Impact of body mass index on the outcome of catheter ablation of atrial fibrillation

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

Obesity effect on newly diagnosed and recurrent post-ablation atrial fibrillation: a systematic review and meta-analysis

BACKGROUND AND AIMS

The role of overweight and obesity in the development of atrial fibrillation (AF) is well established; however, the differential effect on the occurrence and recurrence of AF remains uncertain. The aim of this review is to compare the effect of underweight and varying degrees of obesity on onset of AF and in recurrent post-ablation AF, and, when possible, in relation to sex.

METHODS

A systematic literature search was conducted in PubMed, Embase, and Cochrane Library from inception to January 31, 2023. Studies reporting frequency of newly-diagnosed AF and of recurrent post-ablation AF in different BMI categories, were included. 3400 records were screened and 50 met the inclusion criteria. Standardized data search and abstraction were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement. Data were extracted from the manuscripts and were analyzed using a random effect model. The outcome was the occurrence of AF in population studies and in patients undergoing ablation.

RESULTS

Data from 50 studies were collected, of which 27 for newly-diagnosed AF and 23 for recurrent post-ablation AF, for a total of 15,134,939 patients, of which 15,115,181 in studies on newly-diagnosed AF and 19,758 in studies on recurrent post-ablation AF. Compared to normal weight, the increase in AF was significant (p < 0.01) for overweight, obese, and morbidly obese patients for newly-diagnosed AF, and for obese and morbidly obese patients for recurrent post-ablation AF. Newly-diagnosed AF was more frequent in obese female than obese male patients.

CONCLUSION

The effect of increased BMI was greater on the onset of AF, and obese women were more affected than men.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

The Role of Risk Factor Modification in Atrial Fibrillation: Outcomes in Catheter Ablation

The management of atrial fibrillation has evolved significantly over the last ten years with advancements in medical and catheter ablation approaches, but these have limited success when used in isolation. Trends in the management of lifestyle modifications have surfaced, as it is now better understood that modifiable risk factors contribute significantly to the development and propagation of atrial fibrillation, as well as failure of treatment. International guidelines have integrated the role of lifestyle modification in the management of atrial fibrillation and specifically in the persistent form of atrial fibrillation; these guidelines must be addressed prior to considering catheter ablation. Effective risk factor modification is critical in increasing the likelihood of an arrhythmia-free survival following catheter ablation.

Multimorbidity in patients with atrial fibrillation

There is an escalating trend in both the incidence and prevalence of atrial fibrillation (AF). AF is linked to numerous other comorbidities, contributing to the emergence of multimorbidity. The sustained rise in multimorbidity and AF prevalences exerts a significant strain on healthcare systems globally. The understanding of the relation between multimorbidity and AF is essential to determine effective healthcare strategies, improve patient outcomes to adequately address the burden of AF. It not only begins with the accurate identification of comorbidities in the setting of AF. There is also the need to understand the pathophysiology of the different comorbidities and their common interactions, and how multimorbidity influences AF perpetuation. To manage the challenges that rise from the increasing incidence and prevalence of both multimorbidity and AF, such as adverse events and hospitalisations, the treatment of comorbidities in AF has already gained importance and will need to be a primary focus in the forthcoming years. There are numerous challenges to overcome in the treatment of multimorbidity in AF, whereby the identification of comorbidities is essential. Integrated care strategies focused on a comprehensive multimorbidity management with an individual-centred approach need to be determined to improve healthcare strategies and reduce the AF-related risk of frailty, cardiovascular diseases and improve patient outcomes.

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.

Nurse-led care after ablation of atrial fibrillation: a randomized controlled trial

AIMS

The added value of advanced practitioner nurse (APN) care after ablation of atrial fibrillation (AF) is unknown. The present study investigates the impact of APN-led care on AF recurrence, patient knowledge, lifestyle, and patient satisfaction.

METHODS AND RESULTS

Sixty-five patients undergoing AF ablation were prospectively randomized to usual care (N = 33) or intervention (N = 32) group. In addition to usual care, the intervention consisted of an educational session, three consultations spread over 6 months and telephone accessibility coordinated by the APN. Primary outcome was the AF recurrence rate at 6-month follow-up. Secondary outcomes were lifestyle factors (alcohol intake, exercise, BMI, smoking), patient satisfaction and AF knowledge measured at 1 and 6 months between groups and within each group. Study demographics at 1 month were similar, except AF knowledge was higher in the intervention group (8.6 vs. 7, P = 0.001). At 6 months, AF recurrence was significantly lower in the intervention group (13.5 vs. 39.4%, P = 0.014). Between groups, patient satisfaction and AF knowledge were significantly higher in the intervention group, respectively, 9.4 vs. 8.7 (P < 0.001) and 8.6 vs. 7.0 out of 10 (P < 0.001). Within the intervention group, alcohol intake decreased from 3.9 to 2.6 units per week (P = 0.031) and physical activity increased from 224.4 ± 210.7 to 283.8 ± 169.3 (P = 0.048). No changes occurred within the usual care group. Assignment to the intervention group was the only protective factor for AF recurrence [Exp(B) 0.299, P = 0.04] in multivariable-adjusted analysis.

CONCLUSION

Adding APN-led care after ablation of AF improves short-term clinical outcome, patient satisfaction and physical activity and decreases alcohol intake.

Influence of body mass index on recurrence of atrial fibrillation after electrical cardioversion

BACKGROUND

Several studies have shown an independent relationship between body mass index (BMI) and the incidence of atrial fibrillation (AF). However, little is known about the influence of BMI on AF recurrence after electrical cardioversion (ECV).

METHODS

We selected 1121 patients who reverted to sinus rhythm after scheduled ECV and were included in three prospective Spanish registries of ECV in persistent AF. The patients were classified according to baseline BMI into three categories (normal weight, overweight, obesity). We assessed the influence of BMI on the rate of AF recurrence at 3 months.

RESULTS

We identified 538 patients (48%) who had AF recurrence in the first 3 months after successful ECV. The patients who suffered AF recurrence had a higher BMI than those who remained in sinus rhythm (29.66±4.57 vs. 28.87±4.64 Kg/m2, respectively; p = 0.004). We observed a higher incidence of AF recurrence in the overweight and obese patients (BMI ≥25 kg/m2) than in those classified as normal weight (50.5% vs. 35.6%, respectively; p<0,001). BMI≥25 Kg/m2 was shown to be independently related to of AF recurrence in the multivariate analysis (OR = 1.75, 95% confidence interval = 1.20-2.58; p = 0.004).

CONCLUSIONS

Increased BMI is independently related to AF recurrence after ECV. BMI should also be taken into account when making decisions about the indication for ECV in persistent AF.

Impact of Obesity on Atrial Electrophysiological Substrate

(1) Background. Obesity is a well-established worldwide recognised risk factor for atrial fibrillation (AF). Prior review papers reported on the associations between obesity and AF development, but not on the relation between obesity and atrial electrophysiology. We therefore conducted a systematic review to describe the current knowledge of the characteristics of the atrial electrophysiological substrate in obese individuals and how they relate to the development of AF. (2) Methods. A search was conducted in Pubmed, Embase, and the Cochrane Library for publications evaluating the impact of obesity on atrial electrophysiology, electrical substrates, and their relation to the development of AF. (3) Results. A systematic literature search retrieved 477 potential publications based on the inclusion criteria; 76 full-text articles were selected for the present systematic review. The literature demonstrated that obesity predisposes to not only a higher AF incidence but also to more extensive atrial electrophysiological abnormalities increasing susceptibility to AF development. (4) Conclusion. Obesity may predispose to an overall increase in atrial electropathology, consisting of an increase in the slowing of the conduction, conduction block, low-voltage areas, and complex fractionated electrograms. To determine the impact of obesity-induced atrial electrical abnormalities on the long-term clinical outcome, further prospective studies are mandatory.

Cryoballoon pulmonary vein isolation for atrial fibrillation in obese patients: A non-inferiority analysis

Background

Patients with obesity are at higher risk of developing atrial fibrillation (AF) and benefit from radiofrequency ablation. Potentially, cryoballoon ablation (CBA) may be equally effective and safe in such patients.

Methods

We conducted a prospective, single-center study to investigate whether CBA for pulmonary vein isolation is as effective and safe in obese patients as it is in non-obese controls. Primary efficacy endpoint was recurrence of AF, atrial flutter or atrial tachycardia after a 90-day blanking period. Safety endpoints were death, stroke or procedure-associated complications. Conduction of a subgroup analysis regarding the impact of additional diabetes was predefined in case the primary efficacy endpoint was met. The study was event driven and powered for noninferiority.

Results

A total of 949 patients underwent CBA (251 obese with mean body-mass-index 33.5 ± 3 kg/m2 and 698 non-obese with mean body-mass-index 25.3 ± 3 kg/m2) during a 5-year recruitment period. Median follow-up was 15 months. The primary efficacy endpoint occurred in 78/251 obese and 247/698 non-obese patients (12-months Kaplan-Meier event-rate estimates, hazard ratio 0.79; 95% confidence interval [CI], 0.58 to 1.07; log-rank P = 0.0002 for noninferiority). No differences were observed in safety end point occurrence (P = 0.78). The occurrence of primary efficacy end point was found to be unaffected by the presence of diabetes in the prespecified subgroup analysis (log-rank P = 0.57).

Conclusion

CBA is effective and safe in obese and DM patients. Weighing the high cardiovascular risk of obese patients against a reduction of cardiovascular events by early rhythm control, CBA should be offered to this patient population.

Impact of obesity on catheter ablation of atrial fibrillation: Patient characteristics, procedural complications, outcomes, and quality of life

INTRODUCTION

Obesity is a well-known risk factor for atrial fibrillation (AF). We aim to evaluate the effect of baseline obesity on procedural complications, AF recurrence, and symptoms following catheter ablation (CA).

METHODS

All consecutive patients undergoing AF ablation (2013-2021) at our center were enrolled in a prospective registry. The study included all consecutive patients with available data on body mass index (BMI). Primary endpoint was AF recurrence based on electrocardiographic documentation. Patients were categorized into five groups according to their baseline BMI. Patients survey at baseline and at follow-up were used to calculate AF symptom severity score (AFSS) as well as AF burden (mean of AF duration score and AF frequency score; scale 0: no AF to 10: continuous and 9 frequencies/durations in between). Patients were scheduled for follow-up visits with 12-lead electrocardiogram at 3, 6, and 12 months after ablation, and every 6 months thereafter.

RESULTS

A total of 5841 patients were included (17% normal weight, 34% overweight, 27% Class I, 13% Class II, and 9% Class III obesity). Major procedural complications were low (1.5%) among all BMI subgroups. At 3 years AF recurrence was the highest in Class III obesity patients (48%) followed by Class II (43%), whereas Class I, normal, and overweight had similar results with lower recurrence (35%). In multivariable analyses, Class III obesity (BMI ≥ 40) was independently associated with increased risk for AF recurrence (hazard ratio, 1.30; confidence interval, 1.06-1.60; p = .01), whereas other groups had similar risk in comparison to normal weight. Baseline AFSS was lowest in normal weight, and highest in Obesity-III, median (interquartile range) 10 (5-16) versus 15 (10-21). In all groups, CA resulted in a significant improvement in their AFSS with a similar magnitude among the groups. At follow-up, AF burden was minimal and did not differ significantly between the groups.

CONCLUSION

AF ablation is safe with a low complication rate across all BMI groups. Morbid obesity (BMI ≥ 40) was significantly associated with reduced AF ablation success. However, ablation resulted in improvement in QoL including reduction of the AFSS, and AF burden regardless of BMI.

Safety and Efficacy of Excimer Laser Powered Lead Extractions in Obese Patients: A GALLERY Subgroup Analysis

BACKGROUND

The incidence of cardiac implantable electronic device (CIED)-related complications, as well as the prevalence of obesity, is rising worldwide. Transvenous laser lead extraction (LLE) has grown into a crucial therapeutic option for patients with CIED-related complications but the impact of obesity on LLE is not well understood.

METHODS AND RESULTS

All patients (n = 2524) from the GermAn Laser Lead Extraction RegistrY (GALLERY) were stratified into five groups according to their body mass index (BMI, <18.5; 18.5-24.9; 25-29.9; 30-34.9; ≥35 kg/m²). Patients with a BMI ≥ 35.0 kg/m² had the highest prevalence of arterial hypertension (84.2%, p < 0.001), chronic kidney disease (36.8%, p = 0.020) and diabetes mellitus (51.1%, p < 0.001). The rates for procedural minor (p = 0.684) and major complications (p = 0.498), as well as procedural success (p = 0.437), procedure-related (p = 0.533) and all-cause mortality (p = 0.333) were not different between groups. In obese patients (BMI ≥ 30 kg/m²), lead age ≥10 years was identified as a predictor of procedural failure (OR: 2.99; 95% CI: 1.06-8.45; p = 0.038). Lead age ≥10 years (OR: 3.25; 95% CI: 1,31-8.10; p = 0.011) and abandoned leads (OR: 3.08; 95% CI: 1.03-9.22; p = 0.044) were predictors of procedural complications, while patient age ≥75 years seemed protective (OR: 0.27; 95% CI: 0.08-0.93; p = 0.039). Systemic infection was the only predictor for all-cause mortality (OR: 17.68; 95% CI: 4.03-77.49; p < 0.001).

CONCLUSIONS

LLE in obese patients is as safe and effective as in other weight classes, if performed in experienced high-volume centers. Systemic infection remains the main cause of in-hospital mortality in obese patients.

Obesity and atrial fibrillation: Prevalence, pathogenesis, and prognosis

The prevalence of atrial fibrillation (AF) and obesity are rising significantly. There is a shared association between these conditions with obesity predisposing individuals to a number of shared risk factors. In addition, obesity in itself has been shown to cause changes to the structure, function and hemodynamics of the heart. There is evidence to show that weight-loss has significant impact on AF symptoms, burden and more recently the potential to reverse the type of AF. Through risk factor management and in the case of morbid obesity, bariatric surgery, there is an improved prognosis for patients with AF and obesity. In this paper we provide a review of the current data on obesity and AF prevalence, pathogenesis and prognosis.

Efficacy and safety of catheter ablation for atrial fibrillation in patients with history of cancer

BACKGROUND

Though the incidence of atrial fibrillation (AF) is increased in patients with cancer, the effectiveness of catheter ablation (CA) for AF in patients with cancer is not well studied.

METHODS

We conducted a retrospective cohort study of patients who underwent CA for AF. Patients with a history of cancer within 5-years prior to, or those with an exposure to anthracyclines and/or thoracic radiation at any time prior to the index ablation were compared to patients without a history of cancer who underwent AF ablation. The primary outcome was freedom from AF [with or without anti-arrhythmic drugs (AADs), or need for repeat CA at 12-months post-ablation]. Secondary endpoints included freedom from AF at 12 months post-ablation with AADs and without AADs. Safety endpoints included bleeding, pulmonary vein stenosis, stroke, and cardiac tamponade. Multivariable regression analysis was performed to identify independent risk predictors of the primary outcome.

RESULTS

Among 502 patients included in the study, 251 (50%) had a history of cancer. Freedom from AF at 12 months did not differ between patients with and without cancer (83.3% vs 72.5%, p 0.28). The need for repeat ablation was also similar between groups (20.7% vs 27.5%, p 0.29). Multivariable regression analysis did not identify a history of cancer or cancer-related therapy as independent predictors of recurrent AF after ablation. There was no difference in safety endpoints between groups.

CONCLUSION

CA is a safe and effective treatment for AF in patients with a history of cancer and those with exposure to potentially cardiotoxic therapy.

Body mass index and atrial fibrillation recurrence post ablation: A systematic review and dose-response meta-analysis

Objectives

The aim of this study was to evaluate the shape of the dose-response relationship between body mass index (BMI) and atrial fibrillation (AF) recurrence in patients who have undergone radiofrequency ablation.

Methods

Studies investigating BMI and AF recurrence in patients with AF after ablation were identified through electronic searches in the PubMed, EMBASE, and Cochrane Library databases. The potential non-linear relationship was fitted using robust error meta-regression. Our study was registered with PROSPERO (CRD42019121373).

Results

Twenty-six cohort studies with 7,878 cases/26,450 individuals were included, and a linear dose-response relationship between BMI and AF recurrence (P _{non-linearity} = 0.12) was found. The risk of AF recurrence in patients with a BMI over 28 was significantly increased. Specifically, for each 5 kg/m² increase in BMI, the risk of AF recurrence increased by 15% (95% CI: 1.08-1.22) with moderate heterogeneity (I ² = 53%). Subgroup analyses showed that the pooled risk ratio was not significantly changed in subgroup analysis adjustment for the following important potential intermediate factors: left atrial diameter and obstructive sleep apnea.

Conclusion

This study showed that there is a borderline positive linear association between BMI and AF recurrence post ablation. Overweight and obesity are significantly associated with AF recurrence.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42019128770.

Short- and long-term risk of atrial fibrillation recurrence after first time ablation according to body mass index: a nationwide Danish cohort study

AIMS

Overweight is associated with increased risk of atrial fibrillation (AF), but the impact of overweight and AF recurrence after ablation is less clear. Despite this, an increasing number of AF ablations are carried out in overweight patients. We investigated the impact of body mass index (BMI) on AF recurrence rates after ablation.

METHODS AND RESULTS

Through Danish nationwide registers, all patients undergoing first-time AF ablation between 2010 and 2018 were identified. Exposure of interest was BMI. The primary outcome was recurrent AF, defined from either any usage of antiarrhythmic medication, AF hospitalization, cardioversion, or re-ablation. A total of 9188 patients were included. Median age and interquartile range was 64 (60-75) in the normal-weight group and 60 (53-66) in the morbidly obese. There was an increase in comorbidity burden with increasing BMI, including a higher prevalence of heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension. At 1- and 5-year follow ups, recurrence rates of AF increased incrementally by BMI categories. The hazard ratios and 95% confidence intervals of recurrent AF after ablation were 1.15 (1.07-1.23), 1.18 (1.09-1.28), and 1.26 (1.13-1.41) in overweight, obese, and morbidly obese, respectively, compared with normal-weight patients. Procedure duration and X-ray dose exposure also increased with increasing BMI.

CONCLUSION

Following AF ablation, recurrence rates of AF increased incrementally with increasing BMI. Therefore, aggressive weight management pre ablation in overweight patients could potentially provide substantial benefits and improve short- and long-term outcomes after ablation.

A nomogram based on CHADS2 score for predicting atrial fibrillation recurrence after cryoballoon ablation

BACKGROUND

As reported, CHADS₂ scoring system moderately predicts the atrial fibrillation (AF) recurrence, a common event after cryoballoon ablation. We aimed to improve the diagnostic accuracy of the CHADS₂ score by adding several routine auxiliary detection indicators into the scoring system and constructing a CHADS₂ score-based nomogram to predict AF recurrence in patients with paroxysmal AF undergoing cryoballoon ablation.

METHODS

Eighty-four patients with paroxysmal AF undergoing cryoballoon ablation were enrolled. Baseline characteristics were collected. The multivariable Cox proportional hazards model was used to identify the significantly related predictors of recurrence and to construct the nomogram whose performance was evaluated by the discrimination and calibration tests.

RESULTS

Thirty-five patients developed AF recurrence after a mean follow up of 19.0 ± 15.77 months. In the Cox multivariate model, CHADS₂ (>2) (hazard ratio [HR]: 2.38; 95% confidence interval [CI]: 1.14-4.98, p = .021) and albumin-to-globulin ratio (AGR) (HR: 2.49; 95% CI: 1.26-4.92, p < .008) were independent risk factors associated with AF recurrence. In addition to CHADS₂ , AGR and red blood cell distribution width were used to construct the nomogram. As a result, the discrimination of the concordance index for the predictive model of AF recurrence was increased from 0.56 (95% CI: 0.494-0.632) to 0.712 (95% CI: 0.631-0.811). The 24-month one well matched the ideal 45° line among the calibration plots for 6, 12, and 24 months' recurrence-free survival.

CONCLUSION

This novel easy-to-use CHADS₂ score-based nomogram may be used to predict AF recurrence for patient of paroxysmal AF undergoing cryoballoon ablation. Further external validation is still needed.

Left atrial strain for predicting recurrence in patients with non-valvular atrial fibrillation after catheter ablation: a single-center two-dimensional speckle tracking retrospective study

Background

Although catheter ablation (CA) is an effective treatment for non-valvular atrial fibrillation (AF), a good many of patients still have a recurrence following post-operation. Prediction of AF recurrence by evaluating left atrial (LA) phase function with speckle tracking echocardiography (STE) may be helpful for risk stratification and clinical management for AF patients. Therefore, the current study aimed to assess the prognostic value of LA strains in non-valvular AF patients after CA.

Methods

A total of 95 non-valvular AF patients (70.5% paroxysmal AF, 56.8% males, mean age 63.2 ± 9.7 years) were included in this retrospective study between October 2019 and August 2020. Transthoracic echocardiography was performed in all the subjects and STE was used to analyze the LA reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile strain (LASct) during different phases before CA. Patients were followed up with until January 2022. The endpoint was AF recurrence.

Results

Over a median follow-up period of 26.0 months (interquartile range, 24.7–26.7 months), 26 patients experienced recurrence and 69 stayed in sinus rhythm. Compared with no-recurrence group, maximum volume of LA (LAVmax), minimum volume of LA (LAVmin) and LA volume index (LAVI) were increased in the recurrence group, while LAEF, LASr and LASct were worsened (P < 0.05). Multivariable logistic regression analysis revealed that LASct was an independent predictor of AF recurrence (odds ratio, 0.89; 95% confidence interval (CI), 0.82–0.97; P = 0.007) and receiver operating characteristic (ROC) curve analysis showed an area under the curve of LASct<8% was 0.70 (95% CI, 0.59–0.79; P = 0.0008).

Conclusions

LASct was of independent predictive value of AF recurrence. LA function assessed by STE may contribute to the risk stratification for AF patients and selection of suitable patients for CA.

Esophageal safety in CLOSE-guided 50W high-power-short-duration pulmonary vein isolation - The PREHEAT-PVI-Registry

AIMS

Pulmonary vein isolation (PVI) using high-power-short-duration (HPSD) radiofrequency ablation (RF) is emerging as the standard of care for treatment of atrial fibrillation (AF). While procedural short-term to mid-term efficacy and efficiency are very promising, this registry aims to investigate esopahgeal safety using an optimized ablation approach.

METHODS

In a single-centre experience, 388 consecutive standardized first-time AF ablation were performed using a CLOSE-guided-fixed-50W-circumferential PVI and substrate modification without intraprocedural oesophageal temperature measurement. 300 patients underwent post-procedural esophageal endoscopy to diagnose and grade endoscopically detected esophageal lesions (EDEL) and were included in the analysis.

RESULTS

EDEL were detected in 35 of 300 patients (11.6%), 25 of 35 were low-grade KCC 1 lesions with fast healing tendencies. 6 patients suffered KCC 2a lesions, 4 patients had KCC 2b lesions (1.3% of all patients). No esophageal perforation or fistula formation was observed. Patient baseline characteristics, especially patients age, gender and body-mass-index did not influence EDEL incidence. Additional posterior box isolation did not increase the incidence of EDEL. In patients diagnosed with EDEL, mean catheter contact force during posterior wall ablation was higher (11.9 ± 1.8 vs. 14.7 ± 3 grams, p<0.001), mean RF duration was shorter (11.9 ± 1 vs. 10.7 ± 1.2 sec., p<0.001), while achieved AI was not different between groups (434 ± 4.9 vs. 433 ± 9.5, n.s.).

CONCLUSIONS

Incidence of EDEL after CLOSE-guided-50W-HPSD PVI is lower compared to historical cohorts using standard-power RF settings. Catheter contact force during posterior HPSD ablation should not exceed 15 grams. This article is protected by copyright. All rights reserved.

Lifestyle Modification and Atrial Fibrillation: Critical Care for Successful Ablation

Management of atrial fibrillation (AF) requires a comprehensive approach due to the limited success of medical or procedural approaches in isolation. Multiple modifiable risk factors contribute to the development and progression of the underlying substrate, with a heightened risk of progression evident with inadequate risk factor management. With increased mortality, stroke, heart failure and healthcare utilisation linked to AF, international guidelines now strongly support risk factor modification as a critical pillar of AF care due to evidence demonstrating the efficacy of this approach. Effective lifestyle management is key to arrest and reverse the progression of AF, in addition to increasing the likelihood of freedom from arrhythmia following catheter ablation.

Impact of Body Mass Index on Cryoablation of atrial fibrillation: Patient characteristics, procedural data and long-term outcomes

BACKGROUND

Ablation of atrial fibrillation in the context of obesity can be challenging. We sought to evaluate the role of cryoballoon pulmonary vein isolation (CB-PVI) in obese patients with symptomatic atrial fibrillation (AF).

METHODS

Patients with a BMI≥25 kg/m² and symptomatic AF who underwent CB-PVI were retrospectively enrolled. Three groups were defined (G1: BMI of 25-29 kg/m² ; G2: BMI of 30-34 kg/m² ; G3: BMI≥35 kg/m² ).

RESULTS

600 patients were included (59% male; 66±11 years old); 337, 149, 114 were assigned to G1, G2 and G3, respectively. Acute procedural success was recorded in 99,7% of patients. Procedural and fluoroscopy time were comparable but radiation dose was significantly higher in G3. Procedural complications were 3% in G1, 5,4% in G2 and 8,8% in G3 (p=0,01). The overall freedom from AF after 1-year was 77%. G3 had a significantly worse 1-year success rate compared to G1 and G2 (G3:66,5% vs. G1:78,4%; p=0,015 and vs. G2:82,5%; p=0,008) with a reduced 1-year success in paroxysmal AF (G1:84,0%; G2:86,3% and G3:69,6%) but not in persistent AF (G1:68,7%; G2:77,4% and G3:62,1%). G3 showed similar success rates irrespective of AF form (PAF 69,6% vs. persAF 62,1%; p=0,501).

CONCLUSION

Cryoballoon ablation in obese patients can be effective with an acceptable safety profile, 77% of patients were in stable SR at one year. Severe obese patients (BMI≥35) showed reduced procedural safety and 1-year success rate. In association with life style modification, CB ablation may represent a strategy to enhance rhythm control in the context of obesity. This article is protected by copyright. All rights reserved.

Utilization and in-hospital complications of catheter ablation for atrial fibrillation in patients with obesity and morbid obesity

Background

Real‐world data on atrial fibrillation (AF) ablation outcomes in obese populations have remained scarce, especially the relationship between obesity and in‐hospital AF ablation outcome.

Hypothesis

Obesity is associated with higher complication rates and higher admission trend for AF ablation.

Methods

We drew data from the US National Inpatient Sample to identify patients who underwent AF ablation between 2005 and 2018. Sociodemographic and patients' characteristics data were collected, and the trend, incidence of catheter ablation complications and mortality were analyzed, and further stratified by obesity classification.

Results

A total of 153 429 patients who were hospitalized for AF ablation were estimated. Among these, 11 876 obese patients (95% confidence interval [CI]: 11 422–12 330) and 10 635 morbid obese patients (95% CI: 10 200–11 069) were observed. There was a substantial uptrend admission, up to fivefold, for AF ablation in all obese patients from 2005 to 2018 (p < .001). Morbidly obese patients were statistically younger, while coexisting comorbidities were substantially higher than both obese and nonobese patients (p < .01) Both obesity and morbid obesity were significantly associated with an increased risk of total bleeding, and vascular complications (p < .05). Only morbid obesity was significantly associated with an increased risk of ablation‐related complications, total infection, and pulmonary complications (p < .01). No difference in‐hospital mortality was observed among obese, morbidly obese, and nonobese patients.

Conclusion

Our study observed an uptrend in the admission of obese patients undergoing AF ablation from 2005 through 2018. Obesity was associated with higher ablation‐related complications, particularly those who were morbidly obese.

Impact of obesity on acute complications of catheter ablation for cardiac arrhythmia

BACKGROUND

The prevalence of obesity is increasing. However, data on the periprocedural complication rate of catheter ablation for arrhythmia in patients stratified by body mass index (BMI) is scarce.

METHODS AND RESULTS

This study included 1000 consecutive patients (age 62.0±14.4 years) undergoing catheter ablation for cardiac arrhythmia. The primary study endpoint was any periprocedural major complication (cardiac tamponade, pseudoaneurysm, arteriovenous fistula, transient ischemic attack, stroke, valve damage, myocardial infarction or death). The mean BMI was 27.6±5.1 kg/m² and the majority of patients were overweight (BMI 25.0-29.9 kg/m² , 43.4%). A BMI of 30.0-34.9 kg/m² (Class I obesity) was present in 177 (17.7%) of patients, a BMI of 35.0-39.9 kg/m² (Class II obesity) in 67 (6.7%) and a BMI ≥40 kg/m² (Class III obesity) in 16 (1.6%). There were 31 major complications (3.1%) and one fatality (0.1%) due to terminal heart failure in a patient undergoing palliative ventricular tachycardia ablation. There was no significant impact of the BMI on the rate of major complications (p= 0.495). Compared to normal weight patients, odds ratios for complications in overweight patients, as well as class I, II and III obesity were 1.1 (95% confidence interval (CI) 0.8; 1.7), 1.3 (CI 0.6; 2.6), 1.4 (CI 0.5; 4.1) and 1.6 (CI 0.4; 6.3), respectively. Radiation exposure and procedure duration were significantly increased in obese patients (p<0.001 and p=0.001 respectively).

CONCLUSION

In this study, obesity did not have a significant impact on the incidence of periprocedural complications after CA for cardiac arrhythmia. This article is protected by copyright. All rights reserved.

Safety of Catheter Ablation in Obese Patients: Less Complicated than you Think

Cardiac arrhythmias affect over 2% of the population with an incidence of 0.5% per year, highlighting the growing scope of the problem. This article is protected by copyright. All rights reserved.

Preventing esophageal complications from atrial fibrillation ablation: A review

Atrioesophageal fistula is a life-threatening complication of ablation treatment for atrial fibrillation. Methods to reduce the risk of esophageal injury have evolved over the last decade, and diagnosis of this complication remains difficult and therefore challenging to treat in a timely manner. Delayed diagnosis leads to treatment occurring in the context of a critically ill patient, contributing to the poor prognosis associated with this complication. The associated mortality risk can be as high as 70%. Recent important advances in preventative techniques are explored in this review.

Preventative techniques used in current clinical practice are discussed, which include high-power short-duration ablation, esophageal temperature probe monitoring, cryotherapy and laser balloon technologies, and use of proton pump inhibitors. A lack of randomized clinical evidence for the effectiveness of these practical methods are found. Alternative methods of esophageal protection has emerged in recent years, including mechanical deviation of the esophagus and esophageal temperature control (esophageal cooling). Although these are fairly recent methods, we discuss the available evidence to date. Mechanical deviation of the esophagus is due to undergo its first randomized study. Recent randomized study on esophageal cooling has shown promise of its effectiveness in preventing thermal injuries. Lastly, novel ablation technology that may be the future of esophageal protection, pulsed field ablation, is discussed.

The findings of this review suggest that more robust clinical evidence for esophageal protection methods is warranted to improve the safety of atrial fibrillation ablation.

Catheter ablation superiority over the pharmacological treatments in atrial fibrillation: a dedicated review

Atrial fibrillation globally affects roughly 33.5 million people, making it the most common heart rhythm disorder. It is a crucial arrhythmia, as it is linked with a variety of negative outcomes such as strokes, heart failure and cardiovascular mortality. Atrial fibrillation can reduce quality of life because of the potential symptoms, for instance exercise intolerance, fatigue, and palpitation. There are different types of treatments aiming to prevent atrial fibrillation and improve quality of life. Currently, the primary treatment for atrial fibrillation is pharmacology therapy, however, these still show limited effectiveness, which has led to research on other alternative strategies. Catheter ablation is considered the second line treatment for atrial fibrillation when the standard treatment has failed. Moreover, catheter ablation continues to show significant results when compared to standard therapy. Hence, this review will argue that catheter ablation can show superiority over current pharmacological treatments in different aspects. It will discuss the most influential aspects of the treatment of atrial fibrillation, which are recurrence and burden of atrial fibrillation, quality of life, atrial fibrillation in the setting of heart failure and mortality and whether catheter ablation can be the first line treatment for patients with atrial fibrillation.

Impact of abdominal obesity on outcomes of catheter ablation in Korean patients with atrial fibrillation

BACKGROUND

Effects of abdominal obesity on outcomes of atrial fibrillation (AF) ablation remains ill-defined. Here, we evaluated the impact of abdominal obesity on the long-term efficacy and safety of catheter AF ablation among Korean patients.

METHODS

We utilised the Korean National Health Insurance Service database to identify patients who underwent AF ablation. Abdominal obesity was defined as waist circumference ≥90 cm (males) and ≥85 cm (females). The primary endpoint was AF recurrence and secondary endpoints were ischaemic stroke, intracranial haemorrhage and death. Additionally, safety endpoints of peri-procedural complications were studied.

RESULTS

Among 5397 patients (median age 58 [IQR 51-65] years; 23.6% females), abdominal obesity was present in 1759 (32.6%). The rate of AF recurrence was not statistically different between the groups at 1-year (10.3 vs 8.7 events/100-PYs, P = .078), though abdominal obesity was associated with significantly higher rates of AF recurrence at 3-year (7.6 vs 6.3 events/100-PYs, P = .008) and 6-year (6.3 vs 5.2 events/100-PYs, P = .004) follow-ups. Kaplan-Meier survival analysis found significantly higher rates of AF recurrence in patients with obesity based on body mass index (BMI) and waist circumference (log-rank for trend P = .006). Using multivariable regression analysis, obesity by both BMI and waist circumference was an independent predictor for AF recurrence (HR 1.21 [95% CI, 1.05-1.40]), after accounting for other risk factors. There was a trend for increased rates of ischaemic stroke at 3-year and 6-year follow-ups in patients with abdominal obesity. Furthermore, this group of patients had a greater rate of intracranial haemorrhage. All-cause death was comparable between both groups. Total peri-procedural complications were not associated with abdominal obesity.

CONCLUSION

Abdominal obesity as indicated by waist circumference was associated with a greater burden of concomitant diseases and an independent risk factor for long-term redo AF intervention following catheter ablation but had no effects on total peri-procedural complications.

Extra-pulmonary vein driver mapping and ablation for persistent atrial fibrillation in obese patients

AIMS

The aim of this study was to determine whether driver ablation effectively treats persistent atrial fibrillation (AF) in obese patients.

METHODS AND RESULTS

We randomly assigned 124 persistent AF obese patients to two groups, one undergoing conventional ablation (n = 62) and the other undergoing driver ablation (n = 62). Sixty-two non-obese patients with persistent AF undergoing driver ablation served as matched controls. Bipolar electrogram dispersion was analysed for driver mapping. Epicardial adipose tissue (EAT) volume was measured using cardiac computed tomography. Obese patients had a higher proportion of driver regions in the posterior wall (56.5% vs. 32.3%, P = 0.007). Driver complexity, measured as the average number and area of driver regions, was higher in the obese group than in the non-obese group (3.5 ± 1.0 vs. 2.9 ± 0.9, P < 0.001; 15.5% ± 4.2% vs. 9.8 ± 2.6%, P < 0.001, respectively). Left atrial EAT volume correlated better with the proportion of area of driver regions than did body mass index (BMI) and total EAT (BMI: r2 = 0.250, P < 0.001; total EAT: r2 = 0.379, P < 0.001; and left atrial EAT: r2 = 0.439, P < 0.001). The rate of AF termination was significantly higher in the driver ablation group than in the conventional ablation group (82.9% vs. 22.8%, P < 0.001). During the follow-up period of 16.9 ± 6.5 months, patients in the driver ablation group had significantly better AF-free survival (91.91% vs. 79.0%, log rank test, P = 0.026) and AF/atrial tachycardia-free survival (83.9% vs. 64.5%, log rank test, P = 0.011) than did patients in the conventional ablation group.

CONCLUSION

Obesity is associated with increased driver complexity. Driver ablation improves long-term outcomes in obese patients with persistent AF.

Different Determinants of the Recurrence of Atrial Fibrillation and Adverse Clinical Events in the Mid-Term Period After Atrial Fibrillation Ablation

BACKGROUND

It is unclear whether there are differences in the clinical factors between atrial fibrillation (AF) recurrence and adverse clinical events (AEs), including stroke/transient ischemic attack (TIA), major bleeding, and death, after AF ablation.Methods and Results:We examined the data from a retrospective multicenter Japanese registry conducted at 24 cardiovascular centers between 2011 and 2017. Of the 3,451 patients (74.1% men; 63.3±10.3 years) who underwent AF ablation, 1,046 (30.3%) had AF recurrence and 224 (6.5%) suffered AEs (51 strokes/TIAs, 71 major bleeding events, and 36 deaths) over a median follow-up of 20.7 months. After multivariate adjustment, female sex, persistent and long-lasting persistent AF (vs. paroxysmal AF), and stepwise increased left atrial diameter (LAd) quartiles were significantly associated with post-ablation recurrences. A multivariate analysis revealed that an age ≥75 years (vs. <65 years), body weight <50 kg, diabetes, vascular disease, left ventricular (LV) ejection fraction <40% (vs. ≥50%), Lad ≥44 mm (vs. <36 mm), and creatinine clearance <50 mL/min were independently associated with AE incidences, but not with recurrences.

CONCLUSIONS

This study disclosed different determinants of post-ablation recurrence and AEs. Female sex, persistent AF, and enlarged LAd were determinants of post-ablation recurrence, whereas an old age, comorbidities, and LV and renal dysfunction rather than post-ablation recurrence were AEs determinants. These findings will help determine ablation indications and post-ablation management.

Predictors of Early-Recurrence Atrial Fibrillation after Catheter Ablation in Women and Men with Abnormal Body Weight

Our study aimed to select factors that affect the rate of early recurrence (up to 3 months) of atrial fibrillation (AF) (ERAF) following pulmonary veins isolation (PVI) in obese women and men. The study comprised 114 patients: 54 women (age: 63.8 ± 6.3, BMI 31 ± 4 kg/m²), and 60 men (age: 60.7 ± 6.7; BMI 31 ± 3 kg/m²) with paroxysmal, persistent and long-standing persistent AF. They had been scheduled to undergo cryoballoon (men n = 30; women n = 30) and radiofrequency (RF) ablation (men n = 30; women n = 24) using the CARTO-mapping. The blood was collected at baseline and 24 h after ablation. The rate of ERAF was comparable after cryoballoon and RF ablation and constituted 18% in women and 22% in men. Almost 70 parameters were selected to perform univariate and multivariate analysis and to create a multivariate logistic regression (MLR) model of ERAF in the obese men and women. The MLR analysis was performed by forward stepwise logistic regression with three variables. It was only possible to create the MLR model for the group of obese men. It revealed a poor predictive value with an unsatisfactory sensitivity of 31%. Men with ERAF: smokers (OR 39.25, 95% CI 1.050-1467.8, p = 0.0021), with a higher ST2 elevation (OR 1.68, 95% CI 1.115-2.536, p = 0.0021) who received dihydropyridine calcium channel blockers (OR 0.042, 95% CI 0.002-1.071, p = 0.0021) less frequently. Our results indicate a complex pathogenesis of ERAF dependent on the patients' gender.

BMI and atrial fibrillation recurrence post catheter ablation: A dose-response meta-analysis

INTRODUCTION

The evidence on the association between obesity and atrial fibrillation (AF) recurrence was equivocal. We aimed to evaluate the dose-response relationship between body mass index (BMI) and AF recurrence and adverse events.

METHODS

A systematic literature search was conducted using PubMed, Europe PMC, EBSCO, ProQuest and Cochrane Library. Obesity was defined as BMI ≥28 kg/m² . The primary outcome was AF recurrence, and the secondary outcome was adverse events. Adverse events were defined as procedure-related complications and cardio-cerebrovascular events.

RESULTS

There were a total of 52,771 patients from 20 studies. Obesity was associated with higher AF recurrence (Odds ratio [OR] 1.30 [95% confidence interval [CI] 1.16-1.47], P < .001; I² : 72.7%) and similar rate of adverse events (OR 1.21 [95% CI 0.87-1.67], P = .264; I² : 23.9%). Meta-regression showed that the association varies by age (coefficient: -0.03, P = .024). Meta-analysis of highest versus lowest BMI showed that the highest group had higher AF recurrence (OR 1.37 [95% CI 1.18-1.58], P < .001; I² : 64.9%) and adverse events (OR 2.02 [95% CI 1.08-3.76], P = .028; I² : 49.5%). The linear association analysis for AF recurrence was not significant (P = .544). The dose-response relationship for BMI and AF recurrence was nonlinear (p_nonlinearity  < 0.001), the curve became steeper at 30-35 kg/m² . For adverse events, an increase of 1% for every 1 kg/m² increase in BMI (OR 1.01 [95% CI 1.00-1.02], P = .001), the relationship was nonlinear (p_nonlinearity  = 0.001).

CONCLUSION

Obesity was associated with higher AF recurrence in patients undergoing catheter ablation. High BMI might be associated with a higher risk for adverse events.

PROSPERO ID

CRD42020198787.

A new machine learning approach for predicting likelihood of recurrence following ablation for atrial fibrillation from CT

OBJECTIVE

To investigate left atrial shape differences on CT scans of atrial fibrillation (AF) patients with (AF+) versus without (AF-) post-ablation recurrence and whether these shape differences predict AF recurrence.

METHODS

This retrospective study included 68 AF patients who had pre-catheter ablation cardiac CT scans with contrast. AF recurrence was defined at 1 year, excluding a 3-month post-ablation blanking period. After creating atlases of atrial models from segmented AF+ and AF- CT images, an atlas-based implicit shape differentiation method was used to identify surface of interest (SOI). After registering the SOI to each patient model, statistics of the deformation on the SOI were used to create shape descriptors. The performance in predicting AF recurrence using shape features at and outside the SOI and eight clinical factors (age, sex, left atrial volume, left ventricular ejection fraction, body mass index, sinus rhythm, and AF type [persistent vs paroxysmal], catheter-ablation type [Cryoablation vs Irrigated RF]) were compared using 100 runs of fivefold cross validation.

RESULTS

Differences in atrial shape were found surrounding the pulmonary vein ostia and the base of the left atrial appendage. In the prediction of AF recurrence, the area under the receiver-operating characteristics curve (AUC) was 0.67 for shape features from the SOI, 0.58 for shape features outside the SOI, 0.71 for the clinical parameters, and 0.78 combining shape and clinical features.

CONCLUSION

Differences in left atrial shape were identified between AF recurrent and non-recurrent patients using pre-procedure CT scans. New radiomic features corresponding to the differences in shape were found to predict post-ablation AF recurrence.

Cryoablation for pulmonary veins isolation in obese patients with atrial fibrillation compared to nonobese patients

BACKGROUND

Pulmonary veins isolation (PVI) by cryoballoon (CB) ablation is marginally represented in clinical studies in obese patients. The aim of this analysis was to evaluate the safety and efficacy of CB-PVI in a large cohort of overweight and obese patients from the 1STOP project.

METHODS

From 2012 to 2018, 2048 patients with atrial fibrillation (AF) (70% male, 59 ± 11 years; 75% paroxysmal AF) underwent index CB-PVI. The patient data were separated into three cohorts for statistical evaluation, including: normal weight (body mass index [BMI] < 25 kg/m² ), overweight (BMI = 25-30 kg/m² ), and obese patients (BMI > 30 kg/m² ).

RESULTS

Out of 2048 patients, 693 (34%) patients had a BMI < 25 and were deemed as normal. There were 944 (46%) patients categorized as overweight (BMI = 25-30) and 411 (20%) as obese (BMI > 30). Overweight or obese patients were more often in persistent AF, had more frequently hypertension and diabetes, had higher CHA₂ DS₂ -VASc score, and had a number of failed antiarrhythmic drug (AAD). Periprocedural complication rates were similar among the three cohorts. The 12-month freedom from AF recurrence was 76.4% in the normal BMI group as compared to 79.2% in the overweight and 73.5% in the obese group (p = .35). However, 48% of overweight patients were on AAD treatment during the follow-up. By multivariate analysis, BMI was not a predictor for AF recurrence following the index CB-PVI.

CONCLUSION

CB-PVI in obese patients is a safe procedure. Increased BMI (either moderate or severe) does not seem to be associated with a worse outcome or to a different rate of AAD discontinuation at 12 months.

Catheter ablation for atrial fibrillation: current indications and evolving technologies

Catheter ablation for atrial fibrillation (AF) has emerged as an important rhythm-control strategy and is by far the most common cardiac ablation procedure performed worldwide. Current guidelines recommend the procedure in symptomatic patients with paroxysmal or persistent AF who are refractory or intolerant to antiarrhythmic drugs. The procedure might also be considered as a first-line approach in selected asymptomatic patients. Data from large registries indicate that AF ablation might reduce mortality and the risk of heart failure and stroke, but evidence from randomized controlled trials is mixed. Pulmonary vein isolation using point-by-point radiofrequency or with the cryoballoon remains the cornerstone technique in AF ablation. Additional atrial ablation can be performed in patients with persistent AF, but its benefits are largely unproven. Technological advances in the past decade have focused on achieving durable vein isolation, reducing procedure duration and improving safety. Numerous exciting new technologies are in various stages of development. In this Review, we discuss the relevant data to support the recommended and evolving indications for catheter ablation of AF, describe the different ablation techniques, and highlight the latest advances in technology that aim to improve its safety and efficacy. We also discuss lifestyle modification strategies to improve ablation outcomes.

Impact of Nonalcoholic Fatty Liver Disease on Arrhythmia Recurrence Following Atrial Fibrillation Ablation

OBJECTIVES

This study sought to investigate the association between nonalcoholic fatty liver disease (NAFLD) and arrhythmia recurrence following atrial fibrillation ablation; and to examine the impact of NAFLD stage on outcomes.

BACKGROUND

Metabolic derangements, including obesity and diabetes, are associated with incident and recurrent atrial fibrillation (AF), in addition to the development of NAFLD.

METHODS

This was a retrospective study of 267 consecutive patients undergoing AF ablation, 89 of whom were diagnosed with NAFLD prior to ablation and matched in a 2:1 manner based on age, sex, body mass index, ejection fraction, and AF type with 178 patients without NAFLD. Patients were monitored for arrhythmia recurrence during a mean follow-up of 29 months.

RESULTS

Recurrent arrhythmia was observed in 50 (56%) patients with NAFLD compared with 37 (21%) without NAFLD. Epicardial fat volume was measured on computed tomography and was significantly higher among those with NAFLD (248 ± 125 ml vs. 223 ± 97 ml; p = 0.01). On multivariable models adjusting for sleep apnea, body mass index, heart failure, AF type, and left atrial size, NAFLD was independently associated with increased rates of arrhythmia recurrence (hazard ratio: 3.010; 95% confidence interval: 1.980 to 4.680; p < 0.0001).

CONCLUSIONS

NAFLD is associated with significantly increased arrhythmia recurrence rates following AF ablation. Identification and reversal, where possible, may result in improved arrhythmia-free survival.

Frequency of postoperative atrial fibrillation and related parameters in patients who underwent sleeve gastrectomy for obesity

BACKGROUND

In this study, we planned to determine the frequency of postoperative AF and its related parameters in morbidly obese patients who underwent bariatric surgery.

METHODS

The study included 300 patients with morbidly obese who had no history of AF and underwent successful bariatric surgery. Routine anamnesis, physical examination and laboratory parameters of the patients were recorded. Patients with postoperative AF were detected. The participants were grouped as patients with and without AF.

RESULTS

Postoperative AF occurred in 19 (6.3%) patients. Age, BMI and LAd diameter parameters independently determined the presence of AF. When the ROC curve was performed to identify patients with AF, the area under the ROC curve was found to be 0.841, 0.785 and 0.902 for age, BMI and LAd diameter, respectively. According to this analysis, 50 years for age, 43 kg/m² for BMI and 40 mm for LAd were used to determine patients with AF with acceptable sensitivity and specificity (>70% each).

CONCLUSIONS

The most important determinants of postoperative AF are age, LAd and basal BMI. Therefore, morbidly obese patients with LAd >40 mm, BMI >43 kg/m² and >50 years of age should be followed up more closely for postoperative AF development and preoperative precautions should be taken to prevent AF development.

Underweight Predicts Greater Risk of Cardiac Mortality Post Acute Myocardial Infarction

Increased body mass index (BMI) is a well-established risk factor for cardiovascular disease; however, patients with elevated BMI, in comparison to those with low BMI, seem to have better survival, a phenomenon reported as "obesity paradox," which remains controversial. We investigated the effect of BMI on cardiac mortality post acute myocardial infarction (AMI).In this analysis, 3562 AMI patients were included and classified into four groups based on BMI values. The primary endpoint was cardiac death. Compared to normoweight group, overweight and obese group subjects were younger, mostly men, and more likely to receive percutaneous coronary intervention (PCI) and had higher levels of glucose and lipids, but lower level of NTproBNP. Subjects in the underweight group were older, were mostly women, had lower Barthel index (BI), were less likely to receive PCI, and had lower levels of glucose and lipids, but higher level of N-terminal pro-brain natriuretic peptide (NTproBNP) and higher rates of left ventricular ejection fraction (LVEF) < 50%. During a median follow-up period of 1.9 years, cardiac death occurred significantly more in the underweight group (30.0%, 10.6%, 7.0%, and 5.0% among the four groups from underweight to obese; P < 0.001 for trend). The Cox analysis revealed that underweight was an independent predictor of subsequent cardiac death (odds ratio (OR), 1.86; 95% confidence interval (CI), 1.07-3.25) and identified that older age, BI < 60, higher levels of cardiac troponin I (cTnI), LVEF < 50%, and not receiving PCI were independently associated with increased risk of cardiac death.Patients who were underweight were at greater risk of cardiac death post AMI. In addition, older age, frail, higher levels of cTnI, LVEF < 50%, and not receiving PCI also independently predicted cardiac mortality post AMI.

Impact of risk-factor modification on arrhythmia recurrence among morbidly obese patients undergoing atrial fibrillation ablation

BACKGROUND

Morbid obesity is associated with prohibitively high arrhythmia recurrence rates following atrial fibrillation (AF) ablation.

DESIGN

This was a single-center study comprising 239 patients with morbid obesity and symptomatic paroxysmal or persistent AF undergoing AF ablation compared to 239 patients with a body mass index less than 30 kg/m² matched based on age, sex, ejection fraction, AF type, presence and type of heart failure, and left atrial volume index.

METHODS

Our primary outcome of interest was arrhythmia recurrence.

RESULTS

During a mean follow-up of 29 months, arrhythmia recurrence was observed in 65% of the morbidly obese cohort compared to 27% of the control group (P < .0001). Among those with morbid obesity, sleep apnea screening, and treatment (91% vs 40%; P < .0001), blood pressure control (62% vs 53%; P = .001), glycemic control (85% vs 56%; P = .004), and weight loss more than equal to 5% (33% vs 57% in those who lost less than 5% and 83% in those who gained weight, P < .0001) were associated with lower arrhythmia recurrence. Recurrent arrhythmia was observed in one (4%) patient who accomplished all four goals, compared to 36% who achieved 3 of 4, 85% who modified 2 of 4%, and 97% of those who modified zero or one risk-factor. Risk-factor modification (RFM) was also associated with substantial reductions in the need for repeat ablation or direct-current cardioversion and arrhythmia-related hospitalization (P < .0001).

CONCLUSION

RFM through pragmatic noninvasive means such as blood pressure and glycemic control, sleep apnea screening and treatment, and weight loss is associated with substantially lower rates of recurrent arrhythmia among morbidly obese patients undergoing AF ablation.

Impact of body mass index on procedural complications, procedure duration, and radiation dose in patients with atrial fibrillation undergoing radiofrequency ablation: A systematic review and meta-analysis

Background

The association of body mass index (BMI) and procedure‐related factors in patients with atrial fibrillation (AF) after radiofrequency ablation (RFA) is still unclear.

Hypothesis

BMI is associated with increased the radiation dose, procedure duration, and procedural complications.

Methods

Prospective studies assessing BMI and procedure duration, radiation dose, and procedural complications in patients with AF after RFA were identified through electronic searches of PubMed, Embase, and the Cochrane Library database.

Results

Ten studies with 14 735 participants undergoing RFA were included. Procedure duration was significantly longer in patients with overweight or obesity than in patients with normal BMI, with a mean difference (MD) of 0.95. Patients with overweight and obesity were exposed to a larger radiation dose, with standard MD of 1.71 and 1.98, respectively. There was no significant association between overweight or obesity and the risk of procedural complications (RR of 0.91 for overweight, 1.01 for obesity, 0.89 for stage I obesity, 1.00 for stage II obesity, and 0.94 for stage III obesity). Further analysis showed there was no significant difference regarding stroke or transient ischemic attack (overweight, RR: 0.92; obesity, RR: 1.02); cardiac tamponade (overweight, RR: 0.92; obesity, RR: 1.02); groin hematoma (overweight, RR: 0.62; obesity, RR: 0.40); or pulmonary vein stenosis (overweight, RR: 0.49; obesity, RR: 0.40) among BMI groups.

Conclusion

Based on available evidence, we first showed that patients with overweight/obesity undergoing RFA experienced a significantly increased procedure duration and received a larger radiation dose than patients with normal BMI; however, there was no significant difference in procedural complications between patients with overweight/obesity and patients with normal BMI.

Characterization, Pathogenesis, and Clinical Implications of Inflammation-Related Atrial Myopathy as an Important Cause of Atrial Fibrillation

Historically, atrial fibrillation has been observed in clinical settings of prolonged hemodynamic stress, eg, hypertension and valvular heart disease. However, recently, the most prominent precedents to atrial fibrillation are metabolic diseases that are associated with adipose tissue inflammation (ie, obesity and diabetes mellitus) and systemic inflammatory disorders (ie, rheumatoid arthritis and psoriasis). These patients typically have little evidence of left ventricular hypertrophy or dilatation; instead, imaging reveals abnormalities of the structure or function of the atria, particularly the left atrium, indicative of an atrial myopathy. The left atrium is enlarged, fibrotic and noncompliant, potentially because the predisposing disorder leads to an expansion of epicardial adipose tissue, which transmits proinflammatory mediators to the underlying left atrium. The development of an atrial myopathy not only leads to atrial fibrillation, but also contributes to pulmonary venous hypertension and systemic thromboembolism. These mechanisms explain why disorders of systemic or adipose tissue inflammation are accompanied an increased risk of atrial fibrillation, abnormalities of left atrium geometry and an enhanced risk of stroke. The risk of stroke exceeds that predicted by conventional cardiovascular risk factors or thromboembolism risk scores used to guide the use of anticoagulation, but it is strongly linked to clinical evidence and biomarkers of systemic inflammation.

Association of Obesity Measures with Atrial Fibrillation Recurrence After Cryoablation in Patients with Paroxysmal Atrial Fibrillation

BACKGROUND Obesity increases the risk of atrial fibrillation (AF) recurrence after ablation. This study explored the relationship between various obesity indexes and risk of recurrence after cryoablation of paroxysmal AF (PAF). MATERIAL AND METHODS Our prospective study included 100 patients with PAF who underwent first cryoablation. Physical examination and fasting blood lipids levels were measured at baseline. Seven obesity indexes were determined: body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), waist-hip ratio (WHR), cardiometabolic index (CMI), lipid accumulation product (LAP), and body adiposity index (BAI). AF recurrence was confirmed by electrocardiograms and Holter monitor at follow-up visits after the initial 3-month blanking period. Receiver operating characteristic (ROC) curves were drawn to assess the abilities of obesity indicators in predicting AF recurrence. Multivariable Cox regression analysis was used to examine independent predictors of AF recurrence. RESULTS During a mean follow-up of 13.4 months, 31 patients (31.0%) had recurrent AF. Patients with recurrence had higher BMI, WC, WHtR, LAP, and BAI compared with those without recurrence. ROC analysis indicated the potential predictive value of BAI with an AUC of 0.657 (95% confidence interval [CI]: 0.534-0.779), followed by WC, WHtR, LAP, and BMI (all P<0.05). Diagnosis-to-ablation time (HR 1.034, 95% CI: 1.002-1.068), left atrial diameter (HR 1.147, 95% CI: 1.026-1.281), and WC (HR 1.026, 95% CI: 1.000-1.053) were independent predictive factors for AF recurrence after multivariable adjustment. CONCLUSIONS In this study population, WC appears to be a potential indicator for the prediction of recurrence in patients with PAF after cryoablation.

Obesity and atrial fibrillation: making inroads through fat

The global prevalence of obesity has reached epidemic proportions, paralleled by a rise in cases of atrial fibrillation (AF). Data from epidemiological cohorts support the role of obesity as an independent risk factor for AF. Increasing evidence indicates that obesity may contribute to the AF substrate through a number of pathways including by altering epicardial adipose tissue biology, inflammatory pathways, structural cardiac remodelling, and inducing atrial fibrosis. Due to changes in pharmacokinetics and pharmacodynamics, specific therapeutic considerations are required to guide management of patients with AF including anticoagulation and rhythm control. Also, weight loss in patients with AF has been associated with reduced progression from paroxysmal to persistent AF and indeed regression from persistent to proximal AF. However, the role of dietary intervention in AF control remains to be fully elucidated and hard prospective outcome data to support weight loss are required in AF to determine its role as part of a comprehensive risk factor management strategy for AF in obese patients.