The impact of atrial fibrillation on transcatheter mitral valve repair outcomes: A propensity-matched analysis

Interventional management of mitral regurgitation and sleep disordered breathing: "Catching two birds with one stone"

Sleep disordered breathing (SDB), mostly constituting of obstructive and central sleep apnea (OSA and CSA, respectively), is highly prevalent in the general population, and even more among patients with cardiovascular disease, heart failure (HF) and valvular heart disease, such as mitral regurgitation (MR). The coexistence of HF, MR and SDB is associated with worse cardiovascular outcomes and increased morbidity and mortality. Pulmonary congestion, as a result of MR, can exaggerate and worsen the clinical status and symptoms of SDB, while OSA and CSA, through various mechanisms that impair left ventricular dynamics, can promote left ventricular remodelling, mitral annulus dilatation and consequently MR. Regarding treatment, positive airway pressure devices used to ameliorate symptoms in SDB also seem to result in a reduction of MR severity, MR jet fraction and an improvement of left ventricular ejection fraction. However, surgical and transcatheter interventions for MR, and especially transcatheter edge to edge mitral valve repair (TEER), seem to also have a positive effect on SDB, by reducing OSA and CSA-related severity indexes and improving symptom control. The purpose of this review is to provide a comprehensive analysis of the common pathophysiology between SDB and MR, as well as to discuss the available evidence regarding the effect of SDB treatment on MR and the effect of mitral valve surgery or transcatheter repair on both OSA and CSA.

Incidence and Predictors of New-Onset Atrial Fibrillation After Transcatheter Edge-to-Edge Repair of the Mitral Valve (from the Nationwide Readmissions Database)

Patients who underwent transcatheter edge-to-edge repair (TEER) for mitral regurgitation with atrial fibrillation (AF) at baseline have higher mortality than those without AF. Data on new-onset AF (NOAF) after TEER are limited. Using the 2016 to 2018 Nationwide Readmissions Database, we identified a cohort of patients who underwent TEER and classified them into 3 groups based on AF presence during the study period. The primary end point was the incidence and timing of NOAF up to 6 months after TEER. Logistic regression modeling identified independent predictors of NOAF at readmission. Of the 6,861patients that underwent TEER, 4,134 (59.9%) had AF at baseline, and 239 (3.5%) developed NOAF. Median time-to-NOAF admission was 47 days (interquartile range 16 to 113), and 37% of patients with NOAF presented within 30 days after TEER. Patients with NOAF experienced costlier and longer index-TEER hospitalization and had more co-morbidities. Chronic kidney disease (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.03 to 2.20), fluid and electrolyte disorders (OR 1.59, 95% CI 1.01 to 2.52), and heart failure (OR 1.86, 95% CI 1.01 to 3.44) were identified as independent predictors of NOAF. Hypertensive complications and heart failure were the leading causes of readmission. In conclusion, those patients that developed NOAF after TEER tended to be an overall sicker group at baseline compared with the remainder of the study cohort. These data, obtained from a nationally representative cohort, highlight a particular group of patients subject to developing NOAF and their association with increased rehospitalization in the post-TEER setting. Predictors of NOAF can be screened for during TEER workup to identify patients at increased risk.

Beneficial Effect of Edoxaban on Preventing Atrial Fibrillation and Coagulation by Reducing Inflammation via HBG1/HBD Biomarkers

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia. The effectiveness and mechanism of edoxaban in preventing stroke after atrial fibrillation remain unclear.

Methods: The expressions of HBG1 and HBD in red blood cells were tested in AF. Sixty C57B/6J mice were randomly divided into the following groups: the control (CON) group, atrial fibrillation (AF) group, AF + edoxaban group, and AF + rivaroxaban group. H&E staining assay and reticular fiber staining were performed. Myocardial fibrosis was evaluated by the Masson staining assay, Sirius red staining assay, and immunohistochemical assay for the expressions of α-SMA and COL1A1. ELISA and RT-PCR assay were performed for the detection of inflammatory parameters (TNF-α, IL-1β, IL-6, and IL-10). Blood lipids were detected by using the Beckman automatic biochemical analyzer. Furthermore, four items of coagulation were detected, and molecular docking among HBG1, HBD, and MASP1 (Xa) was performed by PyMOL 2.1 software. The BP neural network model, cubic spline interpolation, and support vector machine model were constructed to predict prothrombin time based on HBG1 and HBD expressions. COIP assay was performed to construct the interaction between HBG1 and HBD. The functional enrichment analysis was performed by DAVID and Metascape tools.

Results: The expressions of HBG1 and HBD in red blood cells of the patients with atrial fibrillation were decreased. The results showed a lower level of hemoglobin in red blood cells with HBG1-siRNA and HBG1-siRNA. Compared with the AF group, the collagen fiber percentage in the AF + edoxaban group was decreased (p < 0.05). After using edoxaban, the expressions of TNF-α, IL-1β, IL-6, and IL-10 were significantly decreased (p < 0.05). The LDL-C, TC, and TG levels were downregulated in the AF + edoxaban group. The PT and APTT levels in the AF + edoxaban group were more increasing than in the AF mice (p < 0.05). Compared with the AF group, the expressions of HBG1 and HBD were downregulated in the AF + edoxaban group (p < 0.05). HBG1 protein matched well with HBD and MASP1(Xa) protein surfaces. There exists a significant interaction between HBG1, HBD, and PT via the BP neural network and support vector machine. Enrichment analysis showed that HBG1 and HBD were mainly enriched in blood coagulation.

Conclusion: Edoxaban could prevent atrial fibrillation and coagulation by reducing inflammation, lipids, and fibrosis via HBG1/HBD biomarkers effectively, and the effect was superior to that of rivaroxaban.

Atrial Fibrillation and Transcatheter Repair of Functional Mitral Regurgitation: Evidence From a Meta-Regression

OBJECTIVES

The aim of this study was to assess the impact of atrial fibrillation (AF) on mortality and efficacy in patients with functional mitral regurgitation (FMR) undergoing MitraClip implantation.

BACKGROUND

AF is a common arrhythmia in patients with severe FMR undergoing transcatheter mitral valve repair with the MitraClip device. Although AF has been consistently shown to be associated with poor outcomes after mitral valve surgery, the impact of AF on outcomes of MitraClip placement in patients with FMR has not been well studied.

METHODS

Prospective, retrospective registries, observational studies, and randomized controlled trials on MitraClip reporting AF and FMR as one of the variables from inception until January 2019 were included.

RESULTS

Of the initial 1,694 studies, 15 studies met the inclusion criteria. From a total of 5,184 patients, 2,105 patients were identified to have FMR and AF. All-cause 30-day mortality in patients with FMR was 3.7% (95% confidence interval: 2.87 to 4.66) and 1-year mortality was 17.9% (95% confidence interval: 16.01 to 19.71). The meta-regression analysis studying the impact of AF among patients with FMR treated with the MitraClip demonstrated no difference in mortality at 30 days but demonstrated significantly increased mortality at 1 year (95% confidence interval: 0.0006 to 0.0027) (p = 0.004). AF did not influence procedural success.

CONCLUSIONS

This meta-regression identifies AF as an independent negative predictor of long-term mortality after MitraClip implantation in patients with FMR. The mechanism of worse outcomes in patients with AF requires further study.

Impact of atrial fibrillation on outcomes of patients treated by transcatheter mitral valve repair: A systematic review and meta-analysis

BACKGROUND

Conflicting data have been reported related to the impact of atrial fibrillation (AF) on outcomes after transcatheter mitral valve repair with MitraClip (MC) implantation. In this study, we assessed the prognosis of MC-treated patients according to the presence of pre-existing AF.

METHODS

Randomized and observational studies reporting outcomes of pre-existing AF or sinus rhythm in patients undergoing MC treatment were identified with an electronic search. Outcomes of interest were short-and long-term mortality, stroke, bleeding, rehospitalization, myocardial infarction (MI), cardiogenic shock, acute procedure success, the hospital stay, and the number of Clips implanted.

RESULTS

Eight studies (8466 individuals) were eligible. Compared to sinus rhythm, long-term mortality, the risk of bleeding, rehospitalization, and longer hospital stay were significantly higher in AF groups, whereas similar correlations were found in the analysis of other outcomes.

CONCLUSION

AF may be related with worse outcomes in patients undergoing MC implantation, including long-term mortality, major bleeding, and rehospitalization. AF should be taken into account when referring a patient for MC treatment.

Comparison of In-Hospital Outcomes of Patients With-Versus-Without Atrial Fibrillation and Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome (AWS) has been associated with significant medical complications and length of stay. Cardiovascular effects from AWS include a physiologic tachycardia and hypertensive response. Although atrial fibrillation (AF) is one of the most common arrhythmias, the impact of a known history of AF on AWS is unclear. The purpose of our study is to assess the impact of history of AF on clinical outcomes, cost, and length of stay on AWS. The Nationwide Inpatient Sample was used to identify patients aged 18 years or older who underwent AWS with or without AF using the International Classification of Disease 9 Clinical Modification codes from January 2010 to December 2014. Outcomes were compared between those with or without AF using propensity score method-stratified morbidity ratio weighing- to adjust for baseline patient and hospital characteristics. A total of 280,451 patients with AWS of which 14,459 (5.2%) had history of AF. Patients with AF was older, less likely female, and more had higher burden of co-morbidities. In an adjusted model, in-hospital mortality (odds ratio [OR] 1.98 95% confidence interval [CI] 1.61 to 2.45), ischemic stroke (OR 1.67 95% CI 1.42 to 1.95), acute kidney injury (OR 1.36 95% CI 1.24 to 1.49), acute kidney injury requiring dialysis (OR 1.89 95% CI 1.39 to 2.50), and cost (mean ratio 1.27 95% CI 1.21 to 1.33) were higher in the AF cohort. Length of stay was shorter in patients with AF (mean ratio 0.85 95% CI 0.81 to 0.90). In conclusion, a known history of AF increased the risk of in-hospital mortality, morbidity, and hospital expense in AWS.