrial fibrillation (AF). Although stroke is commonly the first index presentation of clinically silent AF, the growing use of continuous rhythm monitoring through cardiac implanted electronic devices has enabled earlier and increased detection of AF in patients who are otherwise asymptomatic before stroke development. Atrial high-rate episodes (AHREs) are atrial tachyarrhythmias frequently detected by cardiac implanted electronic devices; these events represent subclinical AF and other atrial tachyarrhythmias that can lead to stroke development and AF. Although the presence of AHREs increases the risk of developing both clinical AF and stroke compared with absence of AHREs, there has been a significant clinical variability in anticoagulation initiation in these subjects. In this narrative review, we explore the current evidence and published research surrounding the association between AHREs and stroke development in addition to the utility of anticoagulation in this population for thromboembolic prophylaxis.
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Affiliation(s)
- Alice Ngar Wing Leung
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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Choi S, Choi K, Yun HK, Kim SH, Choi HH, Park YS, Joo S. Diagnosis of atrial fibrillation based on AI-detected anomalies of ECG segments. Heliyon 2024; 10:e23597. [PMID: 38187293 PMCID: PMC10770559 DOI: 10.1016/j.heliyon.2023.e23597] [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: 10/11/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Early detection of atrial fibrillation (AF) is crucial for its effective management and prevention. Various methods for detecting AF using deep learning (DL) based on supervised learning with a large labeled dataset have a remarkable performance. However, supervised learning has several problems, as it is time-consuming for labeling and has a data dependency problem. Moreover, most of the DL methods do not provide any clinical evidence to physicians regarding the analysis of electrocardiography (ECG) for classification or detection of AF. To address these limitations, in this study, we proposed a novel AF diagnosis system using unsupervised learning for anomaly detection with three segments, PreQ, QRS, and PostS, based on the normal ECG. Two independent datasets, PTB-XL and China, were used in three experiments. We used a long short-term memory (LSTM)-based autoencoder to train the segments of the normal ECG. Based on the threshold of anomaly scores using mean squared error (MSE), it distinguished between normal and AF segments. In Experiment A, the best score was that of PreQ, which detected AF with an AUROC score of 0.96. In Experiment B and C for cross validation of each dataset, the best scores were also of PreQ, with AUROC scores of 0.9 and 0.95, respectively. To verify the significance of the anomaly score in distinguishing between AF and normal segments, we utilized an XG-Boosted model after generating anomaly scores in the three segments. The XG-Boosted model achieved an AUROC score of 0.98 and an F1 score of 0.94. AF detection using DL has been controversial among many physicians. However, our study differentiates itself from previous studies in that we can demonstrate evidence that distinguishes AF from normal segments based on the anomaly score.
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Affiliation(s)
- Sanghoon Choi
- Department of Biomedical Engineering, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, Seoul, Republic of Korea
| | - Kyungmin Choi
- Department of Biomedical Engineering, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, Seoul, Republic of Korea
| | - Hong Kyun Yun
- Department of Biomedical Engineering, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, Seoul, Republic of Korea
| | - Su Hyeon Kim
- Department of Biomedical Engineering, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, Seoul, Republic of Korea
| | - Hyeon-Hwa Choi
- Department of Biomedical Engineering, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, Seoul, Republic of Korea
| | - Yi-Seul Park
- Department of Biomedical Engineering, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, Seoul, Republic of Korea
| | - Segyeong Joo
- Department of Biomedical Engineering, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, Seoul, Republic of Korea
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Wyss F, Barrios V, Méndez M, Ramos S, Gonzalez Á, Ortiz H, Díaz MR, Castillo G, Quesada D, Franco CE, Ventura J, López EP, Somoza F, Montealegre AA, Meneses D, Pichel D, Valdez O. Central American and Caribbean Consensus Document for the Optimal Management of Oral Anticoagulation in Patients with Non-Valvular Atrial Fibrillation Endorsed by the Central American and Caribbean Society of Arterial Hypertension and Cardiovascular Prevention. J Clin Med 2024; 13:314. [PMID: 38256448 PMCID: PMC10816126 DOI: 10.3390/jcm13020314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in adults. Prevention of the ischaemic risk with oral anticoagulants (OACs) is widely recommended, and current clinical guidelines recommend direct oral anticoagulants (DOACs) as preference therapy for stroke prevention. However, there are currently no clinical practice guidelines or recommendation documents on the optimal management of OACs in patients with AF that specifically address and adapt to the Central American and Caribbean context. The aim of this Delphi-like study is to respond to doubts that may arise in the management of OACs in patients with non-valvular AF in this geographical area. A consensus project was performed on the basis of a systematic review of the literature, a recommended ADOLOPMENT-like approach, and the application of a two-round Delphi survey. In the first round, 31 recommendations were evaluated and 30 reached consensus, of which, 10 unanimously agreed. The study assessed expert opinions in a wide variety of contextualized recommendations for the optimal management of DOACs in patients with non-valvular atrial fibrillation (NVAF). There is a broad consensus on the clinical practice guideline (CPG) statements used related to anticoagulation indication, patient follow-up, anticoagulation therapy complications, COVID-19 management and prevention, and cardiac interventions.
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Affiliation(s)
- Fernando Wyss
- Cardiovascular Services and Technology of Guatemala, CARDIOSOLUTIONS, Central American and Caribbean Society of Arterial Hypertension and Cardiovascular Prevention, Guatemala City 01010, Guatemala
| | - Vivencio Barrios
- Cardiology Department, University Hospital Ramon y Cajal, School of Medicine, Alcala University, 28034 Madrid, Spain
| | - Máxima Méndez
- Cardiologist-Internal Medicine, Medicine Autonomous University, Santo Domingo 10105, Dominican Republic;
- Cardiometabolic Unity, The Hub Innovation and Investigation of the Iberoamerican University, UNIBE, Santo Domingo 10203, Dominican Republic
- Lipid Master National Lipid Association, Jacksonville, FL 32216, USA
| | - Samuel Ramos
- Cardiology Department, Presidente Estrella Ureña Hospital, Santiago de los Caballeros, Salvador B. Gautier Hospital, Santo Domingo 10514, Dominican Republic;
| | - Ángel Gonzalez
- Cardiology Department, Hospiten Santo Domingo, Autónoma de Santo Domingo University, Santo Domingo 1355, Dominican Republic;
- American and Caribbean Society of Arterial Hypertension and Cardiovascular Prevention, Guatemala City 01010, Guatemala;
| | - Héctor Ortiz
- Cardiology Department, Herrera Llerandi Hospital, Guatemala City 01010, Guatemala;
| | - Marco Rodas Díaz
- Guatemalan Association of Cardiology, Cardiovascular Surgery Unit of Guatemala (UNICAR), Guatemala City 01010, Guatemala;
| | - Gabriela Castillo
- Cardiology Department, Max Peralta Hospital, Costa Rica University Cartago, Cartago 30101, Costa Rica;
| | - Daniel Quesada
- Cardiology Department, Hospital San Vicente de Paul, Universidad de Costa Rica, Heredia 40101, Costa Rica;
| | - Carlos Enrique Franco
- Cardiology Department, Surgical and Oncological Medical Hospital, Instituto Salvadoreño del Seguro Social, Escalon Medical Center, San Salvador 1101, El Salvador;
| | - Jaime Ventura
- Cardiology Department, Instituto Salvadoreño del Seguro Social, San Salvador 1101, El Salvador;
| | - Emilio Peralta López
- Cardiology Department, Instituto Nacional Cardiopulmonar, Tegucigalpa 11101, Honduras;
| | - Francisco Somoza
- Cardiology Department, CEMESA Hospital, San Pedro Sula 21102, Honduras;
| | | | - Daniel Meneses
- Cardiology Department, Del Valle Cardiologic Clinique, Nacional Autónoma of Nicaragua University, Managua 14145, Nicaragua;
| | - Daniel Pichel
- Cardiology Department, Paitilla Hospital, University of Panamá, Paitilla 06001, Panama;
| | - Osiris Valdez
- American and Caribbean Society of Arterial Hypertension and Cardiovascular Prevention, Guatemala City 01010, Guatemala;
- Cardiology Department, Central Romana Hospital, La Romana 22000, Dominican Republic
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Stoller N, Wertli MM, Haynes AG, Chiolero A, Rodondi N, Panczak R, Aujesky D. Large regional variation in cardiac closure procedures to prevent ischemic stroke in Switzerland a population-based small area analysis. PLoS One 2024; 19:e0291299. [PMID: 38166018 PMCID: PMC10760725 DOI: 10.1371/journal.pone.0291299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 08/23/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Percutaneous closure of a patent foramen ovale (PFO) or the left atrial appendage (LAA) are controversial procedures to prevent stroke but often used in clinical practice. We assessed the regional variation of these interventions and explored potential determinants of such a variation. METHODS We conducted a population-based analysis using patient discharge data from all Swiss hospitals from 2013-2018. We derived hospital service areas (HSAs) using patient flows for PFO and LAA closure. We calculated age-standardized mean procedure rates and variation indices (extremal quotient [EQ] and systematic component of variation [SCV]). SCV values >5.4 indicate a high and >10 a very high variation. Because the evidence on the efficacy of PFO closure may differ in patients aged <60 years and ≥60 years, age-stratified analyses were performed. We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors. RESULTS Overall, 2574 PFO and 2081 LAA closures from 10 HSAs were analyzed. The fully adjusted PFO and LAA closure rates varied from 3 to 8 and from 1 to 9 procedures per 100,000 persons per year across HSAs, respectively. The regional variation was high with respect to overall PFO closures (EQ 3.0, SCV 8.3) and very high in patients aged ≥60 years (EQ 4.0, SCV 12.3). The variation in LAA closures was very high (EQ 16.2, SCV 32.1). In multivariate analysis, women had a 28% lower PFO and a 59% lower LAA closure rate than men. French/Italian language areas had a 63% lower LAA closure rate than Swiss German speaking regions and areas with a higher proportion of privately insured patients had a 86% higher LAA closure rate. After full adjustment, 44.2% of the variance in PFO closure and 30.3% in LAA closure remained unexplained. CONCLUSIONS We found a high to very high regional variation in PFO closure and LAA closure rates within Switzerland. Several factors, including sex, language area, and insurance status, were associated with procedure rates. Overall, 30-45% of the regional procedure variation remained unexplained and most probably represents differing physician practices.
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Affiliation(s)
- Nina Stoller
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Emergency Department, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M. Wertli
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Kantonsspital Baden, Baden, Switzerland
| | | | - Arnaud Chiolero
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- School of Population and Global Health, McGill University, Montreal, Canada
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Molon G, Arena G, Tondo C, Ricciardi D, Rossi P, Pieragnoli P, Verlato R, Manfrin M, Girardengo G, Campisi G, Pecora D, Luzi M, Iacopino S. Patient report outcomes in cryoballoon ablation of atrial fibrillation during the COVID Era: Insights from the 1STOP project. J Interv Card Electrophysiol 2024; 67:61-69. [PMID: 37178189 PMCID: PMC10182349 DOI: 10.1007/s10840-023-01561-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Pulmonary vein isolation by cryoablation (PVI-C) is a standard therapy for the treatment of patients with symptomatic atrial fibrillation (AF). AF symptoms are highly subjective; however, they are important outcomes for the patient. The aim is to describe the use and impact of a web-based App to collect AF-related symptoms in a population of patients who underwent PVI-C in seven Italian centers. METHODS A patient App to collect AF-related symptoms and general health status was proposed to all patients who underwent an index PVI-C. Patients were divided into two groups according to the utilization of the App or the non-usage. RESULTS Out of 865 patients, 353 (41%) subjects composed the App group, and 512 (59%) composed the No-App group. Baseline characteristics were comparable between the two cohorts except for age, sex, type of AF, and body mass index. During a mean follow-up of 7.9±13.8 months, AF recurrence was found in 57/865 (7%) subjects with an annual rate of 7.36% (95% CI:5.67-9.55%) in the No-App versus 10.99% (95% CI:9.67-12.48%) in the App group, p=0.007. In total, 14,458 diaries were sent by the 353 subjects in the App group and 77.1% reported a good health status and no symptoms. In only 518 diaries (3.6%), the patients reported a bad health status, and bad health status was an independent parameter of AF recurrence during follow-up. CONCLUSIONS The use of a web App to record AF-related symptoms was feasible and effective. Additionally, a bad health status reporting in the App was associated with AF recurrence during follow-up.
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Affiliation(s)
- Giulio Molon
- IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy.
| | | | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS Department of Electrophysiology&Cardiac Pacing Department of Biomedical, Surgery and Dentist Sciences, University of Milan, Milan, Italy
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18
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Álvaro Thomsen T, Mesa Guadalupe J, Huerta C, de Burgos A, Cea Soriano L. Risk of ischemic stroke associated with direct oral anticoagulants discontinuation on patients with non-valvular atrial fibrillation. Pharmacoepidemiol Drug Saf 2024; 33:e5733. [PMID: 38011912 DOI: 10.1002/pds.5733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 10/04/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Although direct oral anticoagulants' (DOACs) prescriptions have experienced immense growth in the last decade, the proportion of discontinuers is still common yielding an increased risk of ischemic stroke (IS) onset. AIMS We aimed to estimate the association between DOACs discontinuation and risk of IS among patients with non-valvular atrial fibrillation (NVAF). METHODS We used data from a cohort of new DOACs users, followed patients from the first DOAC prescription date up to IS (index date) and conducted a nested case-control analysis using conditional logistic regression. Adjusted odds ratios, 95% confidence intervals were calculated for discontinuation of DOACs (current use compared with past use). The latter, subdivided among those stopping treatment 3 to 2 months and 6 and 3 months prior to index date. The effect of naïve current users against IS onset compared with non-naïve current users was also evaluated. RESULTS DOACs discontinuation showed an OR of IS of 1.47 (95% CI: 1.02-2.12); estimates were 2.51 (95% CI: 1.84-3.42) for whom discontinued treatment within months 3 and 2 and 1.43 (95% CI: 0.96-2.13) for those between months 6 and 3 prior to index date. Analyzing DOACs individually, risk of IS associated with past users compared with current users: 1.98 (95% CI: 1.25-3.12) for apixaban, 1.38 (95% CI: 0.40-4.72) for edoxaban, 1.98 (95% CI: 1.24-2.65) for dabigatran and 1.87 (95% CI: 1.26-2.76) for rivaroxaban. Similar results were found when stratified by naïve and non-naïve users. CONCLUSIONS DOACs' discontinuation is associated with higher risk of IS, especially in the second and third months following interruption.
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Affiliation(s)
- T Álvaro Thomsen
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - J Mesa Guadalupe
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - C Huerta
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - A de Burgos
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- BIFAP, Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - L Cea Soriano
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Aboonabi A, McCauley MD. Myofilament dysfunction in diastolic heart failure. Heart Fail Rev 2024; 29:79-93. [PMID: 37837495 PMCID: PMC10904515 DOI: 10.1007/s10741-023-10352-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/16/2023]
Abstract
Diastolic heart failure (DHF), in which impaired ventricular filling leads to typical heart failure symptoms, represents over 50% of all heart failure cases and is linked with risk factors, including metabolic syndrome, hypertension, diabetes, and aging. A substantial proportion of patients with this disorder maintain normal left ventricular systolic function, as assessed by ejection fraction. Despite the high prevalence of DHF, no effective therapeutic agents are available to treat this condition, partially because the molecular mechanisms of diastolic dysfunction remain poorly understood. As such, by focusing on the underlying molecular and cellular processes contributing to DHF can yield new insights that can represent an exciting new avenue and propose a novel therapeutic approach for DHF treatment. This review discusses new developments from basic and clinical/translational research to highlight current knowledge gaps, help define molecular determinants of diastolic dysfunction, and clarify new targets for treatment.
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Affiliation(s)
- Anahita Aboonabi
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago, 840 S. Wood St., 920S (MC 715), Chicago, IL, 60612, USA.
- Jesse Brown VA Medical Center, Chicago, IL, USA.
| | - Mark D McCauley
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago, 840 S. Wood St., 920S (MC 715), Chicago, IL, 60612, USA.
- Jesse Brown VA Medical Center, Chicago, IL, USA.
- Department of Physiology and Biophysics and the Center for Cardiovascular Research, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA.
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Tamimi O, Tamimi F, Gorthi J. Clinical Outcomes of Decompensated Heart Failure With Reduced Ejection Fraction Admissions With or Without Atrial Fibrillation and Atrial Flutter. Curr Probl Cardiol 2024; 49:102014. [PMID: 37544625 DOI: 10.1016/j.cpcardiol.2023.102014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
The aim of our retrospective study is to determine the influence of co-morbid atrial fibrillation or flutter (AF) on decompensated congestive heart failure (CHF) admissions using data from the 2020 nationwide inpatient sample. We identified 76,835 adults admitted nonelectively with decompensated CHF. After multivariate adjustment, we found decompensated heart failure with reduced ejection fraction (HFrEF) admissions with AF had 37% higher odds of in-hospital mortality, (OR 1.38 [95% CI 1.1-1.72] P < 0.01), 33% higher odds for mechanical ventilation (MV) (OR 1.33 [95% CI 1.14-1.55] P < 0.01), 39% higher odds of early MV (OR 1.39 [95% CI 1.16-1.66] P < 0.01), 54% higher odds of cardiogenic shock (OR 1.54 [95% CI 1.29-1.84] P < 0.01), 61% increased odds of mechanical circulatory support (MCS) requirement (OR 1.61 [95% CI 1.12-2.31] P < 0.02), significantly higher odds of acute renal failure (AKI) necessitating dialysis (OR 2.20 [95% CI 1.39-2.48] P < 0.01), 1-day increase in mean length of stay (LOS) (6.7 vs 5.7 days, adjusted difference: 0.99, P < 0.01), $13,281 increase in total hospitalization charges ($84,316 vs $74,279, adjusted difference: $13,281, P < 0.05) compared to the non-AF cohort. Moreover, we found decompensated heart failure with preserved ejection fraction (HFpEF) admissions with AF had a 23% increased odds of MV (OR 1.23 [95% CI 1.01-1.50] P < 0.01), 24% higher odds of early MV (OR 1.24 [95% CI 1.00-1.53] P < 0.01), 0.36 days increase in mean LOS (5.5 vs 5.2 days, adjusted difference: 0.36, P = < 0.01), but no significant difference in in-hospital mortality (OR 1.23 [95% CI 0.86-1.75] P = 0.25), cardiogenic shock (OR 1.75 [95% CI 0.96-3.19] P < 0.07), dialysis-dependent AKI (OR 0.46 [95% CI 0.18-1.17] P < 0.10), or mean total hospitalization charges ($52,086 vs $47,990, adjusted difference: $5584, P = 0.06) compared to the non-AF cohort.
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Affiliation(s)
- Omar Tamimi
- Department of Medicine, Houston Methodist Hospital, Houston, TX.
| | - Faisal Tamimi
- Department of Medicine, Jamaica Medical Center, Queens, NY
| | - Janardhana Gorthi
- Department of Medicine, Houston Methodist Hospital, Houston, TX; DeBakey Heart and Vascular Institute, Division of Cardiology, Houston Methodist Hospital, Houston, TX
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Luo Y, Tang Y, Huang W, Xiong S, Long Y, Liu H. Age, creatinine, and ejection fraction (ACEF) score as predictive values for late non-valvular atrial fibrillation recurrence after radiofrequency ablation. Clin Exp Hypertens 2023; 45:2207784. [PMID: 37161316 DOI: 10.1080/10641963.2023.2207784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
The clinical risk factors associated with late recurrence in patients with non-valvular atrial fibrillation (AF) (NVAF) undergoing radiofrequency catheter ablation (RFCA) remain unknown. Furthermore, the current prognostic risk score system is commonly used in such patients as a noninvasive method to assess late AF recurrence. According to recent research, the Age, creatinine, and ejection fraction (ACEF) score is a useful risk score for cardiovascular morbidity and mortality. As a result, we hypothesized that pre-ablation ACEF score could be used to assess late recurrence in patients with NVAF. We included 325 NVAF patients undergoing RFCA. During a median follow-up period of 12 months, patients with late AF recurrence had higher ACEF scores (P < .001). The pre-ablation ACEF score was a risk factor for late AF recurrence after RFCA (P = .027). The ACEF score was a predictor of late AF recurrence after RFCA, with an AUC of 0.624 (P = .001). Moreover, the AUC of left atrial diameter (LAD) was 0.7 (P < .001), which was higher than the ACEF score, but no significant difference was found (P = .104). The ACEF score was positively correlated with LAD, advanced age, and B-type natriuretic peptide. In patients with NVAF, the pre-ablation ACEF score is a valuable risk score for assessing late AF recurrence after RFCA, as with LAD.
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Affiliation(s)
- Yan Luo
- The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Yan Tang
- The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Wenchao Huang
- The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Shiqiang Xiong
- The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Yu Long
- The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Hanxiong Liu
- The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
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Popa-Fotea NM, Oprescu N, Scafa-Udriste A, Micheu MM. Impact of rs1805127 and rs55742440 Variants on Atrial Remodeling in Hypertrophic Cardiomyopathy Patients with Atrial Fibrillation: A Romanian Cohort Study. Int J Mol Sci 2023; 24:17244. [PMID: 38139087 PMCID: PMC10743528 DOI: 10.3390/ijms242417244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/25/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Atrial fibrillation (AFib) is characterized by a complex genetic component. We aimed to investigate the association between variations in genes related to cardiac ion handling and AFib in a cohort of Romanian patients with hypertrophic cardiomyopathy (HCM). Forty-five unrelated probands with HCM were genotyped by targeted next-generation sequencing (NGS) for 24 genes associated with cardiac ion homeostasis. Subsequently, the study cohort was divided into two groups based on the presence (AFib+) or absence (AFiB-) of AFib detected during ECG monitoring. We identified two polymorphisms (rs1805127 located in KCNE1 and rs55742440 located in SCN1B) linked to AFib susceptibility. In AFib+, rs1805127 was associated with increased indexed left atrial (LA) maximal volume (LAVmax) (58.42 ± 21 mL/m2 vs. 32.54 ± 6.47 mL/m2, p < 0.001) and impaired LA strain reservoir (LASr) (13.3 ± 7.5% vs. 24.4 ± 6.8%, p < 0.05) compared to those without respective variants. The rs55742440 allele was less frequent in patients with AFib+ (12 out of 25, 48%) compared to those without arrhythmia (15 out of 20, 75%, p = 0.05). Also, AFib+ rs55742440 carriers had significantly lower LAVmax compared to those who were genotype negative. Among patients with HCM and AFib+, the rs1805127 variant was accompanied by pronounced LA remodeling, whereas rs55742440's presence was related to a milder LA enlargement.
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Affiliation(s)
- Nicoleta-Monica Popa-Fotea
- Department 4—Cardio-Thoracic Pathology, University of Medicine and Pharmacy Carol Davila, Eroii Sanitari Bvd. 8, 050474 Bucharest, Romania;
- Department of Cardiology, Clinical Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania;
| | - Nicoleta Oprescu
- Department of Cardiology, Clinical Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania;
| | - Alexandru Scafa-Udriste
- Department 4—Cardio-Thoracic Pathology, University of Medicine and Pharmacy Carol Davila, Eroii Sanitari Bvd. 8, 050474 Bucharest, Romania;
- Department of Cardiology, Clinical Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania;
| | - Miruna Mihaela Micheu
- Department of Cardiology, Clinical Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania;
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Jiang X, Xiong Q, Yin Y, Ling Z. Left atrial appendage closure for stroke prevention in atrial fibrillation patients: A promise that came true. Pacing Clin Electrophysiol 2023; 46:1576-1585. [PMID: 37987556 DOI: 10.1111/pace.14877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023]
Abstract
Anticoagulation therapy plays a crucial role in the management of atrial fibrillation (AF), considering the high morbidity and mortality of AF-related ischemic strokes. With the plausible hypothesis that left atrial appendage is the main source of thrombus in AF patients, left atrial appendage closure (LAAC) has been regarded as a potential substitute to oral anticoagulation in order to meet the unmet needs for stroke prevention, particularly in patients with high bleeding risk. Notable advancements in safety, efficacy, and device innovation have been made in recent years, albeit concerns still remain regarding the insufficient efficacy data, device-related complications, and the need for procedural optimization. We aim to review current knowledge about LAAC and provide potential future directions for the remaining key issues.
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Affiliation(s)
- Xi Jiang
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qingsong Xiong
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiyu Ling
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Nagasaka T, Nakamura M. Left Atrial Appendage Closure: A Narrative Review. Cardiol Ther 2023; 12:615-635. [PMID: 37938523 DOI: 10.1007/s40119-023-00337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and the cause of thromboembolic events in elderly patients worldwide. AF is associated with a significantly increased risk of morbidity and mortality due to cardiac emboli, primarily from left atrial appendage (LAA) thrombus. Oral anticoagulation therapy is the standard treatment to effectively reduce the risk of thromboembolic events in patients with AF. However, anticoagulation treatment increases bleeding risk. LAA closure (LAAC) has recently been introduced as a feasible mechanical preventive intervention for thromboembolic events while minimizing the risk of bleeding. Transcatheter LAAC devices have evolved in the past decade, and several ongoing trials have demonstrated the improvements of safety and outcomes in newer generation devices. This review summarizes the current perspectives and outcomes regarding LAAC as an alternative to pharmacologic therapy.
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Affiliation(s)
- Takashi Nagasaka
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Ding XF, Ding WX, Chen Y, Dai BL, Zhao YN, Duo-Duo Z, Yang YH, Gao LJ, Xia YL, Dong YX. Long duration of atrial high-rate episode is more favorable in predicting ischemic stroke than high CHA 2 DS 2 -VASc score. Pacing Clin Electrophysiol 2023; 46:1635-1642. [PMID: 37942981 DOI: 10.1111/pace.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/19/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE This study aimed to explore the roles of duration and burden of atrial high-rate episode (AHRE) on ischemic stroke in patients with pacemaker implantation. METHODS Patients with pacemaker implantation for bradycardia from 2013 to 2017 were consecutively enrolled. Data such as gender, age, combined diseases, type of AF, left atrial size, left ventricular size, left ventricular ejection fraction, CHA2 DS2 -VASc score, and anticoagulants were collected. The burden and duration of AHRE based on different interval partition were also recorded in detail to evaluate the impacts on ischemic stroke. Cox regression analysis with time-dependent covariates was conducted. RESULTS A total of 220 patients with AHRE were enrolled. The average follow-up time was 48.42 ± 17.20 months. Univariate regression analysis showed that diabetes (p = .024), high CHA2 DS2 -VASc score (≥ 2) (p = .021), long mean AHRE burden (p = .011), long maximal AHRE burden (p = .015), long AHRE duration lasting≥48 h (p = .001) or 24 h (p = .001) or 12 h (p = .005) were prone to ischemic stroke. Further multivariate regression analysis showed that long duration of AHRE (≥48 h) (HR 10.77; 95% CI 3.22-55.12; p = .030) were significantly correlated with stroke in patients with paroxysmal AF. There was no significant correlation between the type of AF and stroke (p = .927). CONCLUSION The longer duration of AHRE (≥48 h) was more favorable in predicting ischemic stroke than high CHA2 DS2 -VASc score (≥2).
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Affiliation(s)
- Xue-Fang Ding
- First affiliated hospital of Dalian Medical University, Dalian, China
| | - Wan-Xuan Ding
- First affiliated hospital of Dalian Medical University, Dalian, China
| | - Ying Chen
- First affiliated hospital of Dalian Medical University, Dalian, China
| | - Bai-Ling Dai
- First affiliated hospital of Dalian Medical University, Dalian, China
| | - Yan-Ni Zhao
- First affiliated hospital of Dalian Medical University, Dalian, China
| | - Zhang Duo-Duo
- First affiliated hospital of Dalian Medical University, Dalian, China
| | - Yi-Heng Yang
- First affiliated hospital of Dalian Medical University, Dalian, China
| | - Lian-Jun Gao
- First affiliated hospital of Dalian Medical University, Dalian, China
| | - Yun-Long Xia
- First affiliated hospital of Dalian Medical University, Dalian, China
| | - Ying-Xue Dong
- First affiliated hospital of Dalian Medical University, Dalian, China
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26
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Butcher C, Rajappan S, Wharmby AL, Ullah W, Wong T, Jones D, Rajappan K, Martin C, Elliott P, Gill JS, Specterman M, Dhinoja MB, Sporton S, Lambiase PD, Hunter RJ, Honarbakhsh S. Atrioventricular nodal ablation is an effective management strategy for atrial fibrillation in patients with hypertrophic cardiomyopathy. Heart Rhythm 2023; 20:1606-1614. [PMID: 37633429 DOI: 10.1016/j.hrthm.2023.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and can be challenging to manage. Atrioventricular nodal (AVN) ablation may be an effective management strategy for AF in these patients. OBJECTIVE The purpose of this study was to assess the efficacy of AVN ablation in HCM patients who have failed medical therapy and/or catheter ablation for AF. METHODS A multicenter study with retrospective analysis of a prospectively collated HCM registry was performed. AVN ablation patients were identified. Baseline characteristics and device and procedural indications were collected. Symptoms defined by New York Heart Association and European Heart Rhythm Association classification and echocardiographic findings during follow-up were assessed. RESULTS Fifty-nine patients were included in the study. Indications for AVN ablation were 6 (10.2%) inappropriate implantable cardioverter-defibrillator shock, 35 (59.3%) ineffective rate control, and 18 (30.5%) to regularize rhythm for symptom improvement. During post-AVN ablation follow-up of 79.4 ± 61.1 months, left ventricular ejection fraction (LVEF) remained stable (pre-LVEF 48.9% ± 12.6% vs post-LVEF 50.1% ± 10.1%; P = .29), even in those without a cardiac resynchronization therapy (CRT) device (pre-LVEF 54.3% ± 8.0% vs post-LVEF 53.8% ± 8.0%; P = .65). Forty-nine patients (83.1%) reported an improvement in symptoms regardless of AF type (17/21 [81.0%] paroxysmal vs 32/38 [84.2%] persistent; P = 1.00), presence of baseline left ventricular impairment (22/26 [84.6%] LVEF ≤50% vs 27/33 [81.8%] LVEF ≥50%; P = 1.00) or CRT device (27/32 [84.4%] CRT vs 22/27 [81.5%] no CRT; P = 1.00). Symptoms improved in 16 patients (89.0%) who underwent AVN ablation to regularize rhythm. CONCLUSION AVN ablation improved symptoms without impacting left ventricular function in the majority of patients. The data suggest that AVN ablation is an effective and safe management approach for AF in HCM and should be further evaluated in larger prospective studies.
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Affiliation(s)
- Charles Butcher
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Saffron Rajappan
- University College London Medical School, London, United Kingdom
| | - Amy L Wharmby
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Waqas Ullah
- University Hospital Southampton, London, United Kingdom
| | - Tom Wong
- Royal Brompton and Harefield NHS Trusts, London, United Kingdom
| | - David Jones
- Royal Brompton and Harefield NHS Trusts, London, United Kingdom
| | - Kim Rajappan
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Claire Martin
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Perry Elliott
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Jaspal Singh Gill
- St. George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark Specterman
- St. George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Mehul B Dhinoja
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Simon Sporton
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Pier D Lambiase
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ross J Hunter
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Shohreh Honarbakhsh
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Queen Mary University of London, London, United Kingdom.
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Zakynthinos GE, Tsolaki V, Oikonomou E, Vavouranakis M, Siasos G, Zakynthinos E. New-Onset Atrial Fibrillation in the Critically Ill COVID-19 Patients Hospitalized in the Intensive Care Unit. J Clin Med 2023; 12:6989. [PMID: 38002603 PMCID: PMC10672690 DOI: 10.3390/jcm12226989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/28/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
New-onset atrial fibrillation (NOAF) is the most frequently encountered cardiac arrhythmia observed in patients with COVID-19 infection, particularly in Intensive Care Unit (ICU) patients. The purpose of the present review is to delve into the occurrence of NOAF in COVID-19 and thoroughly review recent, pertinent data. However, the causality behind this connection has yet to be thoroughly explored. The proposed mechanisms that could contribute to the development of AF in these patients include myocardial damage resulting from direct virus-induced cardiac injury, potentially leading to perimyocarditis; a cytokine crisis and heightened inflammatory response; hypoxemia due to acute respiratory distress; disturbances in acid-base and electrolyte levels; as well as the frequent use of adrenergic drugs in critically ill patients. Additionally, secondary bacterial sepsis and septic shock have been suggested as primary causes of NOAF in ICU patients. This notion gains strength from the observation of a similar prevalence of NOAF in septic non-COVID ICU patients with ARDS. It is plausible that both myocardial involvement from SARS-CoV-2 and secondary sepsis play pivotal roles in the onset of arrhythmia in ICU patients. Nonetheless, there exists a significant variation in the prevalence of NOAF among studies focused on severe COVID-19 cases with ARDS. This discrepancy could be attributed to the inclusion of mixed populations with varying degrees of illness severity, encompassing not only patients in general wards but also those admitted to the ICU, whether intubated or not. Furthermore, the occurrence of NOAF is linked to increased morbidity and mortality. However, it remains to be determined whether NOAF independently influences outcomes in critically ill COVID-19 ICU patients or if it merely reflects the disease's severity. Lastly, the management of NOAF in these patients has not been extensively studied. Nevertheless, the current guidelines for NOAF in non-COVID ICU patients appear to be effective, while accounting for the specific drugs used in COVID-19 treatment that may prolong the QT interval (although drugs like lopinavir/ritonavir, hydrochlorothiazide, and azithromycin have been discontinued) or induce bradycardia (e.g., remdesivir).
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Affiliation(s)
- George E. Zakynthinos
- 3rd Department of Cardiology, “Sotiria” Chest Diseases Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (G.E.Z.); (E.O.); (M.V.); (G.S.)
| | - Vasiliki Tsolaki
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, “Sotiria” Chest Diseases Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (G.E.Z.); (E.O.); (M.V.); (G.S.)
| | - Manolis Vavouranakis
- 3rd Department of Cardiology, “Sotiria” Chest Diseases Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (G.E.Z.); (E.O.); (M.V.); (G.S.)
| | - Gerasimos Siasos
- 3rd Department of Cardiology, “Sotiria” Chest Diseases Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (G.E.Z.); (E.O.); (M.V.); (G.S.)
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Epaminondas Zakynthinos
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
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Gray RA, Franz MR. Amiodarone prevents wave front-tail interactions in patients with heart failure: an in silico study. Am J Physiol Heart Circ Physiol 2023; 325:H952-H964. [PMID: 37656133 PMCID: PMC10907032 DOI: 10.1152/ajpheart.00227.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 09/02/2023]
Abstract
Amiodarone (AM) is an antiarrhythmic drug whose chronic use has proved effective in preventing ventricular arrhythmias in a variety of patient populations, including those with heart failure (HF). AM has both class III [i.e., it prolongs the action potential duration (APD) via blocking potassium channels) and class I (i.e., it affects the rapid sodium channel) properties; however, the specific mechanism(s) by which it prevents reentry formation in patients with HF remains unknown. We tested the hypothesis that AM prevents reentry induction in HF during programmed electrical stimulation (PES) via its ability to induce postrepolarization refractoriness (PRR) via its class I effects on sodium channels. Here we extend our previous human action potential model to represent the effects of both HF and AM separately by calibrating to human tissue and clinical PES data, respectively. We then combine these models (HF + AM) to test our hypothesis. Results from simulations in cells and cables suggest that AM acts to increase PRR and decrease the elevation of takeoff potential. The ability of AM to prevent reentry was studied in silico in two-dimensional sheets in which a variety of APD gradients (ΔAPD) were imposed. Reentrant activity was induced in all HF simulations but was prevented in 23 of 24 HF + AM models. Eliminating the AM-induced slowing of the recovery of inactivation of the sodium channel restored the ability to induce reentry. In conclusion, in silico testing suggests that chronic AM treatment prevents reentry induction in patients with HF during PES via its class I effect to induce PRR.NEW & NOTEWORTHY This work presents a new model of the action potential of the human, which reproduces the complex dynamics during premature stimulation in heart failure patients with and without amiodarone. A specific mechanism of the ability of amiodarone to prevent reentrant arrhythmias is presented.
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Affiliation(s)
- Richard A Gray
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Michael R Franz
- Cardiology Division, Veteran Affairs Medical Center, Washington, District of Columbia, United States
- Department of Pharmacology, Georgetown University Medical Center, Washington, District of Columbia, United States
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Cundari G, Alkadhi H, Eberhard M. The role of CT in arrhythmia management-treatment planning and post-procedural imaging surveillance. Br J Radiol 2023; 96:20230028. [PMID: 37191058 PMCID: PMC10607403 DOI: 10.1259/bjr.20230028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/21/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
Several interventional treatment options exist in patients with atrial and ventricular arrhythmia. Cardiac CT is routinely performed prior to occlusion of the left atrial appendage, pulmonary vein isolation, and cardiac device implantation. Besides the evaluation of coronary artery disease, cardiac CT provides isotropic, high-resolution CT images of the cardiac anatomy with the possibility of multiplanar reformations and three-dimensional reconstructions which are helpful to guide interventional treatment. In addition, cardiac CT is increasingly used to rapidly evaluate periprocedural complications and for the routine post-procedural imaging surveillance in patients after interventions. This review article will discuss current applications of pre- and post-interventional CT imaging in patients with arrhythmia.
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Affiliation(s)
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Jeon KH, Jang JH, Kang S, Lee HS, Lee MS, Son JM, Jo YY, Park TJ, Oh IY, Kwon JM, Lee JH. Identifying Atrial Fibrillation With Sinus Rhythm Electrocardiogram in Embolic Stroke of Undetermined Source: A Validation Study With Insertable Cardiac Monitors. Korean Circ J 2023; 53:758-771. [PMID: 37973386 PMCID: PMC10654409 DOI: 10.4070/kcj.2023.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Paroxysmal atrial fibrillation (AF) is a major potential cause of embolic stroke of undetermined source (ESUS). However, identifying AF remains challenging because it occurs sporadically. Deep learning could be used to identify hidden AF based on the sinus rhythm (SR) electrocardiogram (ECG). We combined known AF risk factors and developed a deep learning algorithm (DLA) for predicting AF to optimize diagnostic performance in ESUS patients. METHODS A DLA was developed to identify AF using SR 12-lead ECG with the database consisting of AF patients and non-AF patients. The accuracy of the DLA was validated in 221 ESUS patients who underwent insertable cardiac monitor (ICM) insertion to identify AF. RESULTS A total of 44,085 ECGs from 12,666 patient were used for developing the DLA. The internal validation of the DLA revealed 0.862 (95% confidence interval, 0.850-0.873) area under the curve (AUC) in the receiver operating curve analysis. In external validation data from 221 ESUS patients, the diagnostic accuracy of DLA and AUC were 0.811 and 0.827, respectively, and DLA outperformed conventional predictive models, including CHARGE-AF, C2HEST, and HATCH. The combined model, comprising atrial ectopic burden, left atrial diameter and the DLA, showed excellent performance in AF prediction with AUC of 0.906. CONCLUSIONS The DLA accurately identified paroxysmal AF using 12-lead SR ECG in patients with ESUS and outperformed the conventional models. The DLA model along with the traditional AF risk factors could be a useful tool to identify paroxysmal AF in ESUS patients.
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Affiliation(s)
- Ki-Hyun Jeon
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong-Hwan Jang
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Sora Kang
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Hak Seung Lee
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Min Sung Lee
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Jeong Min Son
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Yong-Yeon Jo
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Tae Jun Park
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
| | - Il-Young Oh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joon-Myoung Kwon
- Medical Research Team, Medical AI Inc., San Francisco, CA, USA
- Department of Critical Care and Emergency Medicine, Incheon Sejong Hospital, Incheon, Korea.
| | - Ji Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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Lim SK, Chung S, Park I, Chi SA, Kim K, Park KM, Park SJ, Kim JY, Kim JS, On YK, Jeong DS. Totally Thoracoscopic Ablation in Patients With Recurrent Atrial Fibrillation After Catheter Ablation. J Korean Med Sci 2023; 38:e320. [PMID: 37821087 PMCID: PMC10562179 DOI: 10.3346/jkms.2023.38.e320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/07/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND The objective of this study was to evaluate the efficacy and safety of totally thoracoscopic ablation (TTA) in patients with recurrent atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA). METHODS From February 2012 to May 2020, 460 patients who underwent TTA were classified into two groups: CA (presence of RFCA history, n = 74) and nCA groups (absence of RFCA history, n = 386). Inverse probability of treatment weighting (IPTW) analyses were used to adjust for confounders. The primary endpoint was freedom from the composite of AF, typical atrial flutter, atypical atrial flutter and any atrial tachyarrhythmia, lasting more than 30 seconds during the follow-up. All patients were followed up at 3, 6, and 12 months via electrocardiogram and 24-hour Holter monitoring. RESULTS Bilateral pulmonary vein isolation (PVI) was conducted in all patients and the conduction block tests were confirmed. In the CA group, difficult PVI occasionally occurred due to structural changes, such as pericardial adhesion and fibrosis of the pulmonary venous structure, caused by a previous catheter ablation. Early complications such as stroke and pacemaker insertion were not different between the two groups. The normal sinus rhythm was maintained in 70.1% (317/460) patients after a median follow-up period of 38.1 months. The IPTW-weighted Kaplan-Meier curves revealed that freedom from AF events at 5 years was 68.4% (95% confidence interval, 62.8-74.5) in the nCA group and 31.2% (95% confidence interval, 16.9-57.5) in the CA group (P < 0.001). In IPTW-weighted Cox regression, preoperative left atrial diameter, persistent or long-standing AF, the presence of congestive heart failure and catheter ablation history were associated with AF events. CONCLUSION Patients in the CA group showed a higher recurrence rate of AF than those in the nCA group, while TTA was safely performed in both the groups.
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Affiliation(s)
- Suk Kyung Lim
- Department of Thoracic and Cardiovascular Surgery, Heart Stroke Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suryeun Chung
- Department of Thoracic and Cardiovascular Surgery, Heart Stroke Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ilkun Park
- Department of Thoracic and Cardiovascular Surgery, Heart Stroke Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Ah Chi
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunga Kim
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung-Min Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju Youn Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Soo Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Keun On
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Heart Stroke Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Hashimoto N, Arimoto T, Koyama K, Kutsuzawa D, Watanabe K, Aita S, Aono T, Kobayashi Y, Wanezaki M, Otaki Y, Kato S, Tamura H, Nishiyama S, Takahashi H, Ohba M, Haga K, Watanabe T, Watanabe M. Improved cerebral blood flow and hippocampal blood flow in stroke-free patients after catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2023; 34:2055-2064. [PMID: 37681313 DOI: 10.1111/jce.16054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/19/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) is a risk factor for reduced cerebral blood flow (CBF) and cognitive dysfunction, even in stroke-free patients. We aimed to test the hypothesis that CBF and hippocampal blood flow (HBF), measured with arterial spin labeling magnetic resonance imaging (MRI), improve after catheter ablation of AF to achieve sinus rhythm (SR). METHODS A total of 84 stroke-free patients (63.1 ± 9.1 years; paroxysmal AF, n = 50; non-paroxysmal AF, n = 34) undergoing AF catheter ablation were included. MRI studies were done before, 3 months, and 12 months after the procedure with CBF and HBF measurements. RESULTS Baseline CBF and HBF values in 50 paroxysmal AF patients were used as controls. Baseline CBF was higher in patients with paroxysmal AF than with non-paroxysmal AF (100 ± 32% vs. 86 ± 28%, p = .04). Patients with non-paroxysmal AF had increased CBF 3 months after AF ablation (86 ± 28% to 99 ± 34%, p = .03). Differences in CBF and HBF were greater in the group with AF restored to SR (p < .01). Both CBF and HBF levels at 12 months were unchanged from the 3 months level. Successful rhythm control by catheter ablation was an independent predictor of an increase in CBF > 17.5%. The Mini-Mental State Examination score improved after ablation (p = .02). CONCLUSION SR restoration with catheter ablation was associated with improved CBF and HBF at 3 months, maintenance of blood flow, and improved cognitive function at 12 months.
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Affiliation(s)
- Naoaki Hashimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Takanori Arimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Kyoko Koyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Daisuke Kutsuzawa
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Ken Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Satoshi Aita
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Tomonori Aono
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Yuta Kobayashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Masahiro Wanezaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Yoichiro Otaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Shigehiko Kato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Satoshi Nishiyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Hiroki Takahashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Makoto Ohba
- Division of Radiology, Yamagata University School of Medicine, Yamagata, Japan
| | - Kazuyuki Haga
- Division of Radiology, Yamagata University School of Medicine, Yamagata, Japan
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
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Kwon S, Lee E, Ju H, Ahn HJ, Lee SR, Choi EK, Suh J, Oh S, Rhee W. Machine Learning Prediction for the Recurrence After Electrical Cardioversion of Patients With Persistent Atrial Fibrillation. Korean Circ J 2023; 53:677-689. [PMID: 37653713 PMCID: PMC10625851 DOI: 10.4070/kcj.2023.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/25/2023] [Accepted: 06/13/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is limited evidence regarding machine-learning prediction for the recurrence of atrial fibrillation (AF) after electrical cardioversion (ECV). This study aimed to predict the recurrence of AF after ECV using machine learning of clinical features and electrocardiograms (ECGs) in persistent AF patients. METHODS We analyzed patients who underwent successful ECV for persistent AF. Machine learning was designed to predict patients with 1-month recurrence. Individual 12-lead ECGs were collected before and after ECV. Various clinical features were collected and trained the extreme gradient boost (XGBoost)-based model. Ten-fold cross-validation was used to evaluate the performance of the model. The performance was compared to the C-statistics of the selected clinical features. RESULTS Among 718 patients (mean age 63.5±9.3 years, men 78.8%), AF recurred in 435 (60.6%) patients after 1 month. With the XGBoost-based model, the areas under the receiver operating characteristic curves (AUROCs) were 0.57, 0.60, and 0.63 if the model was trained by clinical features, ECGs, and both (the final model), respectively. For the final model, the sensitivity, specificity, and F1-score were 84.7%, 28.2%, and 0.73, respectively. Although the AF duration showed the best predictive performance (AUROC, 0.58) among the clinical features, it was significantly lower than that of the final machine-learning model (p<0.001). Additional training of extended monitoring data of 15-minute single-lead ECG and photoplethysmography in available patients (n=261) did not significantly improve the model's performance. CONCLUSIONS Machine learning showed modest performance in predicting AF recurrence after ECV in persistent AF patients, warranting further validation studies.
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Affiliation(s)
- Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eunjung Lee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hojin Ju
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
| | - Jangwon Suh
- Department of Intelligence and Information, Seoul National University, Seoul, Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Wonjong Rhee
- Department of Intelligence and Information, Seoul National University, Seoul, Korea.
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O'Neill L, Almorad A, El Haddad M, Wielandts JY, Gillis K, Hilfiker G, de Becker B, Lycke M, Tavernier R, le Polain de Waroux JB, Duytschaever M, Knecht S. Impact of Catheter Ablation on Arrhythmia Burden in Patients With Shock-Resistant Persistent Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:2071-2081. [PMID: 37542487 DOI: 10.1016/j.jacep.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Persistent shock-resistant atrial fibrillation (AF) is a challenging entity, with modest results from catheter ablation according to conventional survival analysis. OBJECTIVES The aim of this study was to determine the effect of catheter ablation on atrial tachyarrhythmia (ATA) burden in persistent AF patients undergoing first-time ablation with the use of an implantable cardiac monitor (ICM). METHODS Patients with drug-resistant ongoing persistent AF and at least 1 previous failed cardioversion were implanted with an ICM 2 months before the procedure. All patients underwent pulmonary vein isolation with or without additional substrate ablation depending on the presence of self-terminating AF on ICM and left atrium size. Median AF burden before and after ablation, off antiarrhythmic medication, was determined from ICM recordings after review by 2 independent investigators. RESULTS Sixty patients were recruited (mean age 66 ± 9 years, 70% male). Mean left atrial diameter was 48 ± 6 mm and median CHA2DS2VASc score was 2. Ten patients (17%) unexpectedly demonstrated self-terminating AF before ablation. The median burden of ATA before ablation was 100% (95% CI: 19.6%-100%), decreasing to 0% (95% CI: 0%-95.8%) after ablation during the post-blanking follow-up period (median reduction 100%; 95% CI: 4%-100%; P < 0.001). Twenty-seven patients (45%) experienced recurrent ATA during 12-month follow-up. In these patients, median burden before ablation was 100% (95% CI: 26.9%-100%), decreasing to 11.4% (95% CI: 0.35%-99.7%) after ablation (P < 0.001). Quality of life improved significantly from baseline, driven by lack of recurrence. CONCLUSIONS Patient-tailored catheter ablation results in a significant reduction in ATA burden (off antiarrhythmic medication) in shock-resistant persistent AF patients using ICMs implanted 2-months pre-procedure. These data suggest that conventional arrhythmia-free survival analysis does not capture the true impact of catheter ablation in this challenging cohort.
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Affiliation(s)
- Louisa O'Neill
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium.
| | | | - Milad El Haddad
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium
| | | | - Kris Gillis
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium
| | | | | | - Michelle Lycke
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium
| | - Rene Tavernier
- Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium
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Segan L, Chieng D, Sugumar H, Voskoboinik A, Ling LH, Costello B, Azzopardi S, Nderitu Z, Parameswaran R, Amerena J, McLellan AJ, Lee G, Morton J, Joseph S, Wong M, Taylor A, Kalman JM, Kistler PM, Prabhu S. The impact of age on ablation outcomes in AF-mediated cardiomyopathy. J Cardiovasc Electrophysiol 2023; 34:2065-2075. [PMID: 37694615 DOI: 10.1111/jce.16052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION The absence of ventricular scar in patients with atrial fibrillation (AF) and systolic heart failure (HF) predicts left ventricular (LV) recovery following AF ablation. It is unknown whether age impacts the degree of LV recovery, reverse remodeling, or AF recurrence following catheter ablation (CA) among this population. OBJECTIVES To evaluate the impact of age on LV recovery and AF recurrence in a population with AF and systolic HF without fibrosis (termed AF-mediated cardiomyopathy) following CA. METHODS Consecutive patients undergoing CA between 2013 and 2021 with LV ejection fraction (LVEF) < 45% and absence of cardiac magnetic resonance imaging (CMR) detected LV myocardial fibrosis were stratified by age (<65 vs. ≥65 years). Following CA, participants underwent remote rhythm monitoring for 12 months with repeat CMR for HF surveillance. RESULTS The study population consisted of 70 patients (10% female, mean LVEF 33 ± 9%), stratified into younger (age < 65 years, 63%) and older (age ≥ 65 years, 37%) cohorts. Baseline comorbidities, LVEF (34 ± 9 vs. 33 ± 8 ≥65 years, p = .686), atrial and ventricular dimensions (left atrial volume index: 55 ± 21 vs. 56 ± 14 mL/m2 age ≥ 65, p = .834; indexed left ventricular end-diastolic volume: 108 ± 40 vs. 104 ± 28 mL/m2 age ≥ 65, p = .681), pharmacotherapy and ablation strategy (pulmonary vein isolation in all; posterior wall isolation in 27% vs. 19% age ≥ 65, p = .448; cavotricuspid isthmus in 9% vs. 11.5% age ≥ 65) were comparable (all p > .05) albeit a higher CHADS2 VASc score in the older cohort (2.7 ± 0.9 vs. 1.6 ± 0.6 age < 65, p < .001). Freedom from AF was comparable (hazard ratio: 0.65, 95% confidence interval: 0.38-1.48, LogRank p = .283) as was AF burden [0% (interquartile range, IQR: 0.0-2.1) vs. age ≥ 65: [0% (IQR 0.0-1.7), p = .516], irrespective of age. There was a significant improvement in LV systolic function in both groups (ΔLVEF + 21 ± 14% vs. +21 ± 12% age ≥ 65, p = .913), with LV recovery in the vast majority (73% vs. 69%, respectively, p = .759) at 13 (IQR: 12-16) months. This was accompanied by comparable improvements in functional status (New York Heart Association class p = .851; 6-min walk distance 50 ± 61 vs. 93 ± 134 m in age ≥ 65, p = .066), biomarkers (ΔN-terminal-pro brain natriuretic peptide -139 ± 246 vs. -168 ± 181 age ≥ 65,p = .629) and HF symptoms (Short Form-36 survey Δphysical component summary p = .483/Δmental component summary, p = .841). CONCLUSION In patients undergoing CA for AF with systolic HF in the absence of ventricular scar, comparable improvements in ventricular function, symptoms, and freedom from AF are achieved irrespective of age.
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Affiliation(s)
- Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
- Western Health, Melbourne, Australia
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Ben Costello
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Western Health, Melbourne, Australia
| | - Sonia Azzopardi
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Ziporah Nderitu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Ramanathan Parameswaran
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
- Barwon Health, Geelong, Australia
| | | | - Alex J McLellan
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph Morton
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Michael Wong
- University of Melbourne, Melbourne, Australia
- Western Health, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
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Shrestha DB, Pathak BD, Thapa N, Shrestha O, Karki S, Shtembari J, Patel NK, Kapoor K, Kalahasty G, Bodziock G, Whalen P, Pothineni NVK, Narasimhan B, Koneru J, Shantha G. Catheter ablation using pulmonary vein isolation with versus without left atrial posterior wall isolation for persistent atrial fibrillation: an updated systematic review and meta-analysis. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01656-z. [PMID: 37773559 DOI: 10.1007/s10840-023-01656-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF); however, the results are suboptimal for persistent AF. The left atrial posterior wall (LAPW) is thought to be a major additional area in initiation and perpetuation of persistent AF. Therefore, adjunctive ablation of the posterior wall may reduce AF recurrence in patients with persistent AF. OBJECTIVE The objective of this study was to compare outcomes of catheter ablation in patients with persistent AF using PVI alone versus a combination of PVI and LAPW isolation. METHODS Literature search was conducted in PubMed, PubMed Central, Scopus, and Embase since inception to February 2023. Screening of studies was done via Covidence software. Risk of bias assessment was done using appropriate tools. Data extraction and a narrative synthesis were carried out accordingly. RESULTS Ten studies were included, of which five were randomized controlled trials. PVI with LAPW ablation group had significantly lower recurrence of overall atrial tachyarrhythmia (OR 0.47, CI 0.32-0.70) and AF (OR 0.39, CI 0.23-0.69). In sensitivity analysis, freedom from atrial arrhythmias was noted to be significantly higher in the PVI with LAPW ablation group (OR 2.22, CI 1.36-3.64). However, there was no significant difference in occurrence of atrial flutter (OR 1.36, CI 0.86-2.14) or with periprocedural adverse events (OR 1.10, CI 0.60-1.99). CONCLUSION LAPW ablation, in addition to PVI, significantly improves the rates of arrhythmia freedom and reduces the recurrence of overall atrial tachyarrhythmia. There was no significant difference in atrial flutter or periprocedural adverse events.
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Affiliation(s)
| | - Bishnu Deep Pathak
- Department of Internal Medicine, Jibjibe Primary Health Care Center, Rasuwa, Nepal
| | - Niranjan Thapa
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Oshan Shrestha
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Sagun Karki
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, USA
| | - Nimesh K Patel
- Department of Internal Medicine, Division of Cardiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Kunal Kapoor
- Department of Internal Medicine, Division of Cardiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Gautham Kalahasty
- Department of Internal Medicine, Division of Electrophysiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - George Bodziock
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Patrick Whalen
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | | | - Bharat Narasimhan
- Department of Cardiology, Debakey Cardiovascular Institute, Houston Methodist, Houston, TX, USA
| | - Jayanthi Koneru
- Department of Internal Medicine, Division of Electrophysiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ghanshyam Shantha
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
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Wałek P, Roskal-Wałek J, Dłubis P, Wożakowska-Kapłon B. Echocardiographic Evaluation of Atrial Remodelling for the Prognosis of Maintaining Sinus Rhythm after Electrical Cardioversion in Patients with Atrial Fibrillation. J Clin Med 2023; 12:5158. [PMID: 37568560 PMCID: PMC10419596 DOI: 10.3390/jcm12155158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/02/2023] [Accepted: 08/05/2023] [Indexed: 08/13/2023] Open
Abstract
Atrial fibrillation (AF) is the most common atrial tachyarrhythmia. One of the methods of AF treatment is direct current cardioversion (DCCV), but in the long-term follow-up we observe quite a high percentage of AF recurrences after this procedure. In order to assess the prognosis of DCCV effectiveness, we use clinical, biochemical and echocardiographic parameters. The objective of this review is to systematise the current knowledge on echocardiographic measurements in patients with persistent AF used to assess the progress of remodelling of the atrial wall, which affects the likelihood of maintaining sinus rhythm after DCCV. In this article, echocardiographic parameters for the evaluation of remodelling of the atrial wall are divided into groups referring to structural, mechanical, and electrical remodelling, as well as parameters for the evaluation of left ventricular filling pressure. The article aims to draw attention to the clinical value of echocardiographic measurements, which is the selection of patients who will maintain sinus rhythm after DCCV in the long-term follow-up, which will allow to avoid unnecessary risks associated with the procedure and enable the selection of the appropriate treatment strategy.
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Affiliation(s)
- Paweł Wałek
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland; (J.R.-W.); (P.D.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Joanna Roskal-Wałek
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland; (J.R.-W.); (P.D.); (B.W.-K.)
- Ophthalmology Clinic, Voivodeship Regional Hospital, 25-736 Kielce, Poland
| | - Patryk Dłubis
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland; (J.R.-W.); (P.D.); (B.W.-K.)
| | - Beata Wożakowska-Kapłon
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland; (J.R.-W.); (P.D.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
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Jimenez-Candil J, Hernandez Hernandez J, Cruz Galban A, Blanco F, Moriñigo JL, Sanchez García M, Oterino A, Sanchez PL. Clinical and economic outcomes of a systematic same-day discharge programme after pulmonary vein isolation: comparison between cryoballoon vs. radiofrequency ablation. Europace 2023; 25:euad265. [PMID: 37669318 PMCID: PMC10498138 DOI: 10.1093/europace/euad265] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/28/2023] [Indexed: 09/07/2023] Open
Abstract
AIMS Same-day discharge (SDD) is feasible after pulmonary vein isolation (PVI). We aim to compare prospectively cryoballoon (CRYO) vs. radiofrequency (RF) ablation in a systematic SDD programme. METHODS AND RESULTS We prospectively analysed the 617 scheduled PVI performed consecutively at our institution (n = 377 CRYO, n = 240 RF) from 1 April 2019 to 31 December 2022 within a systematic programme of SDD. The feasibility of SDD, the 10-day incidence of urgent/unplanned medical care after discharge (UUC-10), and the cost per procedure due to hospital resource use were studied. The 100 procedures performed during the previous year, in which patients were systematically hospitalized, were used as a control group. Same-day discharge was achieved in 585/617 (95%) procedures, with a significant trend towards a higher monthly SDD rate from 2019 to 2022 (P = 0.03). The frequency of SDD was similar in CRYO (356/377; 94%) vs. RF (229/240; 95%). After SDD, the UUC-10 was 66/585 (11.3%), being similar for CRYO (41/356; 11.5%) and RF (25/229; 10.9%); P = 0.8 (log-rank test). Of these, 10 patients were re-hospitalized, with an identical rate in CRYO-treated (6/356; 1.7%) and RF-treated (4/229; 1.7%) patients and owing to similar causes (4 haematomas, 4 pericarditis, and 2 symptomatic sinus node dysfunction). Same-day discharge was associated with an average savings per procedure of 63% (P < 0.001), but no differences were found between the CRYO and RF (P = 0.8). CONCLUSION In a systematic SDD programme, feasibility (95%, increasing over time), safety (11% UUC-10, 1.7% re-hospitalizations), and savings (63% per procedure) were similar for CRYO and RF ablation procedures.
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Affiliation(s)
- Javier Jimenez-Candil
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- CIBER-CV
- Universidad de Salamanca, Salamanca, Spain
| | - Jesus Hernandez Hernandez
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Alba Cruz Galban
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Fabian Blanco
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Jose Luis Moriñigo
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- Universidad de Salamanca, Salamanca, Spain
| | - Manuel Sanchez García
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Armando Oterino
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Pedro L Sanchez
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- CIBER-CV
- Universidad de Salamanca, Salamanca, Spain
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Duong E, Lin M, Hodgson M, Jickling G, George-Phillips K, Bungard TJ. Choice of Oral Anticoagulant: Outcomes in Atrial Fibrillation Patients Post-Stroke Despite Direct Oral Anticoagulant Use. CJC Open 2023; 5:603-610. [PMID: 37720181 PMCID: PMC10502439 DOI: 10.1016/j.cjco.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/03/2023] [Indexed: 09/19/2023] Open
Abstract
Background For patients with atrial fibrillation who have an ischemic stroke or transient ischemic attack (TIA) despite taking direct oral anticoagulants (DOACs), the optimal strategy for ongoing anticoagulation is unknown. Methods Using provincial administrative databases in Alberta, Canada, we compared anticoagulant use before/after the breakthrough stroke/TIA and assessed recurrence of stroke/TIA or bleeding, with consideration of medication adherence. Adherence was defined as the proportion of days covered (PDC) being ≥ 80%. Results Among 985 patients, the median age was 80 years (interquartile range 13), with a mean CHADS2 score of 1.7± 1 prior to the index event. Patients were followed for a median of 643 days (interquartile range 836). Following the index stroke/TIA event, 623 patients (63%) filled a prescription for the same DOAC regimen, 83 (8%) filled a prescription for a different dose, 155 (16%) switched DOAC agents, 51 (5%) switched to warfarin, and 73 (7%) filled no oral anticoagulant prescription. Patients who kept the same regimen more commonly had TIA index events (59%); patients who changed dose or drug more often had stroke index events (55%-78%). During follow-up, 135 (14%) had stroke/TIA recurrence, and 46 (5%) had bleeding; rates of each did not differ between prescribing patterns. Post-index event, the proportion of patients with a proportion of days covered ≥ 80% improved from 55% to 80%. Conclusions Although most maintained the same DOAC regimen after stroke/TIA, rates of recurrent stroke/TIA and bleeding were similar across prescribing patterns. Stroke/TIA severity may have influenced prescribing practices. DOAC prescription adherence improved poststroke/TIA and signals an opportunity for optimization in patients with atrial fibrillation.
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Affiliation(s)
- Eric Duong
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mu Lin
- Data and Research Services, Alberta Strategy for Patient-Oriented Research Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mathew Hodgson
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Glen Jickling
- Division of Neurology, Faculty of Medicine & Dentistry, Stroke Program, University of Alberta, Edmonton, Alberta, Canada
| | | | - Tammy J. Bungard
- Division of Cardiology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Bucci T, Proietti M, Shantsila A, Romiti GF, Teo WS, Park HW, Shimizu W, Tse HF, Lip GY, Chao TF. Integrated Care for Atrial Fibrillation Using the ABC Pathway in the Prospective APHRS-AF Registry. JACC. ASIA 2023; 3:580-591. [PMID: 37614548 PMCID: PMC10442886 DOI: 10.1016/j.jacasi.2023.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 04/18/2023] [Indexed: 08/25/2023]
Abstract
Background The Atrial Fibrillation Better Care (ABC) has been proposed as an integrated approach to improve management in patients with atrial fibrillation (AF), based on 3 pillars: "A" Avoid stroke with Anticoagulation; "B" Better symptoms control; "C" Cardiovascular risk-factor and comorbidities management. Objectives This study sought to investigate the association with outcomes of ABC adherence in the prospective multinational Asia-Pacific Heart Rhythm Society (APHRS) Atrial Fibrillation registry. Method Cox-regression analyses adjusted for age, sex, CHA2DS2-VASc score, paroxysmal AF, chronic obstructive pulmonary disease, chronic kidney disease, cancer, dyslipidemia, and dementia were performed to investigate the association with outcomes. Primary outcome was a composite of all-cause death, any thromboembolic events, acute coronary syndrome or percutaneous interventional procedures, and advancing heart failure. Results Of the 4,013 included patients with AF (mean age 68 ± 12 years; 34.4% female); 38.6% were adherent to all 3 main ABC pillars. After 1 year of follow-up, adherence to the ABC pathway was associated with a low incidence of composite outcome (4.0% vs 8.5%, P < 0.001), all-cause and cardiovascular death, and advancing heart failure. On Cox regression analysis, ABC adherence was associated with a lower risk of primary outcome (HR: 0.72; 95% CI: 0.53-0.97), with risk reduction progressively higher with a higher number of ABC criteria attained. No significant interaction in the association was seen according to the different geographic areas (Pint = 0.217). Conclusions In a large contemporary cohort of Asian patients with AF, adherence to ABC pathway was associated with a reduction of the risk for adverse outcomes. (Clinical Survey on the Stroke Prevention in Atrial Fibrillation in Asia (AF-Registry; NCT04807049).
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Affiliation(s)
- Tommaso Bucci
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
| | - Marco Proietti
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Alena Shantsila
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Giulio Francesco Romiti
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Wee-Siong Teo
- Department of Cardiology, National Heart Centre, Singapore
| | - Hyung-Wook Park
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Gregory Y.H. Lip
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Denmark
| | - Tze-Fan Chao
- Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - APHRS-AF Registry Investigators
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Department of Cardiology, National Heart Centre, Singapore
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
- Division of Cardiology, Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Denmark
- Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Wu C, Hu L, Kong Y, Zhao B, Mao W, Zhou X. Bayesian network meta-analysis comparing hot balloon, laser balloon and cryoballoon ablation as initial therapies for atrial fibrillation. Front Cardiovasc Med 2023; 10:1184467. [PMID: 37560114 PMCID: PMC10407100 DOI: 10.3389/fcvm.2023.1184467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/10/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Balloon-based catheter ablation (CA) technologies, including hot balloon ablation (HBA), laser balloon ablation (LBA) and cryoballoon ablation (CBA) have been introduced in recent years as alternatives to conventional radiofrequency ablation therapy for atrial fibrillation (AF). However, the results remain controversial concerning the optimal approach. Thus, we conducted a network meta-analysis (NMA) to comprehensively evaluate the efficacy and safety of HBA, LBA and CBA. METHODS Clinical trials comparing the efficacy and safety of HBA, LBA and CBA were identified through a systematic search up to October 2022. The primary outcomes of interest were the recurrence of AF and procedure-related complications. RESULTS Twenty clinical trials with a total of 1,995 patients were included in the meta-analysis. The NMA results demonstrated that HBA, LBA and CBA had comparable AF recurrence rates (HBA vs. CBA: odds ratio OR = 0.88, 95% credible interval CrI: 0.56-1.4; LBA vs. CBA: OR = 1.1, 95% CrI: 0.75-1.5; LBA vs. HBA: OR = 1.2, 95% CrI: 0.70-2.0) and procedure-related complications (HBA vs. CBA: OR = 0.93, 95% CrI: 0.46-2.3; LBA vs. CBA: OR = 1.1, 95% CrI: 0.63-2.1; LBA vs. HBA: OR = 1.2, 95% CrI: 0.44-2.8). The surface under the cumulative ranking curve (SUCRA) suggested that HBA may be the optimal approach concerning the primary outcomes (SUCRA = 74.4%; 61.1%, respectively). However, HBA (40.1%) had a significantly higher incidence of touch-up ablation (TUA) than LBA (8.5%, OR = 2.8, 95% CrI: 1.1-7.1) and CBA (11.9%, OR = 3.7, 95% CrI: 1.9-7.5). LBA required more procedure time than CBA [mean difference (MD = 32.0 min, 95% CrI: 19.0-45.0 min)] and HBA (MD = 26.0 min, 95% CrI: 5.6-45.0 min), but less fluoroscopy time than HBA (MD = -9.4 min, 95% CrI: -17.0--2.4 min). CONCLUSIONS HBA, LBA and CBA had comparable efficacy and safety as initial treatments for AF. HBA ranked highest in the primary outcomes, but at the cost of a higher incidence of TUA and longer fluoroscopy time. SYSTEMATIC REVIEW REGISTRATION www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022381954, identifier: CRD42022381954.
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Affiliation(s)
- Chenxia Wu
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Luoxia Hu
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Youjin Kong
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Bowen Zhao
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Wei Mao
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China
- Key Laboratory of Integrative Chinese and Western Medicine for the Diagnosis and Treatment of Circulatory Diseases of Zhejiang Province, Hangzhou, China
| | - Xinbin Zhou
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
- Key Laboratory of Integrative Chinese and Western Medicine for the Diagnosis and Treatment of Circulatory Diseases of Zhejiang Province, Hangzhou, China
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42
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Roychoudhury R, Ma S, Qian C. Stroke prevention and intracranial hemorrhage risk in atrial fibrillation management: A mini review. Brain Circ 2023; 9:148-153. [PMID: 38020950 PMCID: PMC10679623 DOI: 10.4103/bc.bc_22_23] [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: 03/24/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 12/01/2023] Open
Abstract
This mini-review examines the management of atrial fibrillation (AF) in patients at high risk of bleeding, with a focus on stroke prevention and intracranial hemorrhage risk. Anticoagulant therapy is commonly advised for AF patients, but it can elevate the risk of intracranial hemorrhage in certain individuals prone to bleeding. Two primary perspectives for managing high-risk patients are discussed: adhering to strict anticoagulation therapy or opting for alternative treatments like left atrial appendage closure (LAAC) or aspirin. The benefits and drawbacks of each approach are evaluated, emphasizing the importance of a personalized management plan based on patient risk profiles, comorbidities, and preferences. Ongoing research, including artificial intelligence, advances in LAAC devices, and combination therapies, is explored to enhance stroke prevention and minimize bleeding risk in AF management. A multidisciplinary approach and continuous investigation are vital to achieving better patient outcomes and overall care in this context.
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Affiliation(s)
- Rohon Roychoudhury
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Shuangtao Ma
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Chunqi Qian
- Department of Radiology, Cognitive Imaging Research Center, Michigan State University, East Lansing, Michigan, USA
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Kishore P, Collinet ACT, Brundel BJJM. Prevention of Atrial Fibrillation: Putting Proteostasis Derailment Back on Track. J Clin Med 2023; 12:4352. [PMID: 37445387 DOI: 10.3390/jcm12134352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
Despite the many attempts to treat atrial fibrillation (AF), the most common cardiac tachyarrhythmia in the Western world, the treatment efficacy of AF is still suboptimal. A plausible reason for the suboptimal efficacy is that the current treatments are not directed at the underlying molecular mechanisms that drive AF. Recent discoveries revealed that the derailment of specific molecular proteostasis pathways drive electrical conduction disorders, contractile dysfunction and AF. The degree of this so-called 'electropathology' corresponds to the response to anti-AF treatment. Hence, to develop effective therapies to prevent AF, understanding the molecular mechanisms is of key importance. In this review, we highlight the key modulators of proteostasis derailment and describe the mechanisms that explain how they affect electrical and contractile function in atrial cardiomyocytes and AF. The key modulators of proteostasis derailment include (1) exhaustion of cardioprotective heat shock proteins (HSPs), (2) excessive endoplasmic reticulum (ER) stress and downstream autophagic protein degradation, (3) histone deacetylase 6 (HDAC6)-induced microtubule disruption, (4) activation of DNA damage-PARP1 activation and NAD+ axis and (5) mitochondrial dysfunction. Furthermore, we discuss druggable targets within these pathways that are involved in the prevention of proteostasis derailment, as well as the targets that aid in the recovery from AF. Finally, we will elaborate on the most favorable druggable targets for (future) testing in patients with AF, as well as drugs with potential benefits for AF recovery.
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Affiliation(s)
- Preetam Kishore
- Physiology, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, 1081 HZ Amsterdam, The Netherlands
| | - Amelie C T Collinet
- Physiology, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, 1081 HZ Amsterdam, The Netherlands
| | - Bianca J J M Brundel
- Physiology, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, 1081 HZ Amsterdam, The Netherlands
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Kanthasamy V, Breitenstein A, Schilling R, Hofer D, Tiongco B, Ang R, Hunter R, Earley M, Ahsan S, Mangiafico V, Honarbakhsh S, Ahluwalia N, Maclean E, Creta A, Finlay M. Catheter ablation of atrial fibrillation with a multi-electrode radiofrequency balloon; first and early two centre experience in Europe. J Cardiovasc Electrophysiol 2023; 34:1350-1359. [PMID: 36598422 DOI: 10.1111/jce.15799] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/11/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The Heliostar™ ablation system is a novel RF balloon ablation technology with an integrated three-dimensional mapping system. Here, we describe our early experience and procedural outcomes using this technology for atrial fibrillation catheter ablation. METHODS We sought to comprehensively assess the first 60 consecutive patients undergoing pulmonary vein isolation using the novel HELISOTAR™ RF balloon technology including procedural outcomes. A comparison of the workflow between two different anaesthetic modalities (conscious sedation [CS] vs. general anaesthesia [GA]) was made. Procedural data were collected prospectively from two high-volume centers (Barts Heart Centre, UK and University Hospital of Zurich, Zurich). A standardized approach for catheter ablation was employed. RESULTS A total of 35 patients had the procedure under CS and the remaining under GA. Mean procedural and fluoroscopy times were 84 ± 33 min and 1.1 min. The median duration of RF energy application was 7 (5-9.8) mins per patient. All veins were successfully isolated, and the median isolation time was 10 (7-15) seconds. Our cohort's rate of procedural complications was low, with no mortality within 30 days postprocedure. CONCLUSION Our early experience shows that catheter ablation using the Heliostar™ technology can be performed efficiently and safely; however, long-term data is yet to be established. Low fluoroscopy requirements, short learning curves and use of this technology with CS is possible, including the use of an oesophageal temperature probe.
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Affiliation(s)
- Vijayabharathy Kanthasamy
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | | | - Richard Schilling
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
| | - Daniel Hofer
- Klinik für Kardiologie Herzzentrum, Universitätsspital Zürich, Zürich, Switzerland
| | - Benny Tiongco
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
| | - Richard Ang
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
| | - Ross Hunter
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
| | - Mark Earley
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
| | - Syed Ahsan
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
| | - Valentina Mangiafico
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
| | - Shohreh Honarbakhsh
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
| | - Nikhil Ahluwalia
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Edd Maclean
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Antonio Creta
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
| | - Malcolm Finlay
- Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
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Hindricks G, Theuns DA, Bar-Lev D, Anguera I, Ayala Paredes FA, Arnold M, Geller JC, Merkely B, Dyrda KM, Perings C, Maglia G, Ploux S, Meyhöfer J, Blomström-Lundqvist C, Karjalainen P, Liang Y, Diemberger I, Wranicz JK, Barr C, Quartieri F, Timmel T, Bollmann A. Ability to remotely monitor atrial high-rate episodes using a single-chamber implantable cardioverter-defibrillator with a floating atrial sensing dipole. Europace 2023; 25:euad061. [PMID: 37038759 PMCID: PMC10227664 DOI: 10.1093/europace/euad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 12/06/2022] [Indexed: 04/12/2023] Open
Abstract
AIMS To allow timely initiation of anticoagulation therapy for the prevention of stroke, the European guidelines on atrial fibrillation (AF) recommend remote monitoring (RM) of device-detected atrial high-rate episodes (AHREs) and progression of arrhythmia duration along pre-specified strata (6 min…<1 h, 1 h…<24 h, ≥ 24 h). We used the MATRIX registry data to assess the capability of a single-lead implantable cardioverter-defibrillator (ICD) with atrial sensing dipole (DX ICD system) to follow this recommendation in patients with standard indication for single-chamber ICD. METHODS AND RESULTS In 1841 DX ICD patients with daily automatic RM transmissions, electrograms of first device-detected AHREs per patient in each duration stratum were adjudicated, and the corresponding positive predictive values (PPVs) for the detections to be true atrial arrhythmia were calculated. Moreover, the incidence and progression of new-onset AF was assessed in 1451 patients with no AF history. A total of 610 AHREs ≥6 min were adjudicated. The PPV was 95.1% (271 of 285) for episodes 6min…<1 h, 99.6% (253/254) for episodes 1 h…<24 h, 100% (71/71) for episodes ≥24 h, or 97.5% for all episodes (595/610). The incidence of new-onset AF was 8.2% (119/1451), and in 31.1% of them (37/119), new-onset AF progressed to a higher duration stratum. Nearly 80% of new-onset AF patients had high CHA2DS2-VASc stroke risk, and 70% were not on anticoagulation therapy. Age was the only significant predictor of new-onset AF. CONCLUSION A 99.7% detection accuracy for AHRE ≥1 h in patients with DX ICD systems in combination with daily RM allows a reliable guideline-recommended screening for subclinical AF and monitoring of AF-duration progression.
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Affiliation(s)
- Gerhard Hindricks
- Department of Electrophysiology, Heart Centre Leipzig and Leipzig Heart Institute, Strümpellstrasse 39, 04289 Leipzig, Germany
| | - Dominic A Theuns
- Erasmus University Medical Center,‘s-Gravendijkwal 230, 3015 GD Rotterdam, TheNetherlands
| | - David Bar-Lev
- Chaim Sheba Medical Center,52621 Tel Hashomer, Israel
| | - Ignasi Anguera
- Arrhythmia Unit, Heart Diseases Institute, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, Feixa Llarga, 08907 L'Hospitalet, Barcelona, Spain
| | | | - Martin Arnold
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - J Christoph Geller
- Zentralklinik Bad Berka GmbH,Robert-Koch-Allee 9, 99437 Bad Berka, Germany
| | - Béla Merkely
- Semmelweis Medical University, Városmajorutca 68, 1122 Budapest, Hungary
| | - Katia Marjolaine Dyrda
- Montreal Heart Institute affiliated with Université de Montréal, 5000, rue Belanger, H1T 1C8 Montréal, Québec, Canada
| | | | - Giampiero Maglia
- Azienda Ospedaliera Pugliese Ciaccio, Via Vinicio Cortese 25, 88100 Catanzaro, Italia
| | - Sylvain Ploux
- Hôpital Haut Lévêque (CHU), 1 avenue de Magellan, 33600 Pessac Cedex, France
| | - Jürgen Meyhöfer
- Maria Heimsuchung—Caritas-Klinik Pankow,Breite Str. 46/47, 13187 Berlin, Germany
| | - Carina Blomström-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden
- Department of Medical Science and Cardiology, Uppsala University, S-751 85 Uppsala, Sweden
| | - Pasi Karjalainen
- Satakunta Central Hospital, Sydänyksikkö, Sairaalantie 3, 28500 Pori, Finland
| | - Yanchun Liang
- General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, 110016 Shenyang, China
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Via Massarenti 9, 40138 Bologna, Italia
| | - Jerzy Krzysztof Wranicz
- Department of Electrocardiology, Medical University of Lodz, Ul. Pomorska 251, 92-213 Łódź, Poland
| | - Craig Barr
- Russells Hall Hospital, Pensett Road, DY1 2HQ Dudley, UK
| | - Fabio Quartieri
- Arcispedale Santa Maria Nuova, Viale Risorgimento 80, 42123 Reggio Emilia, Italia
| | - Tobias Timmel
- Biotronik SE & Co. KG,Woermannkehre 1, 12359 Berlin, Germany
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Savelieva I, Fumagalli S, Kenny RA, Anker S, Benetos A, Boriani G, Bunch J, Dagres N, Dubner S, Fauchier L, Ferrucci L, Israel C, Kamel H, Lane DA, Lip GYH, Marchionni N, Obel I, Okumura K, Olshansky B, Potpara T, Stiles MK, Tamargo J, Ungar A. EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2023; 25:1249-1276. [PMID: 37061780 PMCID: PMC10105859 DOI: 10.1093/europace/euac123] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 04/17/2023] Open
Abstract
There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.
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Affiliation(s)
- Irina Savelieva
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
| | - Rose Anne Kenny
- Mercer’s Institute for Successful Ageing, Department of Medical Gerontology, St James’s Hospital, Dublin, Ireland
| | - Stefan Anker
- Department of Cardiology (CVK), Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Germany
- German Centre for Cardiovascular Research (DZHK) partner site Berlin, Germany
- Charité Universitätsmedizin Berlin, Germany
| | - Athanase Benetos
- Department of Geriatric Medicine CHRU de Nancy and INSERM U1116, Université de Lorraine, Nancy, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Jared Bunch
- (HRS representative): Intermountain Medical Center, Cardiology Department, Salt Lake City,Utah, USA
- Stanford University, Department of Internal Medicine, Palo Alto, CA, USA
| | - Nikolaos Dagres
- Heart Center Leipzig, Department of Electrophysiology, Leipzig, Germany
| | - Sergio Dubner
- (LAHRS representative): Clinica Suizo Argentina, Cardiology Department, Buenos Aires Capital Federal, Argentina
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, General Cardiology Division, University of Florence and AOU Careggi, Florence, Italy
| | - Israel Obel
- (CASSA representative): Milpark Hospital, Cardiology Unit, Johannesburg, South Africa
| | - Ken Okumura
- (APHRS representative): Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Brian Olshansky
- University of Iowa Hospitals and Clinics, Iowa CityIowa, USA
- Covenant Hospital, Waterloo, Iowa, USA
- Mercy Hospital Mason City, Iowa, USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Serbia
- Cardiology Clinic, Clinical Center of Serbia, Serbia
| | - Martin K Stiles
- (APHRS representative): Waikato Clinical School, University of Auckland and Waikato Hospital, Hamilton, New Zealand
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, CIBERCV, Universidad Complutense, Madrid, Spain
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
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Thoracoscopic ablation delays progression from paroxysmal to persistent atrial fibrillation. J Thorac Cardiovasc Surg 2023; 165:1387-1394. [PMID: 33992460 DOI: 10.1016/j.jtcvs.2021.03.114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 02/21/2021] [Accepted: 03/01/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The study objective was to determine whether mini-invasive transthoracoscopic atrial fibrillation ablation can delay the progression of atrial fibrillation from paroxysmal to persistent. METHODS Patients aged 18 to 80 years with paroxysmal nonvalvular atrial fibrillation and a history of stroke or systemic thromboembolism were consecutively enrolled from September 2014 to June 2019. In the treatment group, patients underwent transthoracoscopic atrial fibrillation ablation plus left atrial appendage excision (atrial fibrillation ablation plus left atrial appendage excision group). Patients unwilling to receive surgical intervention were treated with antiarrhythmic drugs and oral anticoagulants and recruited as a control group (atrial fibrillation plus antiarrhythmic drugs group). The primary end point was the progression of atrial fibrillation from paroxysmal to persistent. RESULTS This study included 49 patients in the atrial fibrillation plus antiarrhythmic drugs group (29 men) and 77 patients in the atrial fibrillation ablation plus left atrial appendage excision group (48 men). In the atrial fibrillation ablation plus left atrial appendage excision group, after a median follow-up of 951 days (interquartile range, 529-1366 days), 8 patients (10.4%) progressed to persistent atrial fibrillation. In the atrial fibrillation plus antiarrhythmic drugs group, after a median follow-up of 835 days (interquartile range, 548-1214 days), 14 patients (28.6%) progressed to persistent atrial fibrillation. The atrial fibrillation ablation plus left atrial appendage excision group had a significantly lower incidence of atrial fibrillation progression than the atrial fibrillation plus antiarrhythmic drugs group during follow-up (3.9 vs 12.3 per 100 person-years, log-rank 8.6, P = .003). CONCLUSIONS Patients with paroxysmal nonvalvular atrial fibrillation who chose to undergo transthoracoscopic atrial fibrillation ablation had a lower incidence of progression to persistent atrial fibrillation than patients who chose conservative therapy. This strategy might be especially suitable for patients with paroxysmal nonvalvular atrial fibrillation at high risk of stroke and high risk of bleeding.
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Takumi K, Nagano H, Ueda K, Umehara T, Tokunaga T, Kamimura G, Sato M, Nakanosono R, Yoshiura T. Left atrial CT volume and CHA 2DS 2-VASc score predict early pulmonary vein stump thrombus after left upper lobectomy. Sci Rep 2023; 13:4965. [PMID: 36973354 PMCID: PMC10042883 DOI: 10.1038/s41598-023-32240-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
The purpose of this study is to clarify the feasibility of left atrial (LA) volume measurement and CHA2DS2-VASc score for predicting the development of pulmonary vein (PV) stump thrombus after left upper lobectomy (LUL). The study population comprised 50 patients who underwent LUL for pulmonary lesions. All patients were evaluated for the development of PV stump thrombus at 7 days after LUL. LA volume was measured using preoperative CT and the CHA2DS2-VASc score was evaluated. LA volume and CHA2DS2-VASc score were compared between patients with and without the development of PV stump thrombus using the Mann-Whitney U test. Receiver-operating characteristic (ROC) curve analysis was performed to evaluate the accuracy of prediction of PV stump thrombus development. PV stump thrombus was detected in 17 (33.4%) of the 50 patients. LA volume was significantly greater in patients who developed PV stump thrombus than in those without thrombus (79.7 ± 19.4 vs. 66.6 ± 17.0 mL, p = 0.040). CHA2DS2-VASc score was significantly higher in patients with PV stump thrombosis than in those without thrombus (3.4 ± 1.5 vs. 2.5 ± 1.5, p = 0.039). Area under the ROC curve values for predicting PV stump thrombus were 0.679, 0.676, and 0.714 for LA volume, CHA2DS2-VASc score, and their combination, respectively. In conclusion, LA volume measured using preoperative CT and CHA2DS2-VASc score may help predict the development of PV stump thrombus after LUL.
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Affiliation(s)
- Koji Takumi
- Departments of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan.
| | - Hiroaki Nagano
- Departments of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Kazuhiro Ueda
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Tadashi Umehara
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Takuya Tokunaga
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Go Kamimura
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Masami Sato
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Ryota Nakanosono
- Departments of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Takashi Yoshiura
- Departments of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
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Haum M, Kellnar A, Thienel M, Lackermair K. Review: Sex-related differences in the treatment of cardiac arrhythmia. Pharmacol Ther 2023; 244:108388. [PMID: 36940792 DOI: 10.1016/j.pharmthera.2023.108388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/22/2023] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Abstract
Cardiac arrhythmias are a common and potentially serious cardiovascular disorders that affect both men and women. However, there is evidence to suggest that there may be sex-related differences in the prevalence, clinical presentation, and management of cardiac arrhythmias. Hormonal and cellular factors may play a role in these sex-specific differences. In addition, there are differences in the types of arrhythmias that men and women experience, with men more likely to experience ventricular arrhythmias and women more likely to experience supraventricular arrhythmias. The management of cardiac arrhythmias also differs between men and women. For example, some studies have found that women are less likely to receive appropriate treatment for arrhythmias and are more likely to have adverse outcomes following treatment. Despite these sex-related differences, the majority of research on cardiac arrhythmias has been conducted in men, and there is a need for more research to specifically examine the differences between men and women. This is especially important given that the prevalence of cardiac arrhythmia is increasing, and it is essential to understand how to effectively diagnose and treat these conditions in both men and women. In this review, we examine the current understanding of sex-related differences in cardiac arrhythmias. We also review the available data on sex-specific management strategies for cardiac arrhythmias and highlight areas of future research.
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Affiliation(s)
- Magda Haum
- Department of Medicine I, Munich University Hospital, Ludwig-Maximilian-University, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Germany
| | - Antonia Kellnar
- Department of Medicine I, Munich University Hospital, Ludwig-Maximilian-University, Munich, Germany
| | - Manuela Thienel
- Department of Medicine I, Munich University Hospital, Ludwig-Maximilian-University, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Germany.
| | - Korbinian Lackermair
- Department of Medicine I, Munich University Hospital, Ludwig-Maximilian-University, Munich, Germany
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Abstract
Wearable devices, such as smartwatches and activity trackers, are commonly used by patients in their everyday lives to manage their health and well-being. These devices collect and analyze long-term continuous data on measures of behavioral or physiologic function, which may provide clinicians with a more comprehensive view of a patients' health compared with the traditional sporadic measures captured by office visits and hospitalizations. Wearable devices have a wide range of potential clinical applications ranging from arrhythmia screening of high-risk individuals to remote management of chronic conditions such as heart failure or peripheral artery disease. As the use of wearable devices continues to grow, we must adopt a multifaceted approach with collaboration among all key stakeholders to effectively and safely integrate these technologies into routine clinical practice. In this Review, we summarize the features of wearable devices and associated machine learning techniques. We describe key research studies that illustrate the role of wearable devices in the screening and management of cardiovascular conditions and identify directions for future research. Last, we highlight the challenges that are currently hindering the widespread use of wearable devices in cardiovascular medicine and provide short- and long-term solutions to promote increased use of wearable devices in clinical care.
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Affiliation(s)
- Andrew Hughes
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Hiral Master
- Vanderbilt Institute of Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Jessilyn Dunn
- Department of Biomedical Engineering, Duke University, Durham, NC
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC
| | - Evan Brittain
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
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