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Papakonstantinou PE, Kalogera V, Charitos D, Polyzos D, Benia D, Batsouli A, Lampropoulos K, Xydonas S, Gupta D, Lip GYH. When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer. Blood Rev 2024; 65:101171. [PMID: 38310007 DOI: 10.1016/j.blre.2024.101171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/05/2024]
Abstract
Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.
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Affiliation(s)
| | - Vasiliki Kalogera
- Third Cardiology Department, School of Medicine, National and Kapodistrian University of Athens, "Sotiria" Chest Hospital, Mesogeion Ave 152, 11527 Athens, Greece
| | - Dimitrios Charitos
- First Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitrios Polyzos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitra Benia
- Cardiology Department, General Hospital-Health Center of Kithira, Aroniadika, 80200 Kithira Island, Greece
| | - Athina Batsouli
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Konstantinos Lampropoulos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece; School of Medicine, European University of Cyprus, Diogenous 6, 2404 Egkomi, Cyprus
| | - Sotirios Xydonas
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, L14 3PE Liverpool, United Kingdom.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Thomas Dr., L14 3PE Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Aalborg, Denmark.
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Calvert P, Ding WY, Mills MT, Snowdon R, Borbas Z, Modi S, Hall M, Morgan M, Clarkson N, Chackochen S, Barton J, Kemp I, Luther V, Gupta D. Durability of Thermal Pulmonary Vein Isolation in Persistent Atrial Fibrillation Assessed by Mandated Repeat Invasive Study. Heart Rhythm 2024:S1547-5271(24)02388-9. [PMID: 38636929 DOI: 10.1016/j.hrthm.2024.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND No study has assessed durability of pulmonary vein isolation (PVI) with radiofrequency (RF) and Cryoballoon (CB) in patients with persistent AF. These data are especially lacking for those with significantly diseased left atria (LA). OBJECTIVE To assess PVI durability in patients with significant LA disease and compare reconnection rates between RF and CB. METHODS 44 Patients (mean age 63, 77% male, median time since AF diagnosis 22.5 months, median indexed LA volume 36 ml/m2) were randomised 1:1 to RF (StablePoint catheter, Boston Scientific) or CB (Arctic Front Advance, Medtronic) PVI. A redo procedure using ultra high-density electroanatomic mapping (Rhythmia, Boston Scientific) was mandated at 2 months, where PV reconnections were identified and re-isolated. RESULTS 38 patients underwent both procedures (n=17 CB, n=21 RF). Index RF procedures were longer (median 158 vs 97min; p<0.001) but required less fluoroscopy (9.5 vs 23min; p<0.001). At the index RF procedure, median 47% of LA myocardium had voltage <0.5mV, suggesting half of the mapped LA comprised scar. PV reconnection was observed in 73/152 (48.0%) PVs and was more frequent with CB (58.8%) vs RF (39.3%), p=0.022. Reconnection of at least 1 PV was detected in >75% of patients. Significantly more ablation was required at redo to reisolate PVs in the CB arm (median 10.8 vs 1.2min; p<0.001). CONCLUSION PVI durability may be poor in those with significant LA scarring and dilatation, even with modern thermal ablation technologies. RF resulted in significantly better PVI durability than CB in this complex population. CLINICAL TRIAL REGISTRATION NCT04111731.
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Affiliation(s)
- Peter Calvert
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Wern Yew Ding
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Mark T Mills
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Richard Snowdon
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Zoltan Borbas
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Simon Modi
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Mark Hall
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Maureen Morgan
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | | | | | - Janet Barton
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Ian Kemp
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.
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Calvert P, Koniari I, Mills MT, Ashrafi R, Snowdon R, Gupta D, Luther V. Lesion metrics and 12-month outcomes of very-high power short duration radiofrequency ablation (90W/4 s) under mild conscious sedation. J Cardiovasc Electrophysiol 2024. [PMID: 38571287 DOI: 10.1111/jce.16269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/04/2024] [Accepted: 03/21/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Pulmonary vein isolation (PVI) is often performed under general anaesthesia (GA) or deep sedation. Anaesthetic availability is limited in many centers, and deep sedation is prohibited in some countries without anaesthetic support. Very high-power short duration (vHPSD-90W/4 s) PVI using the Q-Dot catheter is generally well tolerated under mild conscious sedation (MCS) though an understanding of catheter stability and long-term effectiveness is lacking. We analyzed lesion metrics and 12-month freedom from atrial arrythmia with this approach. METHODS Our approach to radiofrequency (RF) PVI under MCS is standardized and includes a single catheter approach with a steerable sheath. We identified patients undergoing Q-Dot RF PVI between March 2021 and December 2022 in our center, comparing those undergoing vHPSD ablation under MCS (90W/MCS) against those undergoing 50 W ablation under GA (50 W/GA) up to 12 months of follow-up. Data were extracted from clinical records and the CARTO system. RESULTS Eighty-three patients met our inclusion criteria (51 90W/MCS; 32 50 W/GA). Despite shorter ablation times (353 vs. 886 s; p < .001), the 90 W/MCS group received more lesions (median 87 vs. 58, p < .001), resulting in similar procedure times (149.3 vs. 149.1 min; p = .981). PVI was achieved in all cases, and first pass isolation rates were similar (left wide antral circumferential ablation [WACA] 82.4% vs. 87.5%, p = .758; right WACA 74.5% vs. 78.1%, p = .796; 90 W/MCS vs. 50 W/GA respectively). Analysis of 6647 ablation lesions found similar mean impedance drops (10.0 ± 1.9 Ω vs. 10.0 ± 2.2 Ω; p = .989) and mean contact force (14.6 ± 2.0 g vs. 15.1 ± 1.6 g; p = .248). Only median 2.5% of lesions in the 90 W/MCS cohort failed to achieve ≥ 5 Ω drop. In the 90 W/MCS group, there were no procedural related complications, and 12-month freedom from atrial arrhythmia was observed in 78.4%. CONCLUSION vHPSD PVI is feasible under MCS, with encouraging acute and long-term procedural outcomes. This provides a compelling option for centers with limited anaesthetic support.
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Affiliation(s)
- Peter Calvert
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | | | | | | | | | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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Chen Y, Gue Y, Calvert P, Gupta D, McDowell G, Azariah JL, Namboodiri N, Bucci T, Jabir A, Tse HF, Chao TF, Lip GYH, Bahuleyan CG. Predicting stroke in Asian patients with atrial fibrillation using machine learning: A report from the KERALA-AF registry, with external validation in the APHRS-AF registry. Curr Probl Cardiol 2024; 49:102456. [PMID: 38346609 DOI: 10.1016/j.cpcardiol.2024.102456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/08/2024] [Indexed: 02/16/2024]
Abstract
Atrial fibrillation (AF) is a significant risk factor for stroke. Based on the higher stroke associated with AF in the South Asian population, we constructed a one-year stroke prediction model using machine learning (ML) methods in KERALA-AF South Asian cohort. External validation was performed in the prospective APHRS-AF registry. We studied 2101 patients and 83 were to patients with stroke in KERALA-AF registry. The random forest showed the best predictive performance in the internal validation with receiver operator characteristic curve (AUC) and G-mean of 0.821 and 0.427, respectively. In the external validation, the light gradient boosting machine showed the best predictive performance with AUC and G-mean of 0.670 and 0.083, respectively. We report the first demonstration of ML's applicability in an Indian prospective cohort, although the more modest prediction on external validation in a separate multinational Asian registry suggests the need for ethnic-specific ML models.
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Affiliation(s)
- Yang Chen
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ying Gue
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Garry McDowell
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Jinbert Lordson Azariah
- Department of Clinical Research, Ananthapuri Hospitals and Research Institute, Thiruvananthapuram, India; Department of Research, Global Institute of Public Health, Trivandrum, India
| | - Narayanan Namboodiri
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
| | - A Jabir
- Lisie Heart Institute, Ernakulam, India
| | - Hung Fat Tse
- Division of Cardiology, Department of Medicine, School of Clinical Medicine; Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Tze-Fan Chao
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, DK-9220, Denmark.
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Junejo RT, Gupta D, Snowdon RL, Lip GYH, Fisher JP. Relationship of Warfarin and Apixaban with Vascular Function in Patients with Atrial Fibrillation. J Vasc Res 2024; 61:59-67. [PMID: 38447552 PMCID: PMC10997243 DOI: 10.1159/000535618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/30/2023] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is associated with endothelial damage/dysfunction. Herein, we tested the hypothesis that brachial artery flow-mediated dilation (FMD) is superior in AF patients taking apixaban compared to warfarin. METHODS AF patients on apixaban (n = 46; 67 [7] years; mean [standard deviation]; 15 women) and warfarin (n = 27; 73 [9] years (p < 0.01); 11 women) were recruited. Duplex Doppler ultrasound imaging was undertaken during baseline (2 min), cuff inflation (5 min), and following cuff deflation (3 min). FMD was defined as peak increase in brachial artery diameter following cuff deflation and analysed as percentage change in diameter, as a ratio of FMD, shear rate area under the curve (SRAUC; FMD-to-SRAUC), and using SRAUC as a covariate (FMDSR). RESULTS Baseline artery diameter (4.96 [1.14] vs. 4.89 [0.88] mm), peak diameter (5.12 [1.17] vs. 5.14 [0.93] mm), and FMDSR (3.89 [3.62] vs. 4.80 [3.60] %) were not different between warfarin and apixaban (p > 0.05; analysis of covariance with age, CHA2DS2-VASc, years since AF diagnosis, number of diabetics, alcohol drinkers, and units of alcohol consumed per week as covariates). Stepwise multiple regression identified independent association of fibrillation, hypertension, and increased age with FMD. CONCLUSION AF patients on warfarin and apixaban exhibit similar endothelium-dependent vasodilation. Increased blood pressure negatively impacts vasodilator capacity in AF patients.
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Affiliation(s)
- Rehan T Junejo
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK,
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK,
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Richard L Snowdon
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - James P Fisher
- Department of Physiology, Faculty of Medical and Health Sciences, Manaaki Manawa - The Centre for Heart Research, University of Auckland, Auckland, New Zealand
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Betts TR, Calvert PA, Graham LN, Clesham GJ, Gunarathne A, Clapp B, Gupta D, Kovac J, Newton JD, Hildick-Smith D. Left Atrial Appendage Occlusion: British Cardiovascular Intervention Society and British Heart Rhythm Society Position Statement. Interv Cardiol 2024; 19:e02. [PMID: 38532943 PMCID: PMC10964289 DOI: 10.15420/icr.2023.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/13/2023] [Indexed: 03/28/2024] Open
Abstract
Percutaneous left atrial appendage occlusion aims to reduce the risk of stroke in patients with AF, particularly those who are not good candidates for systemic anticoagulation. The procedure has been studied in large international randomised trials and registries and was approved by the National Institute for Health and Care Excellence in 2014 and by NHS England in 2018. This position statement summarises the evidence for left atrial appendage occlusion and presents the current indications. The options and consensus on best practice for pre-procedure planning, undertaking a safe and effective implant and appropriate post-procedure management and follow-up are described. Standards regarding procedure volume for implant centres and physicians, the role of multidisciplinary teams and audits are highlighted.
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Affiliation(s)
- Tim R Betts
- Cardiac Electrophysiology, Oxford University Hospitals NHS Foundation TrustOxford, UK
| | - Patrick A Calvert
- Cardiology Service, Royal Papworth Hospital NHS Foundation TrustCambridge, UK
| | - Lee N Graham
- Yorkshire Heart Centre, Leeds General InfirmaryLeeds, UK
| | - Gerald J Clesham
- Essex Cardiothoracic Centre, Basildon University HospitalBasildon, UK
| | - Ashan Gunarathne
- Trent Cardiac Centre, Nottingham University Hospitals NHS TrustNottingham, UK
| | - Brian Clapp
- Cardiology Service, Guy's and St Thomas' NHS Foundation TrustLondon, UK
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, University of LiverpoolLiverpool, UK
| | - Jan Kovac
- Glenfield Hospital, University Hospitals of Leicester NHS TrustLeicester, UK
| | - James D Newton
- Cardiothoracic Services, Oxford University Hospitals NHS Foundation TrustOxford, UK
| | - David Hildick-Smith
- Sussex Cardiac Centre, University Hospitals Sussex NHS Foundation TrustBrighton, UK
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Kanthasamy V, Schilling R, Zongo O, Khan K, Earley M, Monk V, Hunter R, Mangiafico V, Ang R, Creta A, Aluwhalia N, Honarbakhsh S, Dhinoja M, Gupta D, Finlay M. Feasibility of double-blinded, placebo-controlled interventional study for assessing catheter ablation efficacy in persistent atrial fibrillation: Insights from the ORBITA AF feasibility study. Am Heart J 2024; 269:56-71. [PMID: 38109985 DOI: 10.1016/j.ahj.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/28/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND To date, there are no randomized, double-blinded clinical trials comparing catheter ablation to DC cardioversion (DCCV) with medical therapy in patients with persistent atrial fibrillation (PersAF). Conducting a large-scale trial to address this question presents considerable challenges, including recruitment, blinding, and implementation. We conducted a pilot study to evaluate the feasibility of conducting a definitive placebo-controlled trial. METHODS This prospective trial was carried out at Barts Heart Centre, United Kingdom, employing a randomized, double-blinded, placebo-controlled design. Twenty patients with PersAF (duration <2 years) were recruited, representing 10% of the proposed larger trial as determined by a power calculation. The patients were randomized in a 1:1 ratio to receive either PVI ± DCCV (PVI group) or DCCV + Placebo (DCCV group). The primary endpoint of this feasibility study was to evaluate patient blinding. Patients remained unaware of their treatment allocation until end of study. RESULTS During the study, 35% of patients experienced recurrence of PersAF prior to completion of 12 months follow-up. Blinding was successfully maintained amongst both patients and medical staff. The DCCV group had a trend to higher recurrence and repeat procedure rate compared to the PVI group (recurrence of PersAF 60% vs 30%; p = .07 and repeat procedure 70% vs 40%; p = .4). The quality of life experienced by individuals in the PVI group showed improvement, as evidenced by enhanced scores on the AF specific questionnaire (AF PROMS) (3 [±4] vs 21 [±8]) and SF-12 mental-component raw score (51.4 [±7] vs 43.24 [±15]) in patients who maintained sinus rhythm at 12 months. CONCLUSION This feasibility study establishes the potential for conducting a blinded, placebo-controlled trial to evaluate the efficacy of PVI versus DCCV in patients with PersAF.
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Affiliation(s)
- Vijayabharathy Kanthasamy
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Richard Schilling
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Olivier Zongo
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Kamran Khan
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mark Earley
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Vivienne Monk
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Ross Hunter
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Valentina Mangiafico
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Richard Ang
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Antonio Creta
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Nikhil Aluwhalia
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Shohreh Honarbakhsh
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mehul Dhinoja
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Malcolm Finlay
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.
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Ding WY, Calvert P, Lip GYH, Gupta D. Novel stroke prevention strategies following catheter ablation for atrial fibrillation. Rev Esp Cardiol (Engl Ed) 2024:S1885-5857(24)00071-9. [PMID: 38428582 DOI: 10.1016/j.rec.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/14/2024] [Indexed: 03/03/2024]
Abstract
Stroke prevention following successful catheter ablation of atrial fibrillation remains a controversial topic. Oral anticoagulation is associated with a significant reduction in stroke risk in the general atrial fibrillation population but may be associated with an increased risk of major bleeding, and the benefit: risk ratio must be considered. Improvement in successful catheter ablation and widespread use of cardiac monitoring devices may allow for novel anticoagulation strategies in a subset of patients with atrial fibrillation, which may optimize stroke prevention while minimizing bleeding risk. In this review, we discuss stroke risk in atrial fibrillation and the effects of successful catheter ablation on thromboembolic risk. We also explore novel strategies for stroke prevention following successful catheter ablation.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Centre for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Eppinger S, Piayda K, Galea R, Sandri M, Maarse M, Güner A, Karabay CY, Pershad A, Ding WY, Aminian A, Akin I, Davtyan KV, Chugunov IA, Marijon E, Rosseel L, Schmidt TR, Amabile N, Korsholm K, Lund J, Guerios E, Amat-Santos IJ, Boccuzzi G, Ellis CR, Sabbag A, Ebelt H, Clapp B, Assa HV, Levi A, Ledwoch J, Lehmann S, Lee OH, Mark G, Schell W, Della Rocca DG, Natale A, de Backer O, Kefer J, Esteban PP, Abelson M, Ram P, Moceri P, Galache Osuna JG, Alvarez XM, Cruz-Gonzalez I, de Potter T, Ghassan M, Osadchiy A, Chen W, Goyal SK, Giannini F, Rivero-Ayerza M, Afzal S, Jung C, Skurk C, Langel M, Spence M, Merkulov E, Lempereur M, Shin SY, Mesnier J, McKinney HL, Schuler BT, Armero S, Gheorghe L, Ancona MBM, Santos L, Mansourati J, Nombela-Franco L, Nappi F, Kühne M, Gaspardone A, van der Pals J, Montorfano M, Fernández-Armenta J, Harvey JE, Rodés-Cabau J, Klein N, Sabir SA, Kim JS, Cook S, Kornowski R, Saraste A, Nielsen-Kudsk JE, Gupta D, Boersma L, Räber L, Sievert K, Sievert H, Bertog S. Embolization of percutaneous left atrial appendage closure devices: timing, management and clinical outcomes. Cardiovasc Revasc Med 2024:S1553-8389(24)00067-8. [PMID: 38448258 DOI: 10.1016/j.carrev.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/25/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Left atrial appendage (LAA) occluder embolization is an infrequent but serious complication. OBJECTIVES We aim to describe timing, management and clinical outcomes of device embolization in a multi-center registry. METHODS Patient characteristics, imaging findings and procedure and follow-up data were collected retrospectively. Device embolizations were categorized according to 1) timing 2) management and 3) clinical outcomes. RESULTS Sixty-seven centers contributed data. Device embolization occurred in 108 patients. In 70.4 % of cases, it happened within the first 24 h of the procedure. The device was purposefully left in the LA and the aorta in two (1.9 %) patients, an initial percutaneous retrieval was attempted in 81 (75.0 %) and surgery without prior percutaneous retrieval attempt was performed in 23 (21.3 %) patients. Two patients died before a retrieval attempt could be made. In 28/81 (34.6 %) patients with an initial percutaneous retrieval attempt a second, additional attempt was performed, which was associated with a high mortality (death in patients with one attempt: 2.9 % vs. second attempt: 21.4 %, p < 0.001). The primary outcome (bailout surgery, cardiogenic shock, stroke, TIA, and/or death) occurred in 47 (43.5 %) patients. Other major complications related to device embolization occurred in 21 (19.4 %) patients. CONCLUSIONS The majority of device embolizations after LAA closure occurs early. A percutaneous approach is often the preferred method for a first rescue attempt. Major adverse event rates, including death, are high particularly if the first retrieval attempt was unsuccessful. CONDENSED ABSTRACT This dedicated multicenter registry examined timing, management, and clinical outcome of device embolization. Early embolization (70.4 %) was most frequent. As a first rescue attempt, percutaneous retrieval was preferred in 75.0 %, followed by surgical removal (21.3 %). In patients with a second retrieval attempt a higher mortality (death first attempt: 2.9 % vs. death second attempt: 24.1 %, p < 0.001) was observed. Mortality (10.2 %) and the major complication rate after device embolization were high.
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Affiliation(s)
| | - Kerstin Piayda
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany; Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, Gießen, Germany
| | - Roberto Galea
- Department of Cardiology, Universitätsspital Bern, Bern, Switzerland
| | | | - Moniek Maarse
- Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Hospital, Istanbul, Turkey
| | - Can Y Karabay
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Education Research Hospital, Istanbul, Turkey
| | - Ashish Pershad
- Department of Cardiology, Banner Health, Phoenix, AZ, USA
| | - Wern Y Ding
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Adel Aminian
- Department of Cardiology, Centre hospitalier universitaire de Charleroi, Charleroi, Belgium
| | - Ibrahim Akin
- Department of Cardiology, Universitätsmedizin Mannheim, Germany
| | - Karapet V Davtyan
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Ivan A Chugunov
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Eloi Marijon
- Department of Cardiology, Hôpital Européen Georges-Pompidou HEGP, Paris, France
| | | | | | - Nicolas Amabile
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Juha Lund
- Heart Center, Turku University Hospital, Turku, Finland
| | - Enio Guerios
- Department of Cardiology, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | | | - Giacomo Boccuzzi
- Department of Cardiology, Ospedale san Giovanni Bosco, Torino, Italy
| | | | - Avi Sabbag
- Department of Cardiology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Henning Ebelt
- Department of Cardiology, Katholisches Krankenhaus St. Nepomuk, Erfurt, Germany
| | - Brian Clapp
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hana Vaknin Assa
- Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Amos Levi
- Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | | | - Sonja Lehmann
- Department of Cardiology, Hôpital Fribourgeois, Fribourg, Switzerland
| | - Oh-Hyun Lee
- Department of Cardiology, Yonsei University Hospital, Yongin, Republic of Korea
| | - George Mark
- The Heart House/Cooper University Camden, NJ, USA
| | - Wendy Schell
- Department of Cardiology, Cooper University Hospital, NJ, USA
| | | | - Andrea Natale
- Department of Cardiology, St David's Medical Center, Austin, TX, USA
| | - Ole de Backer
- Department of Cardiology, Rigshospitalet Copenhagen, Copenhagen, Denmark
| | - Joelle Kefer
- Department of Cardiology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Pablo P Esteban
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Mark Abelson
- Department of interventional Cardiology, Mediclinic Vergelegen, Cape Town, South Africa
| | - Pradhum Ram
- Department of Cardiology, Emory University, Atlanta, GA, USA
| | - Pamela Moceri
- Department of Cardiology, Hopital Pasteur 1, Nice, France
| | | | | | | | | | - Moubarak Ghassan
- Department of Cardiology, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Andrey Osadchiy
- Department of Cardiology, City Hospital #40, St. Petersburg, Russia
| | - Weita Chen
- Department of Cardiology, Taipei Municipal Wanfang Hospital, Taipei, Taiwan
| | | | | | | | - Shazia Afzal
- Department of Cardiology, Heinrich-Heine University, University Hospital, Duesseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Heinrich-Heine University, University Hospital, Duesseldorf, Germany
| | - Carsten Skurk
- Department of Cardiology, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Langel
- Department of Cardiology, Klinikum St. Georg, Leipzig, Germany
| | - Mark Spence
- Department of Cardiology, Royal Victoria Hospital, Belfast Trust, Belfast, UK
| | | | | | - Seung Y Shin
- Cardiovascular & Arrhythmia Center, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Brian T Schuler
- Department of Cardiology, WellSpan York Hospital, York, PA, USA
| | | | - Livia Gheorghe
- Department of Cardiology, Puerta del Mar University Hospital, Cadiz, Spain
| | - Marco B M Ancona
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lino Santos
- Department of Cardiology, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, Portugal
| | | | | | | | - Michael Kühne
- Department of Cardiology, University Hospital Basel, Switzerland
| | | | - Jesper van der Pals
- Department of Cardiology, Lund University and Skane University Hospital, Lund, Sweden
| | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - James E Harvey
- Department of Cardiology, WellSpan York Hospital, York, PA, USA
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Norbert Klein
- Department of Cardiology, Klinikum St. Georg, Leipzig, Germany
| | - Sajjad A Sabir
- Department of Cardiology, Cooper University Hospital, NJ, USA
| | - Jung-Sun Kim
- Department of Cardiology, Yonsei University Hospital, Yongin, Republic of Korea
| | - Stephane Cook
- Department of Cardiology, Hôpital Fribourgeois, Fribourg, Switzerland
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Antti Saraste
- Heart Center, Turku University Hospital, Turku, Finland
| | | | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Lucas Boersma
- Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Lorenz Räber
- Department of Cardiology, Universitätsspital Bern, Bern, Switzerland
| | - Kolja Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany.
| | - Stefan Bertog
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
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Calvert P, Mills MT, Gupta D. Duration of atrial fibrillation: How much is too much? Heart Rhythm 2024:S1547-5271(24)00124-3. [PMID: 38336195 DOI: 10.1016/j.hrthm.2024.01.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, United Kingdom; Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Mark T Mills
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, United Kingdom; Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, United Kingdom; Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom.
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11
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Elsheikh S, Alobaida M, Bucci T, Buckley BJR, Gupta D, Irving G, Hill AM, Lip GYH, Abdul-Rahim AH. Left Atrial Appendage Occlusion Versus Direct Oral Anticoagulants in the Prevention of Ischaemic Stroke in Patients with Atrial Fibrillation. Cerebrovasc Dis 2024:000536546. [PMID: 38310861 DOI: 10.1159/000536546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/15/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction Existing randomised controlled trials assessing the safety and efficacy of left atrial appendage occlusion (LAAO) in atrial fibrillation (AF) were of relatively small sample size, or included patients who could receive oral anticoagulant treatment after device implantation. We compared the outcomes of patients with newly diagnosed AF who received percutaneous LAAO or direct oral anticoagulants (DOAC) treatment, in a large population from a global federated health network (TriNetX). Methods Patients with AF treated with percutaneous LAAO were matched with those treated with DOAC between 1st December 2010 and 1st October 2018. Outcomes were all-cause mortality, ischaemic stroke and intracranial haemorrhage (ICH) at 5 years. Results We included 200 patients with AF, who received either LAAO or DOAC. The risk of all-cause mortality, ischaemic stroke and ICH at 5 years was not significantly different between the two groups (Risk Ratio [RR] for all-cause mortality: 1.52, 95% confidence interval (CI): 0.97- 2.38, RR for ischaemic stroke: 1.09, 95% CI: 0.51- 2.36, and RR for ICH: 1.0, 95% CI: 0.44- 2.30). Conclusion Patients newly diagnosed with AF, eligible for DOAC, showed similar 5-year risk of death, ischemic stroke, and ICH when comparing those who underwent percutaneous LAAO to those receiving DOAC. Future randomised controlled trials are needed to confirm the findings and advise changes in guidelines.
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12
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Gupta D, Rienstra M, van Gelder IC, Fauchier L. Atrial fibrillation: better symptom control with rate and rhythm management. Lancet Reg Health Eur 2024; 37:100801. [PMID: 38362560 PMCID: PMC10866934 DOI: 10.1016/j.lanepe.2023.100801] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 11/07/2023] [Accepted: 11/15/2023] [Indexed: 02/17/2024]
Abstract
Atrial fibrillation (AF) is often associated with limiting symptoms, and with significant impairment in quality of life. As such, treatment strategies aimed at symptom control form an important pillar of AF management. Such treatments include a wide variety of drugs and interventions, including, increasingly, catheter ablation. These strategies can be utilised either singly or in combination, to improve and restore quality of life for patients, and this review covers the current evidence base underpinning their use. In this Review, we discuss the pros and cons of rate vs. rhythm control, while offering practical tips to non-specialists on how to utilise various treatments and counsel patients about all relevant treatment options. These include antiarrhythmic and rate control medications, as well as interventions such as cardioversion, catheter ablation, and pace-and-ablate.
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Affiliation(s)
- Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Isabelle C. van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Laurent Fauchier
- Faculté de Médecine, Centre Hospitalier Universitaire Trousseau, Université François Rabelais, Tours, France
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13
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Calvert P, Ding WY, Griffin M, Bisson A, Koniari I, Fitzpatrick N, Snowdon R, Modi S, Luther V, Mahida S, Waktare J, Borbas Z, Ashrafi R, Todd D, Gupta D. Silent pulmonary veins at redo ablation for atrial fibrillation: Implications and approaches. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01750-w. [PMID: 38261098 DOI: 10.1007/s10840-024-01750-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/14/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Despite promising success rates, redo ablation is sometimes required. At redo, PVs may be found to be isolated (silent) or reconnected. We studied patients with silent vs reconnected PVs at redo and analysed associations with adverse outcomes. METHODS Patients undergoing redo AF ablations between 2013 and 2019 at our institution were included and stratified into silent PVs or reconnected PVs. The primary outcome was a composite of further redo ablation, non-AF ablation, atrioventricular nodal ablation, and death. Secondary outcomes included arrhythmia recurrence. RESULTS A total of 467 patients were included with mean 4.6 ± 1.7 years follow-up, of whom 48 (10.3%) had silent PVs. The silent PV group had had more often undergone >1 prior ablation (45.8% vs 9.8%; p<0.001), had more persistent AF (62.5% vs 41.1%; p=0.005) and had more non-PV ablation performed both at prior ablation procedures and at the analysed redo ablation. The primary outcome occurred more frequently in those with silent PVs (25% vs 13.8%; p=0.053). Arrhythmia recurrence was also more common in the silent PV group (66.7% vs 50.6%; p=0.047). After multivariable adjustment, female sex (aHR 2.35 [95% CI 2.35-3.96]; p=0.001) and ischaemic heart disease (aHR 3.21 [95% CI 1.56-6.62]; p=0.002) were independently associated with the primary outcome, and left atrial enlargement (aHR 1.58 [95% CI 1.20-2.08]; p=0.001) and >1 prior ablation (aHR 1.88 [95% CI 1.30-2.72]; p<0.001) were independently associated with arrhythmia recurrence. Whilst a finding of silent PVs was not itself significant after multivariable adjustment, this provides an easily assessable parameter at clinically indicated redo ablation which informs the clinician of the likelihood of a worse future prognosis. CONCLUSIONS Patients with silent PVs at redo AF ablation have worse clinical outcomes.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Michael Griffin
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Arnaud Bisson
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
- Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Ioanna Koniari
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Noel Fitzpatrick
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Richard Snowdon
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Simon Modi
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Johan Waktare
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Zoltan Borbas
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Reza Ashrafi
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Derick Todd
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK.
- Department of Cardiology, Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE, UK.
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14
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Mesnier J, Simard T, Jung RG, Lehenbauer KR, Piayda K, Pracon R, Jackson GG, Flores-Umanzor E, Faroux L, Korsholm K, Chun JKR, Chen S, Maarse M, Montrella K, Chaker Z, Spoon JN, Pastormerlo LE, Meincke F, Sawant AC, Moldovan CM, Qintar M, Aktas MK, Branca L, Radinovic A, Ram P, El-Zein RS, Flautt T, Ding WY, Sayegh B, Benito-González T, Lee OH, Badejoko SO, Paitazoglou C, Karim N, Zaghloul AM, Agarwal H, Kaplan RM, Alli O, Ahmed A, Suradi HS, Knight BP, Alla VM, Panaich SS, Wong T, Bergmann MW, Chothia R, Kim JS, Pérez de Prado A, Bazaz R, Gupta D, Valderrábano M, Sanchez CE, El Chami MF, Mazzone P, Adamo M, Ling F, Wang DD, O'Neill W, Wojakowski W, Pershad A, Berti S, Spoon DB, Kawsara A, Jabbour G, Boersma LVA, Schmidt B, Nielsen-Kudsk JE, Freixa X, Ellis CR, Fauchier L, Demkow M, Sievert H, Main ML, Hibbert B, Holmes DR, Alkhouli M, Rodés-Cabau J. Persistent and Recurrent Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes. JACC Cardiovasc Interv 2023; 16:2722-2732. [PMID: 38030358 DOI: 10.1016/j.jcin.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Scarce data exist on the evolution of device-related thrombus (DRT) after left atrial appendage closure (LAAC). OBJECTIVES This study sought to assess the incidence, predictors, and clinical impact of persistent and recurrent DRT in LAAC recipients. METHODS Data were obtained from an international multicenter registry including 237 patients diagnosed with DRT after LAAC. Of these, 214 patients with a subsequent imaging examination after the initial diagnosis of DRT were included. Unfavorable evolution of DRT was defined as either persisting or recurrent DRT. RESULTS DRT resolved in 153 (71.5%) cases and persisted in 61 (28.5%) cases. Larger DRT size (OR per 1-mm increase: 1.08; 95% CI: 1.02-1.15; P = 0.009) and female (OR: 2.44; 95% CI: 1.12-5.26; P = 0.02) were independently associated with persistent DRT. After DRT resolution, 82 (53.6%) of 153 patients had repeated device imaging, with 14 (17.1%) cases diagnosed with recurrent DRT. Overall, 75 (35.0%) patients had unfavorable evolution of DRT, and the sole predictor was average thrombus size at initial diagnosis (OR per 1-mm increase: 1.09; 95% CI: 1.03-1.16; P = 0.003), with an optimal cutoff size of 7 mm (OR: 2.51; 95% CI: 1.39-4.52; P = 0.002). Unfavorable evolution of DRT was associated with a higher rate of thromboembolic events compared with resolved DRT (26.7% vs 15.1%; HR: 2.13; 95% CI: 1.15-3.94; P = 0.02). CONCLUSIONS About one-third of DRT events had an unfavorable evolution (either persisting or recurring), with a larger initial thrombus size (particularly >7 mm) portending an increased risk. Unfavorable evolution of DRT was associated with a 2-fold higher risk of thromboembolic events compared with resolved DRT.
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Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Trevor Simard
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Richard G Jung
- Capital Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kyle R Lehenbauer
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Kerstin Piayda
- CardioVascular Center Frankfurt, Frankfurt, Germany; Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, Gießen, Germany
| | - Radoslaw Pracon
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | | | - Eduardo Flores-Umanzor
- Department of Cardiology, Hospital Clínic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Julian K R Chun
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markuskrankenhaus, Frankfurt, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markuskrankenhaus, Frankfurt, Germany
| | - Moniek Maarse
- Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; LB Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Kristi Montrella
- Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh, Altoona, Pennsylvania, USA
| | - Zakeih Chaker
- Division of Cardiology, West Virginia School of Medicine, Morgantown, West Virginia, USA
| | - Jocelyn N Spoon
- International Heart Institute of Montana, Missoula, Montana, USA
| | - Luigi E Pastormerlo
- Fondazione Toscana Gabriele Monasterio Massa, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Carmen M Moldovan
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Mohammed Qintar
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA; Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan
| | - Mehmet K Aktas
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Luca Branca
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Radinovic
- Arrhythmology Department, San Raffaele University Hospital, Milan, Italy
| | - Pradhum Ram
- Emory University Hospital, Atlanta, Georgia, USA
| | - Rayan S El-Zein
- Division of Cardiology, OhioHealth Doctors Hospital/OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | | | - Wern Yew Ding
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Bassel Sayegh
- Heart, Lung and Vascular Institute, Excela Health, Independence Health System, Pittsburgh, Pennsylvania, USA
| | | | - Oh-Hyun Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Solomon O Badejoko
- Division of Internal Medicine, St Joseph's Medical Center (Dignity Health), Stockton, California, USA
| | | | - Nabeela Karim
- Royal Brompton and Harefield Hospitals, Part of Guys' and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Ahmed M Zaghloul
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | - Rachel M Kaplan
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Oluseun Alli
- Division of Cardiology, Novant Health Heart and Vascular Institute, Charlotte, North Carolina, USA
| | - Aamir Ahmed
- Rush University Medical Center, Chicago, Illinois, USA
| | | | - Bradley P Knight
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Venkata M Alla
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Sidakpal S Panaich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Tom Wong
- Royal Brompton and Harefield Hospitals, Part of Guys' and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | | | - Rashaad Chothia
- Division of Internal Medicine, St Joseph's Medical Center (Dignity Health), Stockton, California, USA
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Raveen Bazaz
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Carlos E Sanchez
- Division of Cardiology, OhioHealth Doctors Hospital/OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | | | - Patrizio Mazzone
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marianna Adamo
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Fred Ling
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Dee Dee Wang
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - William O'Neill
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Wojtek Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Ashish Pershad
- Chandler Regional Medical Center, Chandler, Arizona, USA
| | - Sergio Berti
- Fondazione Toscana Gabriele Monasterio Massa, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Daniel B Spoon
- International Heart Institute of Montana, Missoula, Montana, USA
| | - Akram Kawsara
- Division of Cardiology, West Virginia School of Medicine, Morgantown, West Virginia, USA
| | - George Jabbour
- Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh, Altoona, Pennsylvania, USA
| | - Lucas V A Boersma
- Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; LB Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markuskrankenhaus, Frankfurt, Germany
| | | | - Xavier Freixa
- Department of Cardiology, Hospital Clínic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | | | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau Faculté de Médecine, Université François Rabelais, Tours, France
| | - Marcin Demkow
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Horst Sievert
- Heart, Lung and Vascular Institute, Excela Health, Independence Health System, Pittsburgh, Pennsylvania, USA
| | - Michael L Main
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Benjamin Hibbert
- Capital Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Department of Cardiology, Hospital Clínic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain.
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Mills MT, Calvert P, Velavan P, Lip GYH, Gupta D. Concurrent percutaneous left atrial appendage occlusion and catheter ablation for atrial fibrillation: State-of-the-art review. Trends Cardiovasc Med 2023:S1050-1738(23)00100-7. [PMID: 37981202 DOI: 10.1016/j.tcm.2023.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
Stroke prevention and symptom control are two integral pillars in atrial fibrillation (AF) management. Percutaneous left atrial appendage occlusion (LAAO) is effective at reducing stroke risk in high-risk patients with AF who cannot tolerate oral anticoagulant therapy, whilst catheter ablation is effective at reducing AF burden and improving quality-of-life in patients who remain symptomatic despite medical therapy. If both procedures are indicated in an individual patient, they have traditionally been performed on separate occasions, due to long cumulative procedural times, itself associated with thromboembolic risk. Recently, with the advancement of procedural techniques, the concept of concurrent LAAO and AF catheter ablation has gained traction. This review summarises the evidence for and against concurrent LAAO and AF catheter ablation, discussing procedural considerations, including procedural sequencing and post-procedural antithrombotic therapy, safety and efficacy outcomes, and future directions in the field.
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Affiliation(s)
- Mark T Mills
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | - Periaswamy Velavan
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK.
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16
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Boga M, Suhai FI, Orbán G, Salló Z, Nagy KV, Szegedi L, Jokkel Z, Csőre J, Osztheimer I, Perge P, Gupta D, Merkely B, Gellér L, Szegedi N. Incidence and predictors of stroke and silent cerebral embolism following very high-power short-duration atrial fibrillation ablation. Europace 2023; 25:euad327. [PMID: 37931067 PMCID: PMC10653180 DOI: 10.1093/europace/euad327] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/22/2023] [Accepted: 10/02/2023] [Indexed: 11/08/2023] Open
Abstract
AIMS Cerebral thrombo-embolism is a dreaded complication of pulmonary vein isolation (PVI) for atrial fibrillation; its surrogate, silent cerebral embolism (SCE) can be detected by diffusion-weighted brain magnetic resonance imaging (bMRI). Initial investigations have raised a concern that very high-power, short-duration (vHPSD; 90 W/4 s) temperature-controlled PVI with the QDOT Micro catheter may be associated with a higher incidence of SCE compared with low-power long-duration ablation. We aimed to assess the incidence of procedural complications of vHPSD PVI with an emphasis on cerebral safety. METHODS AND RESULTS We enrolled 328 consecutive patients undergoing their PVI procedure using vHPSD. A subgroup of 61 consecutive patients underwent diffusion-weighted bMRI within 24 h of the procedure, and incidence and predictors of SCE were studied. The mean procedure time and left atrial dwell time for the overall cohort were 69.6 ± 24.1 and 46.5 ± 21.5 min, respectively. First-pass isolation was achieved in 82%. No stroke or transient ischaemic attack occurred. Silent cerebral embolism was identified in 5 of 61 patients (8.2%). Silent cerebral embolism following procedures was significantly associated with lower baseline generator impedance (105.8 vs. 112.6 Ω, P < 0.0001) and with intermittent loss of catheter-tissue contact during ablation (14.1% vs. 6.1%, P < 0.0001). CONCLUSION Very high-power, short-duration PVI is a safe technique with an excellent acute success rate. Silent cerebral embolism incidence in our cohort was below the previously reported range, with no clinically overt cerebral complications. Lower baseline generator impedance and loss of contact during ablation may contribute to a higher risk of SCEs.
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Affiliation(s)
- Márton Boga
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Ferenc Imre Suhai
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Gábor Orbán
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Zoltán Salló
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Klaudia Vivien Nagy
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Levente Szegedi
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Zsófia Jokkel
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Judit Csőre
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - István Osztheimer
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Péter Perge
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, UK
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
| | - Nándor Szegedi
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68., Budapest 1122, Hungary
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Lip GYH, Mills MT, Gupta D. The quest to refine atrial fibrillation-related stroke risk stratification: could the answer lie in left atrial appendage angiography? EUROINTERVENTION 2023; 19:625-627. [PMID: 37872802 PMCID: PMC10587838 DOI: 10.4244/eij-e-23-00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, UK; Liverpool John Moores University, Liverpool, UK; and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Mark T Mills
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, UK; Liverpool John Moores University, Liverpool, UK; and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, UK; Liverpool John Moores University, Liverpool, UK; and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
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Calvert P, Lip GYH, Gupta D. Radiofrequency catheter ablation of atrial fibrillation: A review of techniques. Trends Cardiovasc Med 2023; 33:405-415. [PMID: 35421538 DOI: 10.1016/j.tcm.2022.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/21/2022] [Accepted: 04/04/2022] [Indexed: 11/24/2022]
Abstract
Ablation of atrial fibrillation is a key area of current research. A multitude of techniques have been tested, some of which are poorly evidenced and not recommended in routine clinical practice whilst others are more promising. Additionally, a plethora of issues exist when researching ablation techniques, from control arm ablation strategy to the relevance of outcome measures. In this review article, we discuss these issues in the context of the current evidence base.
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Affiliation(s)
- Peter Calvert
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Gregory Y H Lip
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Clinical Medicine, Aalborg University, Denmark
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK.
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Calvert P, Gupta D, Proietti R. SGLT2 Inhibitors and Catheter Ablation for Atrial Fibrillation: Go With the Flow-zin? JACC Clin Electrophysiol 2023; 9:2119-2121. [PMID: 37676204 DOI: 10.1016/j.jacep.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/30/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Heart and Chest Hospital, National Health Service Foundation Trust, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Heart and Chest Hospital, National Health Service Foundation Trust, Liverpool, United Kingdom
| | - Riccardo Proietti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Heart and Chest Hospital, National Health Service Foundation Trust, Liverpool, United Kingdom.
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20
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Kailey B, Kemp I, Taylor M, Crooks J, Katritsis G, Koa-Wing M, Jamil-Copley S, Linton N, Kanagaratnam P, Gupta D, Luther V. Ripple AT Plus - isthmus-guided vs conventional ablation in the treatment of scar-related atrial tachycardia: study protocol for a randomised controlled trial. J Interv Card Electrophysiol 2023; 66:1533-1539. [PMID: 37594646 PMCID: PMC10547628 DOI: 10.1007/s10840-023-01607-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/11/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Catheter ablation is routinely used to treat scar-related atrial tachycardia (s-AT). Conventional ablation often involves creating anatomical "lines" that transect myocardial tissue supporting reentry. This can be extensive, creating iatrogenic scar as a nidus for future reentry, and may account for arrhythmia recurrence. High-density mapping may identify "narrower isthmuses" requiring less ablation, with ripple mapping proven to be an effective approach in identifying. This trial explores whether ablation of narrower isthmuses in s-AT, defined using ripple mapping, results in greater freedom from arrhythmia recurrence compared to conventional ablation. METHODS The Ripple-AT-Plus trial (registration ClinicalTrials.gov , NCT03915691) is a prospective, multicentre, single-blinded, randomised controlled trial with 12-month follow-up. Two hundred s-AT patients will be randomised in a 1:1 fashion to either "ripple mapping-guided isthmus ablation" vs conventional ablation on the CARTO3 ConfiDENSE system (Biosense Webster). The primary outcome will compare recurrence of any atrial arrhythmia. Multicentre data will be analysed over a secure web-based cloud-storage and analysis software (CARTONETTM). CONCLUSION This is the first trial that considers long-term patient outcomes post s-AT ablation, and whether targeting narrower isthmuses in the era of high density is optimal.
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Affiliation(s)
- Balrik Kailey
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Ian Kemp
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
| | - Martika Taylor
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
| | - Jennifer Crooks
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
| | | | - Michael Koa-Wing
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | | | - Nick Linton
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Prapa Kanagaratnam
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
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21
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Vinter N, Calvert P, Kronborg MB, Cosedis-Nielsen J, Gupta D, Ding WY, Trinquart L, Johnsen SP, Frost L, Lip GYH. Social determinants of health and recurrence of atrial fibrillation after catheter ablation: a Danish nationwide cohort study. Eur Heart J Qual Care Clin Outcomes 2023; 9:632-638. [PMID: 36302141 DOI: 10.1093/ehjqcco/qcac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 09/13/2023]
Abstract
AIMS To examine the associations between three social determinants of health (SDOH) and recurrence of AF after ablation. METHODS AND RESULTS We selected patients who underwent a first ablation after an incident hospital diagnosis of AF between 2005 and 2018 from the entire Danish population. Educational attainment, family income, and whether the patient was living alone were assessed at the time of ablation. We used cause-specific proportional hazard models to estimate hazard ratios (HR) with 95% confidence interval (CI) adjusted for age and sex. In secondary analyses, we adjusted for comorbidities, antiarrhythmic medication, and prior electrical cardioversion.We selected 9728 patients (mean age 61 years, 70% men), and 5881 patients had AF recurrence over an average of 1.37 years after ablation (recurrence rate 325.7 (95% CI 317.6-334.2) per 1000 person-years). Lower education (HR 1.09 [1.02-1.17] and 1.07 [1.01-1.14] for lower and medium vs. higher), lower income [HR 1.14 (1.06-1.22) and 1.09 (1.03-1.17) for lower and medium vs. higher], and living alone [HR 1.07 (1.00-1.13)] were associated with increased rates of recurrence of AF. We found no evidence of interaction between sex or prior HF with SDOH. The association between family income and AF recurrence was stronger among patients < 65 years compared with those aged ≥ 65 years. The associations between SDOH and AF recurrence did not persist in the multivariable model. CONCLUSION AF was more likely to recur among patients with lower educational attainment, lower family income, or those living alone. Multidisciplinary efforts are needed to reduce socioeconomic inequity in the effect of ablation.
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Affiliation(s)
- Nicklas Vinter
- Diagnostic Centre, University Clinic for Development of Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg 8600, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus 8200, Denmark
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg 9000, Denmark
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool L69 3BX, UK
| | - Mads B Kronborg
- Department of Clinical Medicine, Aarhus University, Aarhus 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Jens Cosedis-Nielsen
- Department of Clinical Medicine, Aarhus University, Aarhus 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool L69 3BX, UK
| | - Wern Y Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool L69 3BX, UK
| | - Ludovic Trinquart
- Tufts Clinical and Translational Science Institute, Tufts University, Boston 02153, MA, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston 02153, MA, USA
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg 9000, Denmark
| | - Lars Frost
- Diagnostic Centre, University Clinic for Development of Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg 8600, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus 8200, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University, Liverpool Heart & Chest Hospital, Liverpool L69 3BX, UK
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22
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Tamirisa KP, Calvert P, Dye C, Mares AC, Gupta D, Al-Ahmad A, Russo AM. Sex Differences in Atrial Fibrillation. Curr Cardiol Rep 2023; 25:1075-1082. [PMID: 37505398 DOI: 10.1007/s11886-023-01927-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE OF REVIEW Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The estimated lifetime risk of developing AF is higher in men; however, due to differences in life expectancy, the overall prevalence is higher among women, particularly in the older age group. Sex differences play an important role in the pathophysiology, presentation, and clinical outcomes of AF. Awareness of these differences minimizes the potential for disparities in AF management. Our review summarizes the current literature on sex differences in AF, including the epidemiology, pathophysiology, risk factors, clinical symptomatology, mechanisms, treatment, and outcomes. We also explore the implications of these differences for clinical practice and future research. RECENT FINDINGS Women are more likely to present with atypical symptoms, have a higher stroke risk, and have a worse quality of life with AF when compared to men. Despite this, they are less likely to receive rhythm control strategies and anticoagulants. The sex-based differences in AF pathology and management might be a combination of inherent biological and hormonal differences, and implicit bias of the research entities and treating clinicians. Our review stresses the need for further sex-specific research in the pathophysiology of AF and opens a dialogue on personalized medicine, where management strategies can be tailored to individual patient characteristics, including sex.
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Affiliation(s)
- Kamala P Tamirisa
- Texas Cardiac Arrhythmia Institute, 11970 N. Central Expressway, Suite 540, Dallas/Austin, TX, USA.
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Cicely Dye
- Naval Medical Center, San Diego, CA, USA
| | | | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, 11970 N. Central Expressway, Suite 540, Dallas/Austin, TX, USA
| | - Andrea M Russo
- Cardiovascular Division, Cooper Medical School of Rowan University, Camden, NJ, USA
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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Koniari I, Gerakaris A, Kounis N, Velissaris D, Rao A, Ainslie M, Adlan A, Plotas P, Ikonomidis I, Mplani V, Hung MY, de Gregorio C, Kolettis T, Gupta D. Outcomes of Atrioventricular Node Ablation and Pacing in Patients with Heart Failure and Atrial Fibrillation: From Cardiac Resynchronization Therapy to His Bundle Pacing. J Cardiovasc Dev Dis 2023; 10:272. [PMID: 37504528 PMCID: PMC10380427 DOI: 10.3390/jcdd10070272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/18/2023] [Accepted: 06/25/2023] [Indexed: 07/29/2023] Open
Abstract
Objective: To review the relevant literature on the use of atrioventricular node ablation and pacing in patients with heart failure and atrial fibrillation. Methods: APubMed/MEDLINE and SCOPUS search was performed in order to assess the clinical outcomes of atrioventricular node ablation and pacemaker implantation, as well as the complications that may occur. Results: Several clinical trials, observational analyses and meta-analyses have shown that the "pace and ablate" strategy not only improves symptoms but also can enhance cardiac performance in patients with heart failure and atrial fibrillation. Although this procedure is effective and safe, some complications may occur including worsening of heart failure, permanent fibrillation, arrhythmias and sudden death. Regarding pacemaker implantation, cardiac resynchronization therapy is shown to be the optimal choice compared to right ventricle apical pacing. His bundle pacing is a promising alternative to cardiac resynchronization therapy and has shown beneficial effects, while left bundle branch pacing is an innovative modality. Conclusions: Atrioventricular node ablation and pacemaker implantation is shown to have beneficial effects on clinical outcomes of patients with atrial fibrillation ± heart failure who do not respond or are intolerant to medical treatment. Cardiac resynchronization therapy is the treatment of choice and His bundle pacing seems to be an effective alternative way of pacing in these patients.
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Affiliation(s)
- Ioanna Koniari
- Department of Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK; (I.K.); (A.R.); (D.G.)
| | - Andreas Gerakaris
- Department of Internal Medicine, University Hospital of Patras, 26500 Patras, Greece; (A.G.); (D.V.)
| | - Nicholas Kounis
- Department of Medicine, Division of Cardiology, University Hospital of Patras, 26500 Patras, Greece
| | - Dimitrios Velissaris
- Department of Internal Medicine, University Hospital of Patras, 26500 Patras, Greece; (A.G.); (D.V.)
| | - Archana Rao
- Department of Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK; (I.K.); (A.R.); (D.G.)
| | - Mark Ainslie
- Department of Cardiology, Manchester Heart Institute, University Hospital of Manchester, Manchester M23 9LT, UK; (M.A.); (A.A.)
| | - Ahmed Adlan
- Department of Cardiology, Manchester Heart Institute, University Hospital of Manchester, Manchester M23 9LT, UK; (M.A.); (A.A.)
| | - Panagiotis Plotas
- Laboratory Primary Health Care, School of Health Rehabilitation Sciences, University of Patras, 26500 Patras, Greece;
| | - Ignatios Ikonomidis
- 2nd Department of Cardiology, “Attikon” Hospital, National and Kapodistrian University of Athens Medical School, 12462 Athens, Greece;
| | - Virginia Mplani
- Department of Intensive Care Unit, Patras University Hospital, 26500 Patras, Greece;
| | - Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, No.291, Zhongzheng Rd., Zhonghe District, New Taipei City 23561, Taiwan;
- Taipei Heart Institute, Taipei Medical University, Taipei City 110301, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei City 110301, Taiwan
| | - Cesare de Gregorio
- Department of Clinical and Experimental Medicine, University of Messina Medical School, 98122 Messina, Italy;
| | - Theofilos Kolettis
- Cardiovascular Research Institute, Department of Cardiology, Medical School, University of Ioannina, 45110 Ioannina, Greece;
| | - Dhiraj Gupta
- Department of Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK; (I.K.); (A.R.); (D.G.)
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Khan HR, Yakupoglu HY, Kralj-Hans I, Haldar S, Bahrami T, Clague J, De Souza A, Hussain W, Jarman J, Jones DG, Salukhe T, Markides V, Gupta D, Khattar R, Wong T. Left Atrial Function Predicts Atrial Arrhythmia Recurrence Following Ablation of Long-Standing Persistent Atrial Fibrillation. Circ Cardiovasc Imaging 2023:e015352. [PMID: 37288553 DOI: 10.1161/circimaging.123.015352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Left atrial (LA) function following catheter or surgical ablation of de-novo long-standing persistent atrial fibrillation (AF) and its impact on AF recurrence was studied in patients participating in the CASA-AF trial (Catheter Ablation vs. Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation). METHODS All patients underwent echocardiography preablation, 3 and 12 months post-ablation. LA structure and function were assessed by 2-dimensional volume and speckle tracking strain measurements of LA reservoir, conduit, and contractile strain. Left ventricular diastolic function was measured using transmitral Doppler filling velocities and myocardial tissue Doppler velocities to derive the e', E/e', and E/A ratios. Continuous rhythm monitoring was achieved using an implantable loop recorder. RESULTS Eighty-three patients had echocardiographic data suitable for analysis. Their mean age was 63.6±9.7 years, 73.5% were male, had AF for 22.8±11.6 months, and had a mean LA maximum volume of 48.8±13.8 mL/m2. Thirty patients maintained sinus rhythm, and 53 developed AF recurrence. Ablation led to similar reductions in LA volumes at follow-up in both rhythm groups. However, higher LA emptying fraction (36.3±10.6% versus 27.9±9.9%; P<0.001), reservoir strain (22.6±8.5% versus 16.7±5.7%; P=0.001), and contractile strain (9.2±3.4% versus 5.6±2.5%; P<0.001) were noted in the sinus rhythm compared with AF recurrence group following ablation at 3 months. Diastolic function was better in the sinus rhythm compared with the AF recurrence group with an E/A ratio of 1.5±0.5 versus 2.2±1.2 (P<0.001) and left ventricular E/e' ratio of 8.0±2.1 versus 10.3±4.1 (P<0.001), respectively. LA contractile strain at 3 months was the only independent predictor of AF recurrence. CONCLUSIONS Following ablation for long-standing persistent AF, improvement in LA function was greater in those who maintained sinus rhythm. LA contractile strain at 3 months was the most important determinant of AF recurrence following ablation. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02755688.
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Affiliation(s)
- Habib Rehman Khan
- London Health Sciences Centre, University of Western Ontario, London, Canada (H.R.K.)
| | - Haci Yakup Yakupoglu
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Ines Kralj-Hans
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Shouvik Haldar
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Toufan Bahrami
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Jonathan Clague
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Anthony De Souza
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Wajid Hussain
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Julian Jarman
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - David Gareth Jones
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Tushar Salukhe
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Vias Markides
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, United Kingdom (D.G.)
| | - Rajdeep Khattar
- Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Trust, London, United Kingdom (H.Y.Y., I.K.-H., S.H., T.B., J.C., A.D.S., W.H., J.J., D.G.J., T.S., V.M., R.K.)
- National Heart and Lung Institute, Imperial College London, United Kingdom (R.K., T.W.)
| | - Tom Wong
- National Heart and Lung Institute, Imperial College London, United Kingdom (R.K., T.W.)
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Calvert P, Kollias G, Pürerfellner H, Narasimhan C, Osorio J, Lip GYH, Gupta D. Silent cerebral lesions following catheter ablation for atrial fibrillation: a state-of-the-art review. Europace 2023; 25:euad151. [PMID: 37306314 PMCID: PMC10259069 DOI: 10.1093/europace/euad151] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/25/2023] [Indexed: 06/13/2023] Open
Abstract
Atrial fibrillation is associated with neurocognitive comorbidities such as stroke and dementia. Evidence suggests that rhythm control-especially if implemented early-may reduce the risk of cognitive decline. Catheter ablation is highly efficacious for restoring sinus rhythm in the setting of atrial fibrillation; however, ablation within the left atrium has been shown to result in MRI-detected silent cerebral lesions. In this state-of-the-art review article, we discuss the balance of risk between left atrial ablation and rhythm control. We highlight suggestions to lower the risk, as well as the evidence behind newer forms of ablation such as very high power short duration radiofrequency ablation and pulsed field ablation.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | | | | | - Calambur Narasimhan
- Department of Cardiac Electrophysiology, AIG Hospitals, 1-66/AIG/2 to 5, Mindspace Road, Gachibowli Hyderabad, Telangana 500032, India
| | - Jose Osorio
- Grandview Medical Center, Arrhythmia Institute at Grandview, 3686 Grandview Parkway Suite 720, Birmingham, AL 35243, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
- Danish Centre for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
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Ding WY, Lip GYH, Gupta D. Left Atrial Appendage Occlusion-A Choice or a Last Resort? How to Approach the Patient. Card Electrophysiol Clin 2023; 15:133-140. [PMID: 37076225 DOI: 10.1016/j.ccep.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Left atrial appendage (LAA) occlusion is emerging as a viable alternative to oral anticoagulation in high-risk patients with atrial fibrillation. However, there remains limited evidence for this approach, especially in certain subgroups, and therefore patient selection is an important aspect of treatment. Here, the authors present arguments for LAA occlusion as either a last resort versus patient choice by evaluating contemporary studies on this topic and discuss practical steps in the approach of patients who may be suitable for LAA occlusion. Overall, an individualized and multidisciplinary team approach should be adopted in patients who are being considered for LAA occlusion.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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Ng KF, Calvert P, Khalatbari A, Lip GYH, Velavan P, Gupta D. Percutaneous Left Atrial Appendage Occlusion Following Successful Treatment of Large Bi-atrial Thrombi in a Patient with Atrial Fibrillation: A Case Report. European Heart Journal - Case Reports 2023; 7:ytad165. [PMID: 37090758 PMCID: PMC10118626 DOI: 10.1093/ehjcr/ytad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/06/2023] [Accepted: 04/03/2023] [Indexed: 04/07/2023]
Abstract
Abstract
Background
Atrial fibrillation (AF) is a well-established risk factor for intracardiac thrombosis. Left atrial appendage occlusion (LAAO) is emerging as a viable alternative to oral anticoagulation (OAC) for high-risk AF patients who are contraindicated to long term OAC.
Case Summary
A 74-year-old man with a history of permanent AF and subdural haemorrhage on warfarin therapy was referred to our facility for further management. Cardiac CT imaging revealed large bi-atrial thrombi for which apixaban therapy was initiated. Serial imaging over nine months showed gradual shrinkage and then resolution of the thrombi. In line with the patient’s preference to avoid life-long OAC, he received LAAO using an Amplatzer™ Amulet™ device. Follow-up transoesophageal echocardiography showed a well-seated device with no leak and no thrombus.
Discussion
We discussed the key issues surrounding management of bi-atrial thrombi and the decision to perform LAAO in these circumstances, relying on shared decision making and multi-disciplinary team input.
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Affiliation(s)
- Kim Fong Ng
- Liverpool Heart & Chest Hospital , Thomas Drive, Liverpool, L14 3PE
| | - Peter Calvert
- Liverpool Heart & Chest Hospital , Thomas Drive, Liverpool, L14 3PE
- Liverpool Centre for Cardiovascular Science, University of Liverpool , United Kingdom
| | | | - Gregory Y H Lip
- Liverpool Heart & Chest Hospital , Thomas Drive, Liverpool, L14 3PE
- Liverpool Centre for Cardiovascular Science, University of Liverpool , United Kingdom
| | | | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital , Thomas Drive, Liverpool, L14 3PE
- Liverpool Centre for Cardiovascular Science, University of Liverpool , United Kingdom
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Alvarez A, Killian M, Pietra B, Ahmed M, Peek G, Jacobs J, Bleiweis M, Fricker F, Gupta D. Impact of Donor Hypernatremia on Outcomes after Heart Transplantation in Adult and Pediatric Patients. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Magua W, Okoh A, Pranav P, Wang J, Karadkhele G, Cole R, Daneshmand M, Gupta D, Larsen C, Morris A. Belatacept-Based Immunosuppression in Heart Transplant Recipients: National Trends with Outcomes from a Single Center. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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31
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Eichenberger E, Satola S, Gupta D, Pouch S. Bloodstream Infection in Pre-Heart Transplant Patients on Temporary Mechanical Circulatory Support. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Patel K, Yadalam A, DeStefano R, Almuwaqqat Z, Desai S, Alkhoder A, Ejaz K, Alvi Z, Book W, Gupta D, Quyyumi A. Lipoprotein(a) Levels Predict Development of Cardiac Allograft Vasculopathy. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Killian M, Schelbe L, Lustria M, Gupta D. In-App Messaging by Adolescent Heart Transplant Patients During Mobile App-Based Video Directly Observed Therapy. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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34
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McLendon L, Kaufmann E, Killian M, Beckwith S, Coppola J, Martin E, Rackley J, Coleman L, Blanchette H, Shih R, Pietra B, Fricker F, Gupta D. Pediatric Psychosocial Assessment Tool: An Initial Risk Assessment Tool for Pediatric Heart Transplant Candidates. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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35
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Killian M, Tian S, Xing A, Gupta D, He Z. Predicting Health Outcomes Using Machine Learning in Pediatric Heart Transplantation Using UNOS Data. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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36
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Calvert P, Gupta D, Lip GYH. The neurocognitive effects of atrial fibrillation: benefits of the ABC pathway. Eur Heart J Cardiovasc Pharmacother 2023:7086108. [PMID: 36965867 PMCID: PMC10385086 DOI: 10.1093/ehjcvp/pvad021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
Atrial fibrillation has a recognised association with not only stroke, but also neurocognitive impairment and both vascular and Alzheimer's dementia. Effective management of atrial fibrillation can reduce the risk of such complications. In this narrative review article, we discuss the pathophysiological links between atrial fibrillation and dementia, as well as the benefits of adherence to the guideline-recommended 'ABC' Pathway.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science and Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science and Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science and Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE
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Calvert P, Tamirisa K, Al-Ahmad A, Lip GYH, Gupta D. Racial and Ethnic Disparities in Stroke Prevention for Atrial Fibrillation. Am J Med 2023; 136:225-233. [PMID: 36495932 DOI: 10.1016/j.amjmed.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/01/2022] [Accepted: 11/06/2022] [Indexed: 12/13/2022]
Abstract
Racial and ethnic disparities in health care are well documented, although often underappreciated. In the setting of atrial fibrillation, stroke risk and severity may be higher in underrepresented ethnic populations. Additionally, the risk of bleeding is not uniform, and pharmacogenetics play an important role in anticoagulant therapy. In this narrative review, we discuss the complex issues surrounding stroke prevention in underrepresented ethnic groups with atrial fibrillation.
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Affiliation(s)
- Peter Calvert
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom
| | | | | | - Gregory Y H Lip
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom.
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Khanra D, Calvert P, Hughes S, Waktare J, Modi S, Hall M, Todd D, Mahida S, Gupta D, Luther V. An approach to help differentiate postinfarct scar from borderzone tissue using Ripple Mapping during ventricular tachycardia ablation. J Cardiovasc Electrophysiol 2023; 34:664-672. [PMID: 36478627 DOI: 10.1111/jce.15766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/15/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ventricular scar is traditionally highlighted on a bipolar voltage (BiVolt) map in areas of myocardium <0.50 mV. We describe an alternative approach using Ripple Mapping (RM) superimposed onto a BiVolt map to differentiate postinfarct scar from conducting borderzone (BZ) during ventricular tachycardia (VT) ablation. METHODS Fifteen consecutive patients (left ventricular ejection fraction 30 ± 7%) underwent endocardial left ventricle pentaray mapping (median 5148 points) and ablation targeting areas of late Ripple activation. BiVolt maps were studied offline at initial voltage of 0.50-0.50 mV to binarize the color display (red and purple). RMs were superimposed, and the BiVolt limits were sequentially reduced until only areas devoid of Ripple bars appeared red, defined as RM-scar. The surrounding area supporting conducting Ripple wavefronts in tissue <0.50 mV defined the RM-BZ. RESULTS RM-scar was significantly smaller than the traditional 0.50 mV cutoff (median 4% vs. 12% shell area, p < .001). 65 ± 16% of tissue <0.50 mV supported Ripple activation within the RM-BZ. The mean BiVolt threshold that differentiated RM-scar from BZ tissue was 0.22 ± 0.07 mV, though this ranged widely (from 0.12 to 0.35 mV). In this study, septal infarcts (7/15) were associated with more rapid VTs (282 vs. 347 ms, p = .001), and had a greater proportion of RM-BZ to RM-scar (median ratio 3.2 vs. 1.2, p = .013) with faster RM-BZ conduction speed (0.72 vs. 0.34 m/s, p = .001). Conversely, scars that supported hemodynamically stable sustained VT (6/15) were slower (367 ± 38 ms), had a smaller proportion of RM-BZ to RM-scar (median ratio 1.2 vs. 3.2, p = .059), and slower RM-BZ conduction speed (0.36 vs. 0.63 m/s, p = .036). RM guided ablation collocated within 66 ± 20% of RM-BZ, most concentrated around the RM-scar perimeter, with significant VT reduction (median 4.0 episodes preablation vs. 0 post, p < .001) at 11 ± 6 months follow-up. CONCLUSION Postinfarct scars appear significantly smaller than traditional 0.50 mV cut-offs suggest, with voltage thresholds unique to each patient.
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Affiliation(s)
| | - Peter Calvert
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Simon Modi
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Hall
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Derick Todd
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
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Chu G, Calvert P, Sidhu B, Mavilakandy A, Kotb A, Tovmassian L, Kozhuharov N, Biermé C, Denham N, Pius C, O'Brien J, Ding WY, Luther V, Snowdon RL, Ng GA, Gupta D. Patient experience of very high power short duration radiofrequency ablation for atrial fibrillation under mild conscious sedation. J Interv Card Electrophysiol 2023; 66:445-453. [PMID: 35997848 PMCID: PMC9396586 DOI: 10.1007/s10840-022-01351-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Very high power short duration (vHPSD) radiofrequency ablation (RFA) may reduce ablation times and improve patient tolerability, permitting pulmonary vein isolation (PVI) under mild conscious sedation (mCS) and promoting same day discharge (SDD). METHODS First, a retrospective feasibility study was performed at 2 tertiary cardiac centres in the UK. Consecutive cases of first-time PVI using vHPSD ablation with 90 W lesions for up to 4 s were compared against cases performed using standard RF (sRF) and cryoballoon (Cryo) therapy. Subsequently, a prospective study of patients who had vHPSD or Cryo exclusively under mCS was undertaken. Questionnaires based on Likert and visual analogue scales (VAS) were used to measure anxiety, discomfort and pain. RESULTS In total, 182 patients (59 vHPSD, 62 sRF and 61 Cryo) were included in the retrospective study, with 53 (90%) of vHPSD cases successfully performed under mCS. PVI ablation time in the vHPSD group (5.8 ± 1.7 min) was shorter than for sRF (16.5 ± 6.3 min, p < 0.001) and Cryo (17.5 ± 5.9 min, p < 0.001). Fifty-one vHPSD and 52 Cryo patients were included in the prospective study. PVI ablation time in the vHPSD group was shorter than for the Cryo group (6.4 ± 2.9 min vs 17.9 ± 5.7 min, p < 0.001), but overall procedure duration was longer (121 ± 39 min vs 95 ± 20 min, p < 0.001). There were no differences in the patient experience of anxiety, discomfort or pain. SDD rates were the same in both groups (61% vs 67%, p = 0.49). CONCLUSIONS vHPSD RFA for PVI can be performed under mCS to achieve SDD rates comparable to cryoablation, without compromising patient experience.
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Affiliation(s)
- Gavin Chu
- Lancashire Cardiac Centre, Blackpool, UK
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Peter Calvert
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Bharat Sidhu
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Akash Mavilakandy
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ahmed Kotb
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Lilith Tovmassian
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Nikola Kozhuharov
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Cédric Biermé
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Nathan Denham
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Charlene Pius
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Jim O'Brien
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Wern Yew Ding
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Vishal Luther
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Richard L Snowdon
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - G André Ng
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
- Glenfield Hospital, Leicester, UK
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK.
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Calvert P, Gupta D. Left atrial appendage occlusion in patients with cirrhotic liver disease: the importance of patient selection. Europace 2023; 25:1315-1317. [PMID: 36857533 PMCID: PMC10105848 DOI: 10.1093/europace/euad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
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Gupta D, Ding WY, Calvert P, Williams E, Das M, Tovmassian L, Tayebjee MH, Haywood G, Martin CA, Rajappan K, Bates MGD, Temple IP, Reichlin T, Chen Z, Balasubramaniam RN, Ronayne C, Clarkson N, Morgan M, Barton J, Kemp I, Mahida S, Sticherling C. Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter. Heart 2023; 109:364-371. [PMID: 36396438 DOI: 10.1136/heartjnl-2022-321729] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE We aimed to compare cryoballoon pulmonary vein isolation (PVI) with standard radiofrequency cavotricuspid isthmus (CTI) ablation as first-line treatment for typical atrial flutter (AFL). METHODS Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter was an international, multicentre, open with blinded assessment trial. Patients with CTI-dependent AFL and no documented atrial fibrillation (AF) were randomised to either cryoballoon PVI alone or radiofrequency CTI ablation. Primary efficacy outcome was time to first recurrence of sustained (>30 s) symptomatic atrial arrhythmia (AF/AFL/atrial tachycardia) at 12 months as assessed by continuous monitoring with an implantable loop recorder. Primary safety outcome was a composite of death, stroke, tamponade requiring drainage, atrio-oesophageal fistula, pacemaker implantation, serious vascular complications or persistent phrenic nerve palsy. RESULTS Trial recruitment was halted at 113 of the target 130 patients because of the SARS-CoV-2 pandemic (PVI, n=59; CTI ablation, n=54). Median age was 66 (IQR 61-71) years, with 98 (86.7%) men. At 12 months, the primary outcome occurred in 11 (18.6%) patients in the PVI group and 9 (16.7%) patients in the CTI group. There was no significant difference in the primary efficacy outcome between the groups (HR 1.11, 95% CI 0.46 to 2.67). AFL recurred in six (10.2%) patients in the PVI arm and one (1.9%) patient in the CTI arm (p=0.116). Time to occurrence of AF of ≥2 min was significantly reduced with cryoballoon PVI (HR 0.46, 95% CI 0.25 to 0.85). The composite safety outcome occurred in four patients in the PVI arm and three patients in the CTI arm (p=1.000). CONCLUSION Cryoballoon PVI as first-line treatment for AFL is equally effective compared with standard CTI ablation for preventing recurrence of atrial arrhythmia and better at preventing new-onset AF. TRIAL REGISTRATION NUMBER NCT03401099.
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Affiliation(s)
- Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK .,Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Wern Yew Ding
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Peter Calvert
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Emmanuel Williams
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.,Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Moloy Das
- Newcastle Upon Tyne Hospital NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Lilith Tovmassian
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Muzahir H Tayebjee
- Department of Cardiology, Leeds Teaching Hospital NHS Foundation Trust, Leeds, UK
| | - Guy Haywood
- Department of Cardiology, University Hospitals Plymouth NHS Foundation Trust, Plymouth, UK
| | - Claire A Martin
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Kim Rajappan
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matthew G D Bates
- Department of Cardiology, South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Ian Peter Temple
- Department of Cardiology, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Zhong Chen
- Department of Cardiology, Ashford and St Peter's Hospital NHS Foundation Trust, Surrey, UK
| | - Richard N Balasubramaniam
- Department of Cardiology, Royal Bournemouth and Christchurch Hospital NHS Foundation Trust, Bournemouth, UK
| | - Christina Ronayne
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Nichola Clarkson
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Maureen Morgan
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Janet Barton
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Ian Kemp
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Saagar Mahida
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
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Soni B, Gupta D, Gopinathannair R. Quality of life improvement following cardioneuroablation for vasovagal syncope: expected or too early to say? J Interv Card Electrophysiol 2023:10.1007/s10840-023-01489-w. [PMID: 36705871 DOI: 10.1007/s10840-023-01489-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/17/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Bosky Soni
- Department of Medicine, University of Pittsburgh School of Medicine, Harrisburg, PA, USA
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
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Calvert P, Gupta D, Lip GYH. Early atrial fibrillation rhythm control after stroke. Lancet Neurol 2023; 22:3-4. [PMID: 36517166 DOI: 10.1016/s1474-4422(22)00470-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool L14 3PE, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool L14 3PE, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool L14 3PE, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Calvert P, Gupta D. Clinical outcomes with very high power very short duration ablation for atrial fibrillation: The jury is still out. J Cardiovasc Electrophysiol 2022; 33:2514-2516. [PMID: 36124386 DOI: 10.1111/jce.15679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital Liverpool, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital Liverpool, Liverpool, UK
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Granstedt EM, Osin D, Gupta D, Kinley J, Knapp K, Muñoz-Burgos JM. Helium line ratio imaging in the C-2W divertor. Rev Sci Instrum 2022; 93:113533. [PMID: 36461464 DOI: 10.1063/5.0101822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/10/2022] [Indexed: 06/17/2023]
Abstract
A 2D imaging instrument has been designed and deployed on C-2W ("Norman") [H. Gota et al., Nucl. Fusion 61, 106039 (2021)] to study the plasma in the expander divertor by simultaneously measuring three neutral helium spectral lines. Ratios of these images, in conjunction with a collisional-radiative model, yield 2D maps of electron temperature and density. Almost the entire radial plasma cross-section (∼60 cm) can be mapped with a spatial resolution ≲1 cm. These data can, in principle, be acquired at 3 kHz. The neutral helium target is provided by a custom-built supersonic gas injector located inside the divertor vessel, which injects helium toward the magnetic axis and perpendicular to the camera sight-cone. Images of helium emission and reconstructed electron density and temperature profiles of the plasma produced from an end gun are presented. Voltages applied to concentric annular electrodes located in the divertors are used to stabilize beam-driven field reversed configuration plasmas. Magnetic field expansion is also employed to thermally isolate electrons from the end electrodes. Measurements of electron temperature and density in the divertor are important in order to study the effects of both the electrostatic biasing and the divertor magnetic field on electron confinement, neutral gas transport, and the overall machine performance.
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Affiliation(s)
- E M Granstedt
- TAE Technologies, Inc., 19631 Pauling, Foothill Ranch, California 92610, USA
| | - D Osin
- TAE Technologies, Inc., 19631 Pauling, Foothill Ranch, California 92610, USA
| | - D Gupta
- TAE Technologies, Inc., 19631 Pauling, Foothill Ranch, California 92610, USA
| | - J Kinley
- TAE Technologies, Inc., 19631 Pauling, Foothill Ranch, California 92610, USA
| | - K Knapp
- TAE Technologies, Inc., 19631 Pauling, Foothill Ranch, California 92610, USA
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Charan K, Sharma N, Baksi A, Banerjee N, Rodha M, Gupta D. OC-003 PORT POSITIONS IN TEP FOR SHORT PATIENTS: OUR EXPERIENCE. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Totally extraperitoneal repair (TEP) is a popular technique for repair of inguinal hernia. One common technique of TEP involves placement of one 10 mm port 1–2 cm below the umbilicus just off the midline, one 5 mm port 2–3 cm above the pubic symphysis, and a third 5 mm port between these 2 ports in the midline (Figure 1a). In case the distance from the superior border of the symphysis pubis to the inferior edge of the umbilicus is less than 15 cm, this leads to crowding of instruments and results in ergonomic problems during the operation. Daes has popularized eTEP for this indication. The aim is to shift the first 10 mm port to a position 5 cm superior and 4 cm lateral to the umbilicus (Figure 1b). eTEP has also found application in the repair of ventral hernias. However, for most inguinal hernias, we feel that eTEP is an overkill.
Methods
We place the first 10 mm port at the level of the superior border of the umbilicus and just lateral to it (Figure 1c). The two 5 mm ports are placed in the midline. Initial dissection is performed telescopically.
Results
This technique provides 2–3 cm of extra working space, which improves ergonomics while operating on patients with a short pubo-umbilical distance. Other parameters like operating time, postoperative pain and other complications remain the same.
Conclusion
We recommend placement of the 10 mm port at the superior border of the umbilicus, particularly in short patients.
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Affiliation(s)
- K Charan
- General Surgery , AIIMS Jodhpur, Jodhpur , India
| | - N Sharma
- General Surgery , AIIMS Jodhpur, Jodhpur , India
| | - A Baksi
- General Surgery , AIIMS Jodhpur, Jodhpur , India
| | - N Banerjee
- General Surgery , AIIMS Jodhpur, Jodhpur , India
| | - M Rodha
- General Surgery , AIIMS Jodhpur, Jodhpur , India
| | - D Gupta
- General Surgery , AIIMS Jodhpur, Jodhpur , India
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Rodha MS, Gupta D. P-011 FEASIBILITY OF VENTRAL-TAPP FOR VENTRAL HERNIA REPAIR IN A LOW INCOME COUNTRY LIKE INDIA. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Aim
Minimal invasive repair is now the established procedure for ventral hernia. Surgeons are now validating newer techniques each year to deal with the ventral hernia. It becomes difficult to choose, best fit technique from this large armamentarium. For a low income country like India, ventral- trans abdominal preperitoneal (TAPP) technique is cost effective and uses simple polyester or polypropylene mesh.
Methods
For this article we used our experience with ventral-TAPP performed from July 1, 2021 to May 31, 2022. Patients were followed up for 6 months.
Results
In the above time period, we had performed 10 ventral-TAPP. Out of these, 3 had completed the follow up. Median age was 45.0 years, BMI was 26.56 kg/m2. One patient was male (33.33%). All patients were presented to surgery due to bulge or pain in the anterior abdominal wall.
The median hernia defect measured 80 mm, median mesh diameter was 15 cm and median operative time was 125 min. No intraoperative complications occurred.
Postoperatively, none of the patients developed complications. Length of hospital stay was 3.0 days. Six months after surgery, neither recurrence nor chronic pain were recorded.
Conclusion
We have concluded that mesh used in repair with ventral-TAPP costs one fourth to one-fifth to that of composite mesh used in intraperitoneal onlay mesh (IPOM) repair with the comparable results. So in a low income country like India, ventral TAPP should be a preferred approach.
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Affiliation(s)
- M S Rodha
- Of General Surgery, All India Institute Of Medical Sciences , Jodhpur , India
| | - D Gupta
- Of General Surgery, All India Institute Of Medical Sciences , Jodhpur , India
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Ding WY, Khanra D, Kozhuharov N, Shaw M, Luther V, Ashrafi R, Borbas Z, Mahida S, Modi S, Hall M, Snowdon R, Waktare J, Todd D, Gupta D. Incidence of vascular complications for electrophysiology procedures in the ultrasound era: a single-centre experience over 10,000 procedures in the long term. J Interv Card Electrophysiol 2022; 66:693-700. [PMID: 36214805 DOI: 10.1007/s10840-022-01386-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/26/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ultrasound (US) is being increasingly used to guide vascular access for electrophysiology (EP) procedures in many centres. Nonetheless, the incidence and predictors of vascular complications in the US era are limited. In this study, we describe our experience of vascular access-related complications associated with EP procedures which were performed with the routine use of US-guided vascular access. METHODS A total of 10,158 consecutive EP procedures in 8361 patients performed from April 2014 (when our centre moved to a policy of routine US-guided vascular access for EP procedures) to March 2022 were included. The outcome of interest was any vascular access-related complication that occurred within 7 days of the procedure; these were classified as severe if surgical intervention and/or blood transfusion was required, major if non-surgical intervention or delayed hospital discharge was required, or minor if it did not fulfil the criteria for severe or major. RESULTS During the study period, 2 (0.02%) severe vascular complications occurred, including 1 pseudo-aneurysm requiring surgery and 1 retroperitoneal haemorrhage requiring blood transfusion. Nine (0.09%) major complications occurred, including 6 hematomas managed by compression devices, 1 type B aortic dissection, 1 AV fistula managed conservatively and 1 haematoma managed conservatively but delayed hospital discharge. Eighteen (0.18%) minor haematomas were seen that did not require any intervention or delayed hospital discharge. On multivariable analysis, female sex [OR (95% CI): 2.5 (1.2, 5.4)] and use of an arterial access [OR (95% CI): 19.3 (7.1, 52.3)] were seen to be independent predictors of the 29 vascular complications. CONCLUSION With the use of US-guided vascular access in EP procedures, major vascular complications are exceedingly rare, particularly those needing surgical intervention. Our results provide additional evidence for scientific guidelines to support US use.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | | | | | - Matthew Shaw
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | - Reza Ashrafi
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | | | - Simon Modi
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mark Hall
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | | | - Derick Todd
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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Spevack E, Gupta D, Moran A, Watkins K, Seeley N. The impact of an integrative medicine program on ERAS-compliant pancreaticoduodenectomies. Clin Nutr ESPEN 2022. [DOI: 10.1016/j.clnesp.2022.06.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Ding WY, Davies IG, Gupta D, Lip GYH. Relationship between Renal Function, Fibrin Clot Properties and Lipoproteins in Anticoagulated Patients with Atrial Fibrillation. Biomedicines 2022; 10:biomedicines10092270. [PMID: 36140371 PMCID: PMC9496227 DOI: 10.3390/biomedicines10092270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/09/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Mechanisms by which chronic kidney disease (CKD) influences fibrin clot properties in atrial fibrillation (AF) remain ill-defined. We aimed to investigate the effects of AF and CKD on fibrin clot properties and lipoproteins, and determine the relationship between these factors. Methods: Prospective cross-sectional study of patients recruited from cardiology services in Liverpool between September 2019 and October 2021. Primary groups consisted of anticoagulated AF patients with and without CKD in a 1:1 ratio. Control group comprised anticoagulated patients without AF or CKD. Fibrin clot properties were analysed using turbidity and permeation assays. Detailed lipoprotein characteristics, including total cholesterol, low-density lipoprotein cholesterol (LDL-C), small dense LDL and oxidised LDL, were measured. Results: Fifty-six anticoagulated patients were enrolled (median age 72.5; 34% female); 46 with AF (23 with CKD and 23 without CKD) and 10 controls. AF was associated with changes in three indices of fibrin clot properties using PTT (Tlag 314 vs. 358 s, p = 0.047; Abspeak 0.153 vs. 0.111 units, p = 0.031; Tlysis50% 884 vs. 280 s, p = 0.047) and thrombin reagents (Tlag 170 vs. 132 s, p = 0.031; Tmax 590 vs. 462 s, p = 0.047; Tpeak50% 406 vs. 220 s, p = 0.005) while the concomitant presence of CKD led to changes in fibrin clot properties using kaolin (Tlag 1072 vs. 1640 s, p = 0.003; Tmax 1458 vs. 1962 s, p = 0.005; Tpeak50% 1294 vs. 2046, p = 0.008) and PPP reagents (Tlag 566 vs. 748 s, p = 0.044). Neither of these conditions were associated with changes in fibrin clot permeability. Deteriorating eGFR was significantly correlated to the speed of clot formation, and CKD was independently associated with unfavourable clot properties (Tlag −778, p = 0.002; Tmax −867, p = 0.004; Tpeak50% −853, p = 0.004 with kaolin reagent). AF alone was not associated with changes in lipoprotein distribution while AF patients with CKD had lower total cholesterol, LDL-C and small dense LDL due to the presence of other risk factors. No significant relationship was observed between fibrin clot properties and lipoprotein distribution. Conclusions: There are important changes that occur in fibrin clot properties with AF and CKD that may account for the increased risk of thromboembolic complications. However, these changes in fibrin clot properties were not attributable to alterations in lipoprotein distribution.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Correspondence:
| | - Ian G. Davies
- Research Institute of Sport and Exercise Science, Liverpool John Moores University, Liverpool L3 5UX, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
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