Predicting atrial fibrillation recurrence after ablation in patients with heart failure: Validity of the APPLE and CAAP-AF risk scoring systems

MicroRNAs as Prognostic Biomarkers for Atrial Fibrillation Recurrence After Catheter Ablation: Current Evidence and Future Directions

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice and is associated with significant morbidity and mortality. Even though catheter ablation has emerged as an available and effective treatment for AF, recurrence remains a significant challenge. This review presents the existing evidence on the prognostic role of microRNAs (miRNAs) in the prediction of AF recurrence after catheter ablation. We examined studies investigating the association between miRNA expression and post-ablation AF recurrence. Multiple miRNAs have been highlighted as potential biomarkers, which are involved in pathophysiological processes such as atrial remodeling, fibrosis, and inflammation. Despite some promising results, there has been significant heterogeneity across the studies. In this review, we demonstrate the potential miRNAs that can be routinely used as biomarkers of AF recurrence, and we identify areas that require further research to validate their clinical utility.

Association between triglyceride-glucose index trajectories and radiofrequency ablation outcomes in patients with stage 3D atrial fibrillation

BACKGROUND

This study investigates the relationship between triglyceride-glucose (TyG) index trajectories and the results of ablation in patients with stage 3D atrial fibrillation (AF).

METHODS

A retrospective cohort study was carried out on patients who underwent AF Radiofrequency Catheter Ablation (RFCA) at the Cardiology Department of the Fourth Affiliated Hospital of Zhejiang University and Taizhou Hospital of Zhejiang Province from January 2016 to December 2022. The main clinical endpoint was determined as the occurrence of atrial arrhythmia for at least 30 s following a 3-month period after ablation. Using a latent class trajectory model, different trajectory groups were identified based on TyG levels. The relationship between TyG trajectory and the outcome of AF recurrence in patients was assessed through Kaplan-Meier survival curve analysis and multivariable Cox proportional hazards regression model.

RESULTS

The study included 997 participants, with an average age of 63.21 ± 9.84 years, of whom 630 were males (63.19%). The mean follow-up period for the participants was 30.43 ± 17.75 months, during which 200 individuals experienced AF recurrence. Utilizing the minimum Bayesian Information Criterion (BIC) and the maximum Entropy principle, TyG levels post-AF RFCA were divided into three groups: Locus 1 low-low group (n = 791), Locus 2 low-high-low group (n = 14), and Locus 3 high-high group (n = 192). Significant differences in survival rates among the different trajectories were observed through the Kaplan-Meier curve (P < 0.001). Multivariate Cox regression analysis showed a significant association between baseline TyG level and AF recurrence outcomes (HR = 1.255, 95% CI: 1.087-1.448). Patients with TyG levels above 9.37 had a higher risk of adverse outcomes compared to those with levels below 8.67 (HR = 2.056, 95% CI: 1.335-3.166). Furthermore, individuals in Locus 3 had a higher incidence of outcomes compared to those in Locus 1 (HR = 1.580, 95% CI: 1.146-2).

CONCLUSION

The TyG trajectories in patients with stage 3D AF are significantly linked to the outcomes of AF recurrence. Continuous monitoring of TyG levels during follow-up may help in identifying patients at high risk of AF recurrence, enabling the early application of effective interventions.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

New Score for Predicting Results after Catheter Ablation for Atrial Fibrillation: VAT-DHF

INTRODUCTION

Catheter ablation (CA) for atrial fibrillation (AF) has been proven to have the highest efficacy in maintaining sinus rhythm. Several studies have proposed different scores for predicting post-procedural success, but most have not been validated in prospective cohorts. Further research is required to determine the optimal formulae.

PURPOSE

This study aimed to identify independent predictors of AF recurrence after CA and develop a composite score.

METHODS

Consecutive patients with persistent and paroxysmal AF who underwent CA were retrospectively analyzed. The independent predictors of recurrence were used to create a new predictive score.

RESULTS

The cohort included 263 patients with a follow-up of 37.6 ± 23.4 months. Persistent AF, f-waves < 0.1 mV, indexed left atrium volume, the presence of type 2 diabetes, and smaller height were independent predictors of recurrence and were used to create a new scoring model, VAT-DHF (V = Volume, AT = AF Type, D = Diabetes, H = Height, F = f waves). The ROC curve for this new score showed an AUC of 0.869, p < 0.0001, 95% CI [0.802-0.936], while those for APPLE and CHA2DS2-VASc showed an AUC of 0.765, 95% CI [0.637-0.893] and an AUC of 0.655, 95% CI [0.580-0.730], respectively. Patients who had a VAT-DHF score between 0 and 3.25, 3.25 and 6, and ≥6, had success rates of 95.7%, 76.3%, and 25% (p < 0.0001), respectively.

CONCLUSIONS

The novel VAT-DHF score is easy to calculate and may be a useful clinical tool for identifying patients with a low, intermediate, or high risk of AF recurrence after CA.

Photoplethysmography-Based Machine Learning Approaches for Atrial Fibrillation Prediction

Background

Current wearable devices enable the detection of atrial fibrillation (AF), but a machine learning (ML)–based approach may facilitate accurate prediction of AF onset.

Objectives

The present study aimed to develop, optimize, and validate an ML-based model for real-time prediction of AF onset in a population at high risk of incident AF.

Methods

A primary ML-based prediction model of AF onset (M1) was developed on the basis of the Huawei Heart Study, a general-population AF screening study using photoplethysmography (PPG)–based smart devices. After optimization in 554 individuals with 469,267 PPG data sets, the optimized ML-based model (M2) was further prospectively validated in 50 individuals with paroxysmal AF at high risk of AF onset, and compared with 72-hour Holter electrocardiographic (ECG) monitoring, a criterion standard, from September 1, 2019, to November 5, 2019.

Results

Among 50 patients with paroxysmal AF (mean age 67 ± 12 years, 40% women), there were 2,808 AF events from a total of 14,847,356 ECGs over 72 hours and 6,860 PPGs (45.83 ± 13.9 per subject per day). The best performance of M1 for AF onset prediction was achieved 4 hours before AF onset (area under the receiver operating characteristic curve: 0.94; 95% confidence interval: 0.93-0.94). M2 sensitivity, specificity, positive predictive value, negative predictive value, and accuracy (at 0 to 4 hours before AF onset) were 81.9%, 96.6%, 96.4%, 83.1%, and 88.9%, respectively, compared with 72-hour Holter ECG.

Conclusions

The PPG- based ML model demonstrated good ability for AF prediction in advance. (Mobile Health [mHealth] technology for improved screening, patient involvement and optimizing integrated care in atrial fibrillation; ChiCTR-OOC-17014138)

Catheter Ablation of Atrial Fibrillation in Heart Failure: from Evidences to Guidelines

PURPOSE OF REVIEW

Catheter ablation of atrial fibrillation in heart failure seems to be the way to improve the quality of life, life expectance, and prognosis. In this review, we outline the growing role of this therapy and which patients can benefit from it.

RECENT FINDINGS

While previous studies comparing rate control and rhythm control had not demonstrated the superiority of rhythm control in the prognosis of patients with atrial fibrillation and heart failure, recent findings seem to demonstrate that catheter ablation of atrial fibrillation reduces mortality and hospitalization for heart failure and improves the quality of life, when compared to medical therapy alone. An early rhythm-control strategy in atrial fibrillation may reduce cardiovascular death, stroke, hospitalization for HF, or acute coronary syndrome. Catheter ablation in heart failure is an effective and safe solution to obtain a rhythm control and, therefore, to improve outcomes. A better selection of the patients could help to avoid futile procedures and to identify patients requiring a closer follow-up, to redo procedures, or the addition of antiarrhythmic drugs.

Approach to recurrence of atrial fibrillation after catheter ablation

Atrial fibrillation (AF) is the most commonly observed sustained rhythm disorder during adult ages. Since it has been shown that the ectopic beat initiating AF is usually caused by pulmonary veins, AF ablation has become the mainstay of therapy worldwide. Cryoballoon and radiofrequency ablation are the most commonly used methods in today's technologies. However, despite technological advances, the success of a single procedure in AF ablation is still limited and multiple procedures may be required for the majority of patients. In cases in which a redo ablation is required, pulmonary vein isolation is still the main target, but non-pulmonary vein targets should also be considered in AF episodes that continue despite multiple ablations. Many issues are still unclear as to which energy to choose in the first procedure, and what ablation strategy will be utilized when a redo ablation is required. The studies on this subject are very limited but, it still seems feasible and a rational approach to utilize a customized treatment strategy in each specific patient subgroup.

Serum human epididymis protein 4 levels in the prediction of the recurrence of atrial fibrillation after catheter ablation

The aim of this study is to assess serum human epididymis protein 4 (HE-4) levels as a biomarker for predicting the recurrence of atrial fibrillation (AF) after catheter ablation. This was a prospective observational study that enrolled one hundred eighty-four consecutive nonvalvular AF patients (65 persistent, 119 paroxysmal) who were eligible for their first ablation. Multiple Cox proportional hazards models and Kaplan-Meier curve analyses were used to test the association between serum HE-4 levels and AF recurrence after catheter ablation. During the 12-month follow-up, we observed that 47 patients (25.5%) experienced AF recurrence. Patients were divided into tertiles of HE-4 level (T1: < 50 pmol/L; T2: ≥ 50 pmol/L). The AF recurrence rate of higher serum HE-4 level patients was significantly increased (34.6% vs 13.8%, P < 0.001). Generalized additive models were used to visually assess functional relationships between the serum HE-4 levels and the risk of AF recurrence. When stratified with serum levels as the cut-off value, Kaplan-Meier analysis showed that patients with serum HE-4 levels (> 50 pmol/L) had a significantly increased risk of AF recurrence. In addition, multivariate Cox proportional hazard modelling revealed that HE-4 (≥ 50 pmol/L) (HR 2.65; 95% CI 1.34, 5.27, P = 0.005) was independent predictors of AF recurrence. Serum HE-4 levels in patients with AF are associated with postoperative recurrence of AF, and high HE-4 levels are an independent predictor of AF recurrence after ablation.

Shifts in gut microbiome and metabolome are associated with risk of recurrent atrial fibrillation

Alternations of gut microbiota (GM) in atrial fibrillation (AF) with elevated diversity, perturbed composition and function have been described previously. The current work aimed to assess the association of GM composition with AF recurrence (RAF) after ablation based on metagenomic sequencing and metabolomic analyses and to construct a GM-based predictive model for RAF. Compared with non-AF controls (50 individuals), GM composition and metabolomic profile were significantly altered between patients with recurrent AF (17 individuals) and non-RAF group (23 individuals). Notably, discriminative taxa between the non-RAF and RAF groups, including the families Nitrosomonadaceae and Lentisphaeraceae, the genera Marinitoga and Rufibacter and the species Faecalibacterium spCAG:82, Bacillus gobiensis and Desulfobacterales bacterium PC51MH44, were selected to construct a taxonomic scoring system based on LASSO analysis. After incorporating the clinical factors of RAF, taxonomic score retained a significant association with RAF incidence (HR = 2.647, P = .041). An elevated AUC (0.954) and positive NRI (1.5601) for predicting RAF compared with traditional clinical scoring (AUC = 0.6918) were obtained. The GM-based taxonomic scoring system theoretically improves the model performance, and the nomogram and decision curve analysis validated the clinical value of the predicting model. These data provide novel possibility that incorporating the GM factor into future recurrent risk stratification.