The Effect of Diabetes Mellitus on the Recurrence of Atrial Fibrillation after Ablation

P-wave terminal force in lead V1 is associated with recurrence after catheter ablation in patients with paroxysmal atrial fibrillation and normal left atrial size

Background

A previous investigation reported that an abnormal P-wave terminal force in lead V1 (PTFV1) is a marker for electrical remodeling of the left atrium (LA). We aimed to assess the relationship of PTFV1 with LA tachyarrhythmia (LATA) recurrence after radiofrequency catheter ablation (RFCA) in patients with paroxysmal atrial fibrillation (PAF) and normal LA size.

Methods

Patients with PAF and normal LA size (LA volume index < 34 ml/m2) who underwent RFCA were consecutively included between January 2018 and December 2020 and divided into two groups based on the presence (recurrence group) or absence (nonrecurrence group) of LATA recurrence. PTFV1 was measured according to preprocedural electrocardiography. The association between PTFV1 and the recurrence of LATA was investigated.

Results

A total of 385 patients were included. After a median follow-up period of 745 (467, 977) days, 109 (28.3%) patients experienced LATA recurrence. PTFV1 was greater in the recurrence group. Multivariate Cox regression analysis demonstrated that the hazard ratio and 95% confidence interval for PTFV1 per 1,000 μV*ms increase and PTFV1 > 4,000 μV*ms were 1.22 (1.13-1.32, p < 0.001) and 2.32 (1.54-3.48, p < 0.001), respectively.

Conclusion

PTFV1 is an independent predictor for LATA recurrence after RFCA in patients with PAF and normal LA size.

Ablation therapy following unsuccessful electrical cardioversion in patients with persistent atrial fibrillation

Electrical cardioversion (ECV) a widely utilized intervention for persistent atrial fibrillation (AF) aimed at restoring sinus rhythm. However, ECV can be ineffective, raising questions about subsequent treatment options. This study aimed to compare the outcomes of non-ablation therapy versus ablation therapy following unsuccessful ECV. A total of 125 consecutive patients with persistent AF who underwent unsuccessful ECV between November 2017 and August 2023 was included in this retrospective analysis. Of these, 51.2% received only medical therapy (non-ablation therapy group, n = 64), while 48.8% underwent AF ablation (ablation therapy group, n = 61). Various ablation methods were employed, including catheter and thoracoscopic ablation. Ablation therapy was associated with significantly better AF-free survival compared to non-ablation therapy [hazard ratio (HR), 0.37; 95% confidence interval (CI) 0.22-0.61; p < 0.01]. There was no difference of AF-free survival between catheter ablation and thoracoscopic ablation groups (HR 0.79, 95% CI 0.34-1.83; p = 0.58). AF duration > 5 year (HR 1.51; 95% CI 0.930-2.437; p = 0.10), BMI ≤ 25 kg/m2 (HR 1.61; 95% CI 1.004-2.581; p = 0.05) and diabetes (HR 2.38; 95% CI 0.902-6.266; p = 0.08) were considerable as predictor of AF recurrence. Ablation therapy following unsuccessful ECV was associated with maintaining sinus rhythm, regardless of the specific ablation method utilized.

Rethinking appropriate blanking period after atrial fibrillation ablation

BACKGROUND

Early recurrence (ER) within a 90-day blanking period (BP) in catheter ablation (CA) for atrial fibrillation (AF) is a risk factor for late recurrence (LR) after 90 days postoperatively. However, few reports have examined them in the second CA and compared them to the first CA. Moreover, in recent years, there have been reports suggesting that BP should be reduced from 90 to 30 days. Therefore, the association between ER and LR in the first and the second CA was examined, and the validity of a 30-day BP was evaluated.

METHODS

A total of 511 consecutive patients undergoing the first CA and 116 of these patients undergoing the second CA for AF at a single institution from November 2016 to December 2020 were analyzed retrospectively.

RESULTS

When ER within a 90-day BP was divided into 0-30 days and 31-90 days according to the timing of the last ER episode, the hazard ratios on LR of them relative to no ER were 2.7 {95% confidence interval (CI) 1.7-4.2} and 9.7 (95% CI 6.6-14.3), respectively, for the first CA and 15.3 (95% CI 4.7-50.1) and 44.1 (95% CI 14.0-139.4), respectively, for the second CA.

CONCLUSIONS

ER was strongly associated with LR, especially in patients with the last episode of ER more than 30 days after CA. This was pronounced in cases after the second CA, when PVI appeared to be completed. With the current improvement in PVI durability, BP may be acceptable for 30 days.

Radiofrequency Catheter Ablation for Atrial Fibrillation Patients on Hemodialysis (From the Kansai Plus Atrial Fibrillation Registry) - Clinical Impact of Early Recurrence

BACKGROUND

Catheter ablation (CA) for atrial fibrillation (AF) in patients on hemodialysis (HD) is reported to have a high risk of late recurrence (LR). However, the relationship between early recurrence (ER) within a 90-day blanking period after CA in AF patients and LR in HD patients remains unclear.

METHODS AND RESULTS

Of the 5,010 patients in the Kansai Plus Atrial Fibrillation Registry, 5,009 were included in the present study. Of these patients, 4,942 were not on HD (non-HD group) and 67 were on HD (HD group). HD was an independent risk factor for LR after the initial CA (adjusted hazard ratio 1.6; 95% confidence interval 1.1-2.2; P=0.01). In patients with ER, the rate of sinus rhythm maintenance at 3 years after the initial CA was significantly lower in the HD than non-HD group (11.4% vs. 35.4%, respectively; log-rank P=0.004). However, in patients without ER, there was no significant difference in the rate of sinus rhythm maintenance at 3 years between the HD and non-HD groups (67.7% vs. 74.5%, respectively; log-rank P=0.62).

CONCLUSIONS

ER in HD patients was a strong risk factor for LR. However, even HD patients could expect a good outcome without ER after the initial CA.

The individual relationship between atrial fibrillation sources from CARTOFINDER mapping and atrial cardiomyopathy: The catch me if you can trial

BACKGROUND

Targeting individual sources identified during atrial fibrillation (AF) has been used as an ablation strategy with varying results.

OBJECTIVE

Aim of this study was to evaluate the relationship between regions of interest (ROIs) from CARTOFINDER (CF) mapping and atrial cardiomyopathy from late gadolinium enhancement (LGE) cardiovascular magnetic resonance imaging (CMR).

METHODS

Twenty consecutive patients underwent index catheter ablation for persistent AF (PERS AF). Pre-processed LGE CMR images were merged with the results from CF mapping to visualize harboring regions for focal and rotational activities. Atrial cardiomyopathy was classified based on the four Utah stages.

RESULTS

Procedural success was achieved in all patients (n = 20, 100%). LGE CMR revealed an intermediate amount of 21.41% ± 6.32% for LA fibrosis. ROIs were identified in all patients (mean no ROIs per patient n = 416.45 ± 204.57). A tendency towards a positive correlation between the total amount of atrial cardiomyopathy and the total number of ROIs per patient (regression coefficient, β = 10.86, p = .15) was observed. The degree of fibrosis and the presence of ROIs per segment showed no consistent spatial correlation (posterior: β = 0.36, p-value (p) = .24; anterior: β = -0.08, p = .54; lateral: β = 0.31, p = 39; septal: β = -0.12; p = .66; right PVs: β = 0.34, p = .27; left PVs: β = 0.07, p = .79; LAA: β = -0.91, p = .12). 12 months AF-free survival was 70% (n = 14) after ablation.

CONCLUSION

The presence of ROIs from CF mapping was not directly associated with the extent and location of fibrosis. Further studies evaluating the relationship between focal and rotational activity and atrial cardiomyopathy are mandatory.

Association between the systemic immune-inflammation index and outcomes among atrial fibrillation patients with diabetes undergoing radiofrequency catheter ablation

PURPOSE

To investigate the relationship between the incidence of atrial fibrillation (AF) recurrence and the levels of the systemic immune-inflammatory index (SII, platelet × neutrophil/lymphocyte ratio) in patients with AF and diabetes mellitus (DM) undergoing after radiofrequency catheter ablation (RFCA).

PATIENTS AND METHODS

Preoperative SII levels were determined in AF patients with DM undergoing RFCA. Restricted cubic splines were used to determine the correlation between SII and the risk of AF recurrence. Multivariate-adjusted logistic regression models were constructed to determine the relationship between SII levels and AF recurrence. The predictive value of the clinical model and combined with the SII index was estimated by the area under the receiver-operating characteristic curve, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

RESULTS

A total of 204 patients with AF and DM who underwent RFCA in our hospital were included. Seventy-seven patients had AF recurred during a mean follow-up of 20 months. Restricted cubic spline analysis showed that when SII ≥ 444.77 × 109 /L, there was a positive correlation with the incidence of AF recurrence. In addition, adding the SII to the predictive model for AF recurrence after RFCA in patients with DM and AF could contribute to an increase in C-statistics (0.798 vs. 0.749, p = .034). After SII was incorporated into the clinical model, the comprehensive discrimination and net reclassification tended to improve (IDI and NRI > 0, p < .05).

CONCLUSION

SII was independently and positively associated with recurrence after the first catheter ablation in patients with DM and AF.

Epicardial Adipose Tissue and Atrial Fibrillation Recurrence following Catheter Ablation: A Systematic Review and Meta-Analysis

(1)Introduction: Catheter ablation has become a cornerstone for the management of patients with atrial fibrillation (AF). Nevertheless, recurrence rates remain high. Epicardial adipose tissue (EAT) has been associated with AF pathogenesis and maintenance. However, the literature has provided equivocal results regarding the relationship between EAT and post-ablation recurrence.(2) Purpose: to investigate the relationship between total and peri-left atrium (peri-LA) EAT with post-ablation AF recurrence. (3) Methods: major electronic databases were searched for articles assessing the relationship between EAT, quantified using computed tomography, and the recurrence of AF following catheter ablation procedures. (4) Results: Twelve studies (2179 patients) assessed total EAT and another twelve (2879 patients) peri-LA EAT. Almost 60% of the included patients had paroxysmal AF and recurrence was documented in 34%. Those who maintained sinus rhythm had a significantly lower volume of peri-LA EAT (SMD: -0.37, 95%; CI: -0.58-0.16, I2: 68%). On the contrary, no significant difference was documented for total EAT (SMD: -0.32, 95%; CI: -0.65-0.01; I2: 92%). No differences were revealed between radiofrequency and cryoenergy pulmonary venous isolation. No publication bias was identified. (5) Conclusions: Only peri-LA EAT seems to be predictive of post-ablation AF recurrence. These findings may reflect different pathophysiological roles of EAT depending on its location. Whether peri-LA EAT can be used as a predictor and target to prevent recurrence is a matter of further research.

Clinical Outcomes and Predictors of Late Recurrence in Young Patients with Atrial Fibrillation after Catheter Ablation

Background

Catheter ablation (CA) is an established treatment for atrial fibrillation (AF), but the recurrence of AF is not neglected. Young patients with AF were generally more symptomatic and intolerant to long-term drug treatment. We aim to explore clinical outcomes and predictors of late recurrence (LR) in AF patients younger than 45 years after CA to better manage them.

Methods

We retrospectively studied 92 symptomatic AF patients who accepted CA from September 1, 2019, to August 31, 2021. Baseline clinical data (including N-terminal prohormone of brain natriuretic peptide, NT-proBNP), ablation outcomes, and follow-up outcomes were collected. Patients were followed up at 3, 6, 9, and 12 months. Follow-up data were available for 82/92 (89.1%) patients.

Results

One-year arrhythmia-free survival was 81.7% (67/82) in our study group. Major complications occurred in 3/82 (3.7%) patients with an acceptable rate. The value of ln(NT-proBNP) (P = 0.025, odds ratio [OR] = 1.977, 95% confidence interval [CI] 1.087-3.596) and a family history of AF (P = 0.041, HR = 9.269, 95% CI 1.097-78.295) could independently predict AF recurrence. The ROC analysis of ln(NT-proBNP) showed that NT-proBNP greater than 200.05 pg/ml (area under the curve: 0.772, 95% CI 0.642-0.902, P = 0.001, sensitivity 0.800, specificity 0.701) was the cut-off point for predicting late recurrence.

Conclusions

CA is a safe and effective treatment for AF patients younger than 45 years. Elevated NT-proBNP level and a family history of AF could be used as predictors for late recurrence in young patients. The result of this study may help us take more comprehensive management of those with high-recurrence risks to reduce disease burden and improve quality of life.

Diabetes mellitus and atrial fibrillation-from pathophysiology to treatment

Type 2 diabetes mellitus (T2DM) is a leading risk factor for cardiovascular complications around the globe and one of the most common medical conditions. Atrial fibrillation (AF) is the most common supraventricular arrhythmia, with a rapidly increasing prevalence. T2DM has been closely associated with the risk of AF development, identified as an independent risk factor. Regarding cardio-vascular complications, both AF and T2DM have been linked with high mortality. The underlying pathophysiology has not been fully determined yet; however, it is multifactorial, including structural, electrical, and autonomic pathways. Novel therapies include pharmaceutical agents in sodium-glucose cotransporter-2 inhibitors, as well as antiarrhythmic strategies, such as cardioversion and ablation. Of interest, glucose-lowering therapies may affect the prevalence of AF. This review presents the current evidence regarding the connection between the two entities, the pathophysiological pathways that link them, and the therapeutic options that exist.

Predictive value of HMGB1 for atrial fibrillation recurrence after cryoballoon ablation in paroxysmal atrial fibrillation patients

BACKGROUND

Cryoballoon ablation (CBA) is recommended for patients with symptomatic drug refractory paroxysmal atrial fibrillation (pAF). However, substantial atrial fibrillation (AF) recurrence is common during follow-up. Searching for a potential biomarker representing both myocardial injury and inflammation to identify patients at high risk of AF recurrence after CBA is very meaningful for postoperative management of AF patients.

HYPOTHESIS

To evaluate the clinical efficacy of high-mobility group box 1 (HMGB1) protein released from the left atrium to predict AF recurrence in pAF patients after CBA at 1-year follow-up.

METHODS

We included 72 pAF patients who underwent CBA. To determine the expression levels of HMGB1, left atrial blood samples were collected from the patients before CBA and after the procedure through the transseptal sheath. Patients were followed up for AF recurrence for 1 year.

RESULTS

A total of 19 patients of the 72 experienced AF recurrence. The level of postoperative HMGB1 (HMGB1post) was higher in the AF recurrence group than in the AF non recurrence group (p = .03). However, no differences were noted in the levels of other biomarkers such as preoperative high-sensitivity C-reactive protein (hs-CRP), postoperativehs-CRP, and preoperative HMGB1 between the two groups. Multiple logistic regression analysis revealed that a higher level of serum HMGB1post was associated with AF recurrence (odds ratio: 5.29 [1.17-23.92], p = .04). Receiver operating characteristic analysis revealed that HMGB1post had a moderate predictive power for AF recurrence (area under the curve: 0.68; sensitivity: 72%; and specificity: 68%). The 1-year AF-free survival was significantly lower in patients with a high HMGB1post level than in those with a low HMGB1post level (hazard ratio: 3.81 [1.49-9.75], p = .005).

CONCLUSION

In pAF patients who under went CBA, the level of HMGB1 after CBA was associated with AF recurrence and demonstrated a moderate predictive power. Thus, we offer a potential biomarker to identify pAF patients at high risk of AF recurrence.

[Rhythm and metabolic control]

Diabetes mellitus and atrial fibrillation show a steady increase in their prevalence. Diabetes mellitus is a relevant risk factor for the development and maintenance of atrial fibrillation, which should not be underestimated. Fluctuations in blood glucose levels occurring in diabetes, inflammatory processes and oxidative stress lead to structural, electromechanical, electrical and autonomic remodelling processes in the myocardium that promote atrial fibrillation. When atrial fibrillation and diabetes mellitus coincide, this is often associated with more pronounced symptoms, lower quality of life, more frequent hospitalization and a higher mortality rate. Can early and consistent euglycemic blood glucose monitoring effectively influence atrial remodelling processes, cardiovascular end points and the occurrence of atrial fibrillation? Are there new and combined drug treatment approaches for diabetes mellitus and atrial fibrillation? What ablation strategy should be adopted for the interventional treatment of atrial fibrillation in patients with diabetes mellitus? This review article attempts to find answers to these questions.

News from the Cold Chamber: Clinical Experiences of POLARx versus Arctic Front Advance for Single-Shot Pulmonary Vein Isolation

Cryoballoon (CB)-guided pulmonary vein isolation (PVI) represents a cornerstone in the treatment of atrial fibrillation (AF). Recently, a novel balloon-guided single shot device (POLARx, Boston Scientific) was designed. Our study aimed to compare the efficacy, safety and characteristics of the novel CB system with the established one (Arctic Front Advance (Pro), AFA, Medtronic). A total number of 596 patients undergoing CB-guided ablation for AF were included. 65 patients (65.0 ± 11.6, 31% female) undergoing PVI with the POLARx were compared to a cohort of 531 consecutive patients (63.0 ± 27.9, 25% female) treated with AFA. Acute PVI was achieved in all patients (n = 596, 100%). Total procedure duration (POLARx 113.3 ± 23.2 min, AFA 100.9 ± 21.3 min; p < 0.001) and fluoroscopy time (POLARx 10.5 ± 5.9 min, AFA 4.8 ± 3.6 min; p < 0.001) were significantly longer in the POLARx group. The POLARx balloon achieved significantly lower nadir temperatures (POLARx −57.7 ± 0.9 °C, AFA −45.1 ± 2.6 °C; p < 0.001) and a significantly higher percentage of pulmonary veins successfully isolated with the first freeze (p = 0.027 *). One major complication occurred in the POLARx (2%) and three (1%) in the AFA group. Both ablation systems are comparably safe and effective. AF ablation utilizing the POLARx system is associated with longer procedure and fluoroscopy times as well as lower nadir temperatures.