Meta-Analysis of the Incidence, Prevalence, and Correlates of Atrial Fibrillation in Rheumatic Heart Disease

Comparing the outcomes of rheumatic heart disease in pregnancy complicated with and without atrial fibrillation: A propensity score matched analysis

BACKGROUND

Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it.

METHODS

The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them.

RESULTS

Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95%CI 66.3%-85.7%) compared to women without AF (17.3%(95%CI 13.3%-22.1%), P < .001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, P < .001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1-226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF.

CONCLUSIONS

Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

Comparison of short-term efficacy of two bipolar radiofrequency ablation forceps for rheumatic heart disease concomitant with atrial fibrillation

Background

Currently, the bipolar radiofrequency ablation forceps manufactured by AtriCure are the main instrument for surgical ablation in patients with rheumatic heart disease (RHD) concomitant with atrial fibrillation (AF). The bipolar radiofrequency ablation forceps by Med-Zenith has a greater advantage in price compared with AtriCure. However, few studies have been reported on the comparison of their clinical efficacy. The aim of this study is to compare the short-term clinical efficacy of the two ablation forceps for RHD concomitant with AF.

Methods

Clinical data of 167 patients with RHD concomitant with AF admitted to the Department of Cardiac Major Vascular Surgery, Affiliated Hospital of North Sichuan Medical College, were retrospectively analyzed, and the restoration efficacy of sinus rhythm (SR) and cardiac function after surgery were compared with two ablation forceps.

Results

The end-systolic diameter of the right atrium and the end-systolic diameter of the left atrium in the patients of both groups at each postoperative time point decreased compared with that of the preoperative period (P < 0.05), and the left ventricular ejection fraction started to improve significantly at 6 months after surgery compared with that of the preoperative period (P < 0.05). There was no difference between the two groups of patients in the comparison of the aforementioned indicators at different points in time (P > 0.05). At 12 months postoperatively, the SR maintenance rate in using the ablation forceps by Med-Zenith (73.3%) was lower than that for AtriCure (86.4%) and the cumulative recurrence rate of AF in using the Med-Zenith ablation forceps was greater than that for AtriCure.

Conclusions

The two bipolar radiofrequency ablation forceps compared in the study are safe and effective in treating patients of RHD concomitant with AF, and the ablation forceps by AtriCure may be more effective in restoring SR in the short term.

Outcomes and care quality metrics for people living with rheumatic heart disease and atrial fibrillation in Uganda

Background

Atrial fibrillation (AF) is a common complication of rheumatic heart disease (RHD) and is challenging to treat in lower-resourced settings in which RHD remains endemic.

Objective

We characterized demographics, treatment outcomes, and factors leading to care retention for participants with RHD and AF in Uganda.

Methods

We conducted a retrospective analysis of the Uganda national RHD registry between June 2009 and May 2018. Participants with AF or atrial flutter were included. Demographics, survival, and care metrics were compared with participants without AF. Multivariable logistic regression was used to identify factors associated with retention in care among participants with AF.

Results

A total of 1530 participants with RHD were analyzed and 293 (19%) had AF. The median age was 24 (interquartile range 14-38) years. Mortality was similar in both groups (adjusted hazard ratio 1.183, P = .77) over a median follow-up of 203 (interquartile range 98-275) days. A total of 79% of AF participants were prescribed anticoagulation, and 43% were aware of their target international normalized ratio. Retention in care was higher in participants with AF (18% vs 12%, P < .01). Factors associated with decreased retention in care include New York Heart Association functional class III/IV (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.30-0.76) and distance to nearest health center (adjusted OR 0.94, 95% CI 0.90-0.99). Anticoagulation prescription was associated with enhanced care retention (adjusted OR 1.86, 95% CI 1.24-2.79).

Conclusion

Participants with RHD and AF in Uganda do not experience higher mortality than those without AF. Anticoagulation prescription rates are high. Although retention in care is poor among RHD participants, those with concurrent AF are more likely to be retained.

Long-term results of atrial fibrillation surgery concomitant with mitral valve surgery: A propensity score-matched multicenter study

OBJECTIVE

The aim of the study was to elucidate the long-term outcomes of atrial fibrillation surgery in patients with atrial fibrillation and mitral valve disease by comparing the patients who underwent mitral valve surgery with and without atrial fibrillation surgery.

METHODS

Between 2005 and 2017, 2680 patients with atrial fibrillation who underwent mitral valve surgery (mitral valve surgery with atrial fibrillation surgery, n = 1841; mitral valve surgery without atrial fibrillation surgery, n = 839) at 5 centers were included. After propensity score matching, 1442 patients were extracted (atrial fibrillation surgery group, n = 721; non-atrial fibrillation surgery group, n = 721). All-cause mortality, cardiac mortality, major adverse cardiac and cerebrovascular events, stroke or transient ischemic attack, and permanent pacemaker implantation were compared between the atrial fibrillation surgery and non-atrial fibrillation surgery groups.

RESULTS

Overall survivals at 5 and 10 years postoperatively were 91.0% and 80.7% in the atrial fibrillation surgery group and 86.5% and 75.9% in the non-atrial fibrillation surgery group, respectively (P = .013). Cardiac mortality-free survivals at 5 and 10 years postoperatively were 96.9% and 91.7% in the atrial fibrillation surgery group and 90.9% and 83.7% in the non-atrial fibrillation surgery group, respectively (P < .001). Cumulative incidence of reoperation, major adverse cardiac and cerebrovascular events, and stroke or transient ischemic attack was lower in the matched atrial fibrillation surgery group compared with the matched non-atrial fibrillation surgery group up to 15 years postoperatively (P = .010, P < .001, and P = .012, respectively). Cumulative incidence of permanent pacemaker implantation was higher in the matched atrial fibrillation surgery group compared with the matched non-atrial fibrillation surgery group (P < .001).

CONCLUSIONS

In patients with atrial fibrillation and mitral valve disease, mitral valve surgery concomitant with atrial fibrillation surgery was associated with lower mortality, cardiac mortality, major adverse cardiac and cerebrovascular events, and stroke or transient ischemic attack up to 15 years after surgery when compared with mitral valve surgery without atrial fibrillation surgery.

Clinical predictive factors of coronary stenosis in patients with high‑risk valvular heart disease who received diagnostic coronary angiography prior to cardiac valve surgery

Valvular heart disease (VHD) may lead to morbidities and mortality due to heart failure or sudden death. Concomitant coronary artery disease (CAD) is a crucial condition that needs to be explored in patients with VHD prior to cardiac valve surgery as it may increase morbidity and mortality. Patient age >40 years and mitral regurgitation are key risk factors for CAD in patients with VHD. The present study aimed to identify clinical risk factors for coronary stenosis in patients with high-risk VHD. The retrospective cohort study recruited patients aged >40 years who received cardiac valve surgery and coronary angiogram prior to cardiac valve surgery. Clinical factors predictive of coronary stenosis were computed by logistic regression analysis. There were 533 patients; 114 patients (21.38%) had coronary stenosis. Four factors were positively associated with coronary stenosis including age, male sex, mitral regurgitation and hypertension, while two factors were negatively associated with coronary stenosis, namely estimated glomerular filtration rate and rheumatic heart disease. Hypertension had the highest adjusted odds ratio at 2.596, while rheumatic heart disease had the lowest adjusted odds ratio at 0.428. Patient age >55 years showed a sensitivity and specificity of coronary stenosis of 80.70 and 37.47%, respectively. Clinical factors predictive of coronary stenosis in patients with high-risk VHD were age >55 years, male sex, mitral regurgitation and hypertension, while a high estimated glomerular filtration rate and presence of rheumatic heart disease were protective factors.

Two-incision totally thoracoscopic mitral valve repair combined with radiofrequency atrial fibrillation ablation in rheumatic mitral valve disease: Early results of a case series of 43 consecutive patients

BACKGROUND

Few studies have reported the outcomes of two-incision total thoracoscopic mitral valve repair (MVr) and concomitant radiofrequency atrial fibrillation ablation (RAFA) in patients with rheumatic mitral valve disease and atrial fibrillation (AF).

METHODS

We retrospectively analyzed 43 consecutive patients who underwent MVr and RAFA through two-incision total thoracoscopic technique from October 2018 to June 2022. We collected data on baseline characteristics, perioperative outcomes, and early-term results.

RESULTS

The mean age was 55.67 ± 7.64 years and 29 (67.4%) patients had New York Heart Association (NYHA) class III or IV. The mean cardiopulmonary bypass (CPB) time was 115.56 ± 8.53 min and aortic clamping time was 81.42 ± 7.54 min. There were no in-hospital deaths or strokes. The mean preoperative mitral valve orifice area (MVOA) was 0.95 (0.84-1.16) cm2 and increased to 2.56 (2.41-2.87) cm2 at discharge and 2.54 (2.44-2.76) cm2 at 3 months after surgery (P < .001). At discharge, 32 (74.4%) patients were in sinus rhythm, 7 (20.9%) were in junctional or atrial flutter rhythm, and 4 (9.3%) remained in AF. At 6 months, 35 (81.4%) patients were in sinus rhythm, 5 (11.63%) were in junctional or atrial flutter rhythm, and 3 (4.7%) were in AF.

CONCLUSIONS

Two-incision total thoracoscopic MVr and RAFA is a safe and effective procedure that can improve the MVOA and promote conversion of AF to sinus rhythm in patients with rheumatic mitral valve disease and AF. Further studies with larger sample size and longer follow-up are needed to confirm the long-term benefits of this approach.

Warfarin faring better: vitamin K antagonists beat rivaroxaban and apixaban in the INVICTUS and PROACT Xa trials

Although guidelines give preference to direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF), DOACs are not recommended in those with rheumatic heart disease or mechanical heart valves. The results of the INVICTUS trial (Investigation of Rheumatic AF Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies), which compared rivaroxaban with a VKA in patients with rheumatic heart disease-associated AF, and the PROACT Xa trial (A Trial to Determine if Participants with an On-X Aortic Valve Can be Maintained Safely on Apixaban), which compared apixaban with warfarin in patients with an On-X valve in the aortic position, support the use of VKAs for these indications. In this paper, we review the results of these trials, provide perspective on why VKAs were superior to DOACs, and discuss future directions for anticoagulation in these disorders.

Pattern of rheumatic heart disease among patients attending at a tertiary care hospital in Somalia: first report from Somalia

Rheumatic heart disease (RHD) is the leading cause of valvular heart disease in underdeveloped nations. It remains a significant public health issue in Sub-Saharan African countries. This study aimed to determine the pattern, severity, and complications of RHD in Somalia. This was a retrospective cross-sectional study of all patients diagnosed with rheumatic heart disease. A total of 8526 echocardiographic examinations were done in our center over a two-year study period from January 2020 to December 2021. Patients with congenital cardiac disease, post-operative cases, myxomatous and old age degenerative disease were all excluded. Of 433 patients, 286 (66.1%) were female, and the mean age was 46.5 ± 20.3. The isolated mitral valve (MV) affected 222 (51.3%). Dual involvement of mitral and aortic valve (AV) was present in 190 (44%). Overall isolated or combined valve involvement, mitral regurgitation (MR) was the most common valve lesion 345 (79.7%), followed by mitral stenosis (MS) 160 (37%). According to the severity of lesions, severe MR was 230 (53.1%) patients, followed by severe MS (n=129, 29.8%). The most common complication of RHD depicted in our study were secondary pulmonary hypertension and enlarged left atrium, 23.8% (n=103) and 19.6% (n=85), respectively. In conclusion, in our study majority of RHD patients were females. Both isolated and in combination, MV was the most commonly affected, and mitral regurgitation was the most common valvular lesion. In our study high percentage of patients already had complications at the time of diagnosis.

Radiomics Based on Single-Phase CTA for Distinguishing Left Atrial Appendage Thrombus from Circulatory Stasis in Patients with Atrial Fibrillation before Ablation

Differentiation of left atrial appendage thrombus (LAAT) and left atrial appendage (LAA) circulatory stasis is difficult when based only on single-phase computed tomography angiography (CTA) in routine clinical practice. Radiomics provides a promising tool for their identification. We retrospectively enrolled 204 (training set: 144; test set: 60) atrial fibrillation patients before ablation, including 102 LAAT and 102 circulatory stasis patients. Radiomics software was used to segment whole LAA on single-phase CTA images and extract features. Models were built and compared via a multivariable logistic regression algorithm and area under of the receiver operating characteristic curves (AUCs), respectively. For the radiomics model, radiomics clinical model, radiomics radiological model, and combined model, the AUCs were 0.82, 0.86, 0.90, 0.93 and 0.82, 0.82, 0.84, 0.85 in the training set and the test set, respectively (p < 0.05). One clinical feature (rheumatic heart disease) and four radiological features (transverse diameter of left atrium, volume of left atrium, location of LAA, shape of LAA) were added to the combined model. The combined model exhibited excellent differential diagnostic performances between LAAT and circulatory stasis without increasing extra radiation exposure. The single-phase, CTA-based radiomics analysis shows potential as an effective tool for accurately detecting LAAT in patients with atrial fibrillation before ablation.

Cardiac imaging in rheumatic heart disease and future developments

Rheumatic heart disease (RHD) is the most common cause of valvular heart disease worldwide, affecting millions, especially in low- and middle-income countries. Multiple imaging modalities such as cardiac CT, cardiac MRI, and three-dimensional echocardiography may be utilized in diagnosing, screening, and managing RHD. However, two-dimensional transthoracic echocardiography remains the cornerstone of imaging in RHD. Criteria developed by the World Heart Foundation in 2012 sought to unify the diagnostic imaging criteria for RHD, but concerns remain regarding their complexity and reproducibility. In the intervening years, further measures have been developed to find a balance between simplicity and accuracy. Nonetheless, there remain significant unresolved problems within imaging in RHD, including the development of a practical and sensitive screening tool to identify patients with RHD. The emergence of handheld echocardiography has the potential to revolutionize RHD management in resource-poor settings, but its role as a screening or diagnostic tool is yet to be fully established. The dramatic evolution of imaging modalities over the last few decades has not addressed RHD compared to other forms of structural heart disease. In this review, we examine the current and latest developments concerning cardiac imaging and RHD.

Anticoagulation for rheumatic mitral stenosis, INVICTUS in perspective

PURPOSE OF REVIEW

Rheumatic mitral stenosis (MS) while declining in high- and middle-income countries, continues to be a major cause of death and disability in low-income countries. Although the nonvitamin-K antagonist oral anticoagulants (NOACs) have essentially supplanted vitamin K antagonists (VKA) in patients with nonvalvular atrial fibrillation (AF), their efficacy for stroke prevention in patients with rheumatic MS and AF has not been widely studied until recently. The purpose of this review is to provide a succinct synopsis of the current anticoagulation recommendations for patients with native and prosthetic heart valve disease, with a specific focus on patients with rheumatic MS.

RECENT FINDINGS

The INVICTUS trial was the first large randomized evaluation of a NOAC vs. VKA in approximately 4600 patients with moderate to severe rheumatic MS and AF. The primary outcome of stroke, systemic embolization, myocardial infarction, vascular and all-cause death, VKA treated patients exhibited lower event rates (including mortality) compared to rivaroxaban. We discuss and contextualize these findings as they relate to the broader use of anticoagulants in patients with valvular heart disease, with and without concomitant AF.

SUMMARY

VKA remains the standard of care for patients with moderate to severe rheumatic MS who have concomitant AF. Rates of stroke in anticoagulated patients with rheumatic MS and AF are lower than what is traditionally held, while nonstroke related deaths remain the most common mechanism of mortality.

INVICTUS: Vitamin K antagonists remain the standard of care for rheumatic heart disease-associated atrial fibrillation

INTRODUCTION

Rheumatic heart disease (RHD) remains a major healthcare problem. Atrial fibrillation (AF) is the commonest sustained arrhythmia in RHD, leading to major complications and morbidity in a young population. Currently, anticoagulation with vitamin K antagonists (VKA) is the mainstay of therapy for the prevention of thromboembolic adverse events. However, effective use of VKA remains challenging, especially in developing countries, showing a need for alternatives. Novel oral anticoagulants (NOACs), including rivaroxaban, could form a safe and effective alternative to fulfil a major unmet need in RHD patients with AF. However, until recently, no data was available for the use rivaroxaban in patients with rheumatic heart disease associated AF. Study and Results: The INVICTUS trial was conducted to assess efficacy and safety of once-daily rivaroxaban compared with a dose-adjusted VKA for the prevention of cardiovascular events in patients with RHD-associated AF. A total of 4531 patients (age: 50.5 ± 14.6 years) were followed for 3.1 ± 1.2 years in which 560/2292 patients in the rivaroxaban group and 446/2273 in the VKA group had a primary-outcome adverse event. The restricted mean survival time was 1599 days in the rivaroxaban group and 1675 days in the VKA group (difference, -76 days; 95% confidence interval [CI], -121 to -31; P <0.001). A higher incidence of death occurred in the rivaroxaban group than in the VKA group (restricted mean survival time, 1608 days vs. 1680 days; difference, -72 days; 95% CI, -117 to -28). No significant between-group difference in the rate of major bleeding was noted.

LESSONS LEARNED

The INVICTUS trial shows that Rivaroxaban is inferior to Vitamin K-antagonists in patients with RHD associated AF as VKA therapy led to a lower rate of ischemic and lower mortality due to vascular causes, without significantly increasing the rate of major bleeding. The results support current guidelines, which recommend vitamin K antagonist therapy for the prevention of stroke in patients with RHD associated AF.

Neutrophil-Lymphocyte Ratio and Red Blood Cell Distribution Width in Patients with Atrial Fibrillation and Rheumatic Valve Disease

The lifetime risk of developing atrial fibrillation (AF) is 1 in 3 adults, resulting in a prevalence of 2-4%. Rheumatic heart disease (RHD) is a frequent aetiology of valvular heart disease in lowand middle-income countries. Between 21% and 80% of patients with mitral valve disease, especially with stenosis, may have AF. Both these conditions, AF and RHD, present a state of persistent inflammation. In turn, inflammation is a frequent cause of anisocytosis, which can be evidenced through the parameter RDW (red bold cell distribution width). Factors associated with increased RDW are also known as risk factors associated with a higher incidence of AF. RDW may have an independent role in the pathogenesis of AF and the increased propensity of both thromboembolic and bleeding events. Another marker involved in the incidence of AF is the neutrophil-lymphocyte ratio. This is also a marker of oxidative stress and inflammation and is associated with a higher rate of AF recurrence. This review will evaluate these biomarkers and their association with cardiovascular events in patients with AF and RHD. The hypotheses and current debates about the relationship of biomarkers with the severity of chronic valve dysfunction, with acute rheumatic carditis in the paediatric population, and with the presence of thrombus in the left atrium will be discussed.

Management of atrial fibrillation in rheumatic heart disease

Rheumatic heart disease (RHD) is the underlying cause of a significant proportion of atrial fibrillation (AF) in the low- and middle-income countries, while nonvalvular AF is the most common cause of AF in high-income countries. RHD is also common among African Americans, migrants, and the indigenous population of high-income countries. The onset of AF in RHD patients is a clinical marker of worse outcomes and is associated with significant morbidity and mortality. Despite RHD being a major cause of morbidity and mortality in the young in many parts of the world, it is often neglected by policymakers, the media, and even the medical fraternity. Stroke risk assessment using various risk scores has not been systematically evaluated in rheumatic AF patients. Rate control may not be ideal for symptom control in rheumatic AF patients considering the young age and an active lifestyle. There is limited information regarding the nonpharmacological management of rheumatic AF. The current management guidelines based on nonvalvular AF do not apply to rheumatic AF patients who are often younger, are women, and have fewer comorbidities. This review critically looks at specific areas such as stroke prevention with reference to direct oral anticoagulants, cardioversion, rate and rhythm control strategies, and the role of nonpharmacological methods in rheumatic AF management. Future recommendations must be cognizant of local health care systems and resourcing considering the geographic distribution of the disease.

Prevalence and risk factors for atrial fibrillation in a semi-rural sub-Saharan African population: The hEart oF ethiopia: Focus on Atrial Fibrillation (TEFF-AF) Study

Background

There is a scarcity of reported data on the prevalence of atrial fibrillation (AF) in sub-Saharan Africa.

Objectives

To undertake AF screening in semi-rural Ethiopia.

Methods

The TEFF-AF (The hEart oF Ethiopia: Focus on Atrial Fibrillation) study conducted AF screening using a single-lead electrocardiogram device (KardiaMobile) on willing community participants at the Soddo Christian Hospital, Ethiopia. Participants' clinical parameters and medical history were obtained to characterize their risk factor profile, including calculation of CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology Atrial Fibrillation) score.

Results

A total of 3000 Ethiopians (median 31 [interquartile range 25-41] years of age; 65% men) were screened. The participants were generally well educated, from the local region and with a low burden of cardiovascular risk factors. A total of 50 participants had a CHARGE-AF score (5-year AF risk) of ≥2%. AF was detected in 13 (0.43%) individuals (median 50 [interquartile range 36-60] years of age; n = 7 men). The prevalence among participants over 40 years of age was 1% (n = 9 of 930). AF prevalence was higher for older age groups, with ≥70 years of age reaching 6.67% (n = 3 of 45). Population prevalence was estimated to be 234 (95% confidence interval 7-460) per 10,000 persons for ≥60 years of age. Four (31%) of the 13 participants with AF had a CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score of ≥2, and others likely had rheumatic valvular AF, but only 2 of the 13 participants with AF were on oral anticoagulation therapy.

Conclusion

In this semi-rural Ethiopian community of relatively younger participants, AF prevalence was found to be low but increased with increasing age. Mobile single-lead electrocardiogram technology can be used effectively for AF screening in low-resource settings.

Bi-atrial versus left atrial ablation for patients with rheumatic mitral valve disease and non-paroxysmal atrial fibrillation (ABLATION): rationale, design and study protocol for a multicentre randomised controlled trial

INTRODUCTION

Atrial fibrillation (AF) is common in patients with rheumatic mitral valve disease (RMVD) and increase the risk of stroke and death. Bi-atrial or left atrial ablation remains controversial for treatment of AF during mitral valve surgery. The study aims to compare the efficacy and safety of bi-atrial ablation with those of left atrial ablation among patients with RMVD and persistent or long-standing persistent AF.

METHODS AND ANALYSIS

The ABLATION trial (Bi-atrial vs Left Atrial Ablation for Patients with RMVD and Non-paroxysmal AF) is a prospective, multicentre, randomised controlled study. The trial will randomly assign 320 patients with RMVD and persistent or long-standing persistent AF to bi-atrial ablation procedure or left atrial ablation procedure in a 1:1 randomisation. The primary end point is freedom from documented AF, atrial flutter or atrial tachycardia of >30 s at 12 months after surgery off antiarrhythmic drugs. Key secondary end point is the probability of freedom from permanent pacemaker implantation at 12 months after surgery. Secondary outcomes include the probability of freedom from any recurrence of atrial tachyarrhythmias with antiarrhythmic drugs, AF burden, incidence of adverse events and cardiac function documented by echocardiography at 12 months after operation.

ETHICS AND DISSEMINATION

The central ethics committee at Fuwai Hospital approved the ABLATION trial. The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05021601.

Atrial Fibrillation among Patients Admitted to the Department of Internal Medicine in a Tertiary Care Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Atrial fibrillation is one of the commonest arrhythmias with an overall prevalence estimated to be 0.4-1% in the general population. The objective of this study was to find out the prevalence of atrial fibrillation among patients admitted to the Department of Internal Medicine in a tertiary care centre.

METHODS

A descriptive cross-sectional study was conducted among patients admitted to the Department of Internal Medicine of a tertiary care centre from 01 March 2021 to 01 March 2022. Ethical approval was obtained from the Institutional Review Committee (Reference number: IRC-478/2021). Convenience sampling method was used. Data were collected from the hospital records using a semi-structured study proforma including demography, clinical presentation, laboratory investigations, electrocardiogram, 2-dimension echocardiography, and CHA2DS2VASc score. Point estimate and 95% Confidence Interval were calculated.

RESULTS

Among 27,980 patients, atrial fibrillation was found in 185 (0.66%) (0.58-0.77, 95% Confidence Interval). Among them 66 (35.67%) were in the age group of 61-70 years and 97 (52.43%) were females. Dyspnea was present in 149 (80.54%), palpitation in 137 (74.05%) and pedal edema in 117 (63.27%). Valvular atrial fibrillation was seen in 101 (54.59%) and non-valvular atrial fibrillation was seen in 84 (45.41%) patients.

CONCLUSIONS

The prevalence of atrial fibrillation was found to be similar when compared to other studies conducted in similar settings.

Rhythm disorders after isolated mitral valve surgery: Consideration of the variations of the sinoatrial nodal artery in choice of atriotomy

Background: This study aims to investigate the effect of atriotomy approaches applied in mitral valve surgery and variations of the sinoatrial nodal artery on postoperative arrhythmias and the need for a temporary or permanent pacemaker.

Methods: Data of 241 patients (108 males, 133 females, mean age: 53.7±12.3 years; range, 18 to 82 years) who underwent isolated mitral valve surgery with a median sternotomy between January 2009 and December 2019 were retrospectively analyzed. The patients were divided into three groups according to the surgical approach for mitral valve exploration as left atriotomy (n=47), transseptal (n=131), and superior transseptal (n=63). By scanning the hospital records, the origin of the sinoatrial nodal artery was determined in the coronary angiography images obtained before surgery. Postoperative rhythm changes were analyzed based on electrocardiography and telemetry recordings.

Results: Temporary pacing was required in 31 (49.2%) patients in the superior transseptal group, 40 (30.5%) patients in the transseptal group, and 12 (25.5%) patients in the left atriotomy group, indicating a statistically significantly higher rate in the superior transseptal group (p=0.013). Permanent pacemaker implantation was required in only one patient (superior transseptal), indicating no significant difference among the groups. The first-degree atrioventricular block was seen in 28 (44.4%) patients in the superior transseptal group, 42 (32.1%) patients in the transseptal group, and 13 (27.7%) patients in the left atriotomy group (p=0.130). The PR interval in the postoperative period was longer in the superior transseptal group than in the left atriotomy group in patients with the sinoatrial nodal artery originating from the right coronary artery (p=0.049). No significant difference was observed among the surgical approaches regarding the PR interval in patients with the sinoatrial nodal artery originating from the left circumflex coronary artery after surgery.

Conclusion: We believe that the choice of atriotomy in isolated mitral valve surgery and sinoatrial nodal artery variations do not affect permanent arrhythmia alone. Still, the superior transseptal approach causes the electrical conduction to slow down temporarily more than the left atriotomy and transseptal method.

Rheumatic Myocarditis: A Poorly Recognized Etiology of Left Ventricular Dysfunction in Valvular Heart Disease Patients

Background: Heart failure occurs in ~10% of patients with acute rheumatic fever (RF), and several studies have shown that cardiac decompensation in RF results primarily from valvular disease and is not due to primary myocarditis. However, the literature on this topic is scarce, and a recent case series has shown that recurrent RF can cause ventricular dysfunction even in the absence of valvular heart disease. Methods: The present study evaluated the clinical, laboratory and imaging characteristics of 25 consecutive patients with a clinical diagnosis of myocarditis confirmed by 18F-FDG PET/CT or gallium-67 cardiac scintigraphy and RF reactivation according to the revised Jones Criteria. Patients underwent three sequential echocardiograms at (1) baseline, (2) during myocarditis and (3) post corticosteroid treatment. Patients were divided according to the presence (Group 1) or absence (Group 2) of reduced left ventricular ejection fraction (LVEF) during myocarditis episodes. Results: The median age was 42 (17-51) years, 64% of patients were older than 40 years, and 64% were women. Between Group 1 (n = 16) and in Group 2 (n = 9), there were no demographic, echocardiographic or laboratory differences except for NYHA III/IV heart failure (Group 1: 100.0% vs. Group 2: 50.0%; p = 0.012) and LVEF (30 [25-37] vs. 56 [49-62]%, respectively; p < 0.001), as expected. Group 1 patients showed a significant reduction in LVEF during carditis with further improvement after treatment. There was no correlation between LVEF and valvular dysfunction during myocarditis. Among all patients, 19 (76%) underwent 18F-FDG PET/CT, with a positive scan in 68.4%, and 21 (84%) underwent gallium-67 cardiac scintigraphy, with positive uptake in 95.2%, there was no difference between these groups. Conclusion: Myocarditis due to rheumatic fever reactivation can cause left ventricular dysfunction despite valvular disease, and it is reversible after corticosteroid treatment.