Cardiac tamponades related to interventional electrophysiology procedures are associated with higher risk of short-term hospitalization for pericarditis but favourable long-term outcome

AIMS

To investigate the association of iatrogenic cardiac tamponades as a complication of invasive electrophysiology procedures (EPs) and mortality as well as serious cardiovascular events in a nationwide patient cohort during long-term follow-up.

METHODS

From the Swedish Catheter Ablation Registry between 2005 and 2019, a total of 58 770 invasive EPs in 44 497 patients were analysed. From this, all patients with periprocedural cardiac tamponades related to invasive EPs were identified (n = 200; tamponade group) and matched (1:2 ratio) to a control group (n = 400). Over a follow-up of 5 years, the composite primary endpoint-death from any cause, acute myocardial infarction, transitory ischaemic attack (TIA)/stroke, and hospitalization for heart failure-revealed no statistically significant association with cardiac tamponade [hazard ratio (HR) 1.22 (95% CI, 0.79-1.88)]. All single components of the primary endpoint as well as cardiovascular death revealed no statistically significant association with cardiac tamponade. Cardiac tamponade was associated with a significantly higher risk with hospitalization for pericarditis [HR 20.67 (95% CI, 6.32-67.60)].

CONCLUSION

In this nationwide cohort of patients undergoing invasive EPs, iatrogenic cardiac tamponade was associated with an increased risk of hospitalization for pericarditis during the first months after the index procedure. In the long-term, however, cardiac tamponade revealed no significant association with mortality or other serious cardiovascular events.

A decade of catheter ablation of cardiac arrhythmias in Sweden: ablation practices and outcomes

Aims

Catheter ablation is considered the treatment of choice for many tachyarrhythmias, but convincing ‘real-world’ data on efficacy and safety are lacking. Using Swedish national registry data, the ablation spectrum, procedural characteristics, as well as ablation efficacy and reported adverse events are reported.

Methods and Results

Consecutive patients (≥18 years of age) undergoing catheter ablation in Sweden between 01 January 2006 and 31 December 2015 were included in the study. Follow-up (repeat ablation and vital status) was collected through 31 December 2016. A total of 26 642 patients (57 ± 15 years, 62% men), undergoing a total of 34 428 ablation procedures were included in the study. In total, 4034 accessory pathway/Wolff–Parkinson–White syndrome (12%), 7358 AV-nodal re-entrant tachycardia (21%), 1813 atrial tachycardia (5.2%), 5481 typical atrial flutter (16%), 11 916 atrial fibrillation (AF, 35%), 2415 AV-nodal (7.0%), 581 premature ventricular contraction (PVC, 1.7%), and 964 ventricular tachycardia (VT) ablations (2.8%) were performed. Median follow-up time was 4.7 years (interquartile range 2.7–7.0). The spectrum of treated arrhythmias changed over time, with a gradual increase in AF, VT, and PVC ablation (P < 0.001). Decreasing procedural times and utilization of fluoroscopy with time, were seen for all arrhythmia types. The rates of repeat ablation differed between ablation types, with the highest repeat ablation seen in AF (41% within 3 years). The rate of reported adverse events was low (n = 595, 1.7%). Death in the immediate period following ablation was rare (n = 116, 0.34%).

Conclusion

Catheter ablations have shifted towards more complex procedures over the past decade. Fluoroscopy time has markedly decreased and the efficacy of catheter ablation seems to improve for AF.

Effect of Catheter Ablation vs Antiarrhythmic Medication on Quality of Life in Patients With Atrial Fibrillation: The CAPTAF Randomized Clinical Trial

IMPORTANCE

Quality of life is not a standard primary outcome in ablation trials, even though symptoms drive the indication.

OBJECTIVE

To assess quality of life with catheter ablation vs antiarrhythmic medication at 12 months in patients with atrial fibrillation.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial at 4 university hospitals in Sweden and 1 in Finland of 155 patients aged 30-70 years with more than 6 months of atrial fibrillation and treatment failure with 1 antiarrhythmic drug or β-blocker, with 4-year follow-up. Study dates were July 2008-September 2017. Major exclusions were ejection fraction <35%, left atrial diameter >60 mm, ventricular pacing dependency, and previous ablation.

INTERVENTIONS

Pulmonary vein isolation ablation (n = 79) or previously untested antiarrhythmic drugs (n = 76).

MAIN OUTCOMES AND MEASURES

Primary outcome was the General Health subscale score (Medical Outcomes Study 36-Item Short-Form Health Survey) at baseline and 12 months, assessed unblinded (range, 0 [worst] to 100 [best]). There were 26 secondary outcomes, including atrial fibrillation burden (% of time) from baseline to 12 months, measured by implantable cardiac monitors. The first 3 months were excluded from rhythm analysis.

RESULTS

Among 155 randomized patients (mean age, 56.1 years; 22.6% women), 97% completed the trial. Of 79 patients randomized to receive ablation, 75 underwent ablation, including 2 who crossed over to medication and 14 who underwent repeated ablation procedures. Of 76 patients randomized to receive antiarrhythmic medication, 74 received it, including 8 who crossed over to ablation and 43 for whom the first drug used failed. General Health score increased from 61.8 to 73.9 points in the ablation group vs 62.7 to 65.4 points in the medication group (between-group difference, 8.9 points; 95% CI, 3.1-14.7; P = .003). Of 26 secondary end points, 5 were analyzed; 2 were null and 2 were statistically significant, including decrease in atrial fibrillation burden (from 24.9% to 5.5% in the ablation group vs 23.3% to 11.5% in the medication group; difference -6.8% [95% CI, -12.9% to -0.7%]; P = .03). Of the Health Survey subscales, 5 of 7 improved significantly. Most common adverse events were urosepsis (5.1%) in the ablation group and atrial tachycardia (3.9%) in the medication group.

CONCLUSIONS AND RELEVANCE

Among patients with symptomatic atrial fibrillation despite use of antiarrhythmic medication, the improvement in quality of life at 12 months was greater for those treated with catheter ablation compared with antiarrhythmic medication. Although the study was limited by absence of blinding, catheter ablation may offer an advantage for quality of life.

TRIAL REGISTRATION

clinicaltrialsregister.eu Identifier: 2008-001384-11.

Cardioversion of atrial fibrillation does not affect obstructive sleep apnea

BACKGROUND

Sleep apnea is common in patients with atrial fibrillation, but the effect of the cardioversion of atrial fibrillation to sinus rhythm on central and obstructive apneas is mainly unknown. The primary aim of the study was to analyze the association between cardioversion of atrial fibrillation and sleep apneas, to investigate whether obstructive or central sleep apneas are reduced following cardioversion. A secondary objective was to study the effect on sleep quality.

METHODS

Twenty-three patients with atrial fibrillation were investigated using overnight polysomnography, including esophagus pressure monitoring and ECG, before and after the cardioversion of persistent atrial fibrillation.

RESULTS

Obstructive sleep apnea occurred in 17/23 patients (74%), and central sleep apnea in 6/23 patients (26%). Five patients had both obstructive and central sleep apnea. Sinus rhythm at follow-up was achieved in 16 patients. The obstructive apnea-hypopnea index, central apnea-hypopnea index, and the number of patients with obstructive or central sleep apnea did not differ before and after restoration of sinus rhythm. Sleep time, sleep efficiency, time in different sleep stages, and subjective daytime sleepiness were normal and unaffected by cardioversion.

CONCLUSIONS

Both obstructive and central sleep apneas are highly prevalent in patients with persistent atrial fibrillation. Obstructive sleep apneas are unaffected by the cardioversion of atrial fibrillation to sinus rhythm. The sleep pattern is normal and unaffected by cardioversion in patients with atrial fibrillation.

CLINICAL TRIAL REGISTRATION

Trial number NCT00429884.

U22 protocol as measure of symptomatic improvement after catheter ablation of atrial fibrillation

INTRODUCTION

Left atrial catheter ablation is useful as symptomatic treatment in selected patients with atrial fibrillation (AF). Evaluation requires measurement of arrhythmia-related symptoms. Many of the published protocols have drawbacks and have been used in AF only, with no possible comparison to other ablations that compete for the same resources. U22 is a published protocol that quantifies paroxysmal tachycardia symptoms through scales with 11 answer alternatives, translated into discrete numerical scales 0-10. It has been shown to reflect the clinical improvement after ablation of supraventricular tachycardia. Here we report the use of U22 in measuring improvement after catheter ablation for AF.

MATERIAL AND METHODS

A total of 105 patients underwent first-time ablation for AF and answered U22 and SF-36 forms at baseline and follow-up 304 (SD 121) days after ablation. Independently, the patients underwent a clinical follow-up. All decisions regarding medication and reablation were taken without knowledge of the symptom scores. Results. The U22 scores for well-being, arrhythmia as cause for impaired well-being, derived time-aspect score for arrhythmia, and discomfort during attack detected relevant improvements of symptoms after the ablation. U22 showed larger improvement in patients undergoing only one procedure than in patients who later underwent repeated interventions, thus reflecting the independent clinical decision for reablation.

CONCLUSION

U22 quantifies the symptomatic improvement after AF ablation with adequate internal consistency and construct validity. U22 mirrors aspects of the arrhythmia symptomatology other than SF-36.

The predictive value of C-reactive protein on recurrence of atrial fibrillation after cardioversion with or without treatment with atorvastatin

BACKGROUND

The aim of this study was to investigate whether high-sensitivity C-reactive protein (hsCRP) levels prior to cardioversion (CV) predict recurrence of atrial fibrillation (AF) in patients randomized to treatment with either atorvastatin or placebo 30 and 180 days after CV.

METHODS

This was a prespecified substudy of 128 patients with persistent AF randomized to treatment with atorvastatin 80 mg/day or placebo, initiated 14 days before CV, and continued 30 days after CV. HsCRP levels were measured at randomization, at the time of CV, and 2 days and 30 days after CV.

RESULTS

In univariate analysis of those who were in sinus rhythm 2h after CV, hsCRP did not significantly (odds ratio [OR] 1.11, 95% confidence interval [CI] 0.99-1.25) predict recurrence of AF at 30 days. However, after adjusting for treatment with atorvastatin, hsCRP predicted the recurrence of AF (OR 1.14, 95% CI 1.01-1.27). In a multivariate logistic regression analysis with gender, age, body mass index (BMI), smoking, cholesterol, and treatment with atorvastatin as covariates, the association was still significant (OR 1.14, 95% CI 1.01-1.29). Six months after CV, hsCRP at randomization predicted recurrence of AF in both univariate analysis (OR 1.30, 95% CI 1.06-1.60) and in multivariate logistic regression analysis (OR 1.33, 95% CI 1.06-1.67).

CONCLUSION

HsCRP was associated with AF recurrence one and six months after successful CV of persistent AF. However, the association at one month was significant only after adjusting for atorvastatin treatment.

Symptomatic improvement after catheter ablation of supraventricular tachycardia measured by the arrhythmia-specific questionnaire U22

INTRODUCTION

The main indication for ablation of supraventricular tachycardia is symptomatic relief. Generic measures of quality of life are not suitable for direct evaluation of arrhythmia-related symptoms, and a specific tool is needed. The questionnaire U22 quantifies symptoms associated with arrhythmic events. It uses discrete 0-10 scales for quantification of influence of arrhythmia on well-being, intensity of discomfort, type of dominant symptom, and a time aspect that summarizes duration and frequency of spells. We evaluated U22 in a well defined group of patients with paroxysmal supraventricular tachycardia, undergoing an intervention with a distinct end-point and a high success rate.

METHODS

Symptoms in patients with accessory pathway and atrioventricular nodal re-entrant tachycardia scheduled for ablation were measured with U22 and SF-36 on admission. The evaluation was repeated after 6 months.

RESULTS

Altogether 58 patients successfully ablated in 2006-2008 completed the four forms (U22 and SF-36 at base-line and follow-up, 210 ± 35 days after ablation). The score for well-being (0-10; 10 being best) increased from 5.9 ± 2.6 to 7.9 ± 1.9 (P < 0.0005). The score for arrhythmia as cause for impairment in well-being (0-10; 10 being highest) decreased from 7.5 ± 2.8 to 2.0 ± 3.1 (P < 0.0005). The time aspect score (0-10) decreased from 4.7 ± 1.5 to 1.4 ± 1.8 (P < 0.0005). The two SF-36 summary measures PCS and MCS increased from 46.9 ± 9.4 to 48.4 ± 10.7 and from 44.9 ± 12.5 to 49.1 ± 9.9 (P = 0.04 and 0.002).

CONCLUSION

After successful ablation of accessory pathway and atrioventricular nodal re-entrant tachycardia, the U22 protocol detected a relevant increase in arrhythmia-related well-being. Modest improvement in general well-being was detected by the SF-36 protocol.

U22, a protocol to quantify symptoms associated with supraventricular tachycardia

BACKGROUND

The main indication for ablation of supraventricular tachyarrhythmias (SVTA) is symptomatic relief. Specific paroxysmal symptoms cannot be quantified with general measures of quality of life, such as with the SF-36 questionnaire. U22 is a new protocol which measures the effects of arrhythmia on well-being, the intensity of discomfort during an episode, the type and temporal characteristics of dominant symptoms, and the duration and frequency of episodes. Discrete 0-10 scales are used. Unlike SF-36, U22 can be used in individual patients.

METHODS

U22 and SF-36 protocols were used in the symptomatic evaluation of 88 patients (mean age = 49.6 +/- 16.4 years; 43 men), who underwent catheter ablation of SVTA.

RESULTS

The U22 scores (SD) for (a) well-being (10 being best), (b) effects of arrhythmia on well-being (10 being worst), and (c) discomfort during arrhythmia (10 being worst) were 5.6 (2.7), 7.5 (2.8), and 8.0 (2.4), respectively. For comparison, the physical and mental component summaries of SF-36 were 45.3 (11.0) and 45.2 (12.1), respectively, slightly lower than the expected normal of 50. The intensity of dominant symptom scored by U22 was 9.7 (1.2), 10 being worst. In 29% of patients > or =4 symptoms were equally dominant. Multiple dominant symptoms in U22 were associated with a low general well-being in SF-36.

CONCLUSION

We found U22 useful to quantify symptoms associated with SVTA.

Reduction of fluoroscopy duration in radiofrequency ablation obtained by the use of a non-fluoroscopic catheter navigation system

AIMS

Radiofrequency (RF) ablation requires placement of several catheters at critical positions. The catheters are positioned with fluoroscopy, resulting in a significant radiation exposure. We have investigated to what degree an intracardiac navigation system reduces the fluoroscopy duration in different groups of routine RF ablations.

METHODS AND RESULTS

The fluoroscopy time was evaluated in 365 consecutive routine RF ablations, performed between 2002 and 2005. An intracardiac navigation system (LocaLisa, Medtronic) was used from 2003. The data were prospectively entered into a database and subsequently retrieved, and the procedures classified as being performed with fluoroscopy only or with the aid of the LocaLisa system. After introduction of the LocaLisa system, the median fluoroscopy time decreased from 24 to 10 min in the 141 atrioventricular nodal re-entry tachycardia (AVNRT) ablations and from 43 to 28 min in the 71 atrial flutter (AFl) ablations (P<0.005 for both). In the 145 Wolff-Parkinson-White (WPW) ablations, a decrease from 27 to 23 min was observed (P=0.03). The decrease in AVNRT and AFl, but not in WPW was associated with the introduction of the LocaLisa system.

CONCLUSION

The use of the LocaLisa system during RF ablations significantly reduced the fluoroscopy time in AVNRT and AFl ablations, by a median of 58% and 46%, respectively.

Injury tolerance and response of the ankle joint in dynamic dorsiflexion

Forced dorsiflexion in frontal vehicle crashes is considered a common cause of injury to the ankle joint. Although a few studies have been published on the dynamic fracture tolerance of the ankle in dorsiflexion, this work reexamines the topic with increased statistical power, adds an evaluation of articular cartilage injury, and utilizes methods to detect the true time of fracture. The objective of this study was to measure the response and injury tolerance of the human ankle in a loading condition similar to that found in a vehicle crash with toepan intrusion. A test fixture was constructed to apply forefoot impacts to twenty cadaveric lower limbs, that were anatomically intact distal to the femur mid-diaphysis. Specimen instrumentation included implanted tibial and fibular load cells, accelerometers, angular rate sensors, and an acoustic sensor. Following the tests, specimens were radiographed and dissected to determine the extent of injury. Eleven of the twenty specimens sustained fracture of the ankle joint. Fractures of the medial malleolus were the most common, while two specimens sustained bimalleolar fractures, and two a talar neck fracture. Other injuries included ligament tears, osteochondral fractures, and cartilage abrasions. Analysis of the acoustic emission indicated that fracture did not always occur at the peak ankle moment. Based on the results of this study, an ankle joint moment of 59 N-m represents a 25% risk of ankle fracture in dorsiflexion for a 50(th) percentile male. When applied to the Thor-Lx dummy, the 25% risk of injury occurs at 36 degrees of dorsiflexion as measured by the ankle potentiometer.

Absorption of irrigating fluid during percutaneous transrenal lithotripsy

Twenty-eight patients who underwent percutaneous lithotripsy with isotonic mannitol solution as the irrigating fluid were studied. Intraoperative intravenous and total absorption of irrigating fluid was estimated from postoperative analyses of plasma and urinary concentrations of mannitol. Most operating times were short and only minor fluid absorption was recorded. In six cases, however, the fluid absorption exceeded 100 ml and two of these had a maximal calculated absorption of more than 1000 ml (1220 and 1860 ml, respectively). Intraoperative bleeding was a warning sign of absorption of irrigating fluid.

Duplex ultrasound in patients with suspected aorto-iliac occlusive disease

Duplex ultrasound scanning was used to localise and classify aorto-iliac occlusive disease. The study included 76 consecutive examinations of 73 patients with signs suggestive of proximal occlusive disease either by history or from traditional non-invasive laboratory investigation. Duplex ultrasound scanning indicated the presence of significant proximal occlusive disease in 70/101 limbs with suspected aorto-iliac disease. In total, 383/393 proximal arterial segments were assessed. A complete evaluation of the aorto-iliac region was possible in 91% of the patients. Duplex scanning was superior to oscillometric amplitude measurements and to CW Doppler examination, especially in patients with concomitant disease of the proximal superficial and deep femoral arteries. Duplex classification of stenoses correlated well with angiographic results obtained in 60 limbs with exact agreement in 194/211 (92%) arterial segments. Three of the patients with disparity between ultrasonography and angiography were investigated with intraarterial pressure measurements demonstrating that these lesions were underestimated by angiography. We conclude that Duplex ultrasound is feasible and accurate in detecting and grading lesions in the aorto-iliac region. This method provides important clinically useful haemodynamic information non-invasively in patients with suspected aorto-iliac occlusive disease.