Low incidence of major complications after the first six hours post-atrial fibrillation ablation – same-day discharge safe and feasible in most patients

Background/Introduction

Catheter ablation of atrial fibrillation (AF) is associated with a complication risk. It is common practice to monitor patients overnight post-procedurally which is resource craving.

Purpose

To evaluate the incidence of procedural complications related to catheter ablation of AF to assess the potential feasibility and safety of same day discharge in a large cohort.

Methods

We performed an analysis of prospectively collected data of complications of all patients staying overnight after undergoing AF ablation between 2001 and 2020 at a tertiary centre. By studying medical records, we analysed complications occurring intraprocedurally until six hours post-ablation, and between six hours post-ablation until discharge the day after ablation procedure (up to 24 hours post-procedure).

Results

In 5414 AF ablations we identified a total of 108 (2.0%) major complications occurring intraprocedural or until discharge the day after procedure. Most major complications occurred early and were detected intraprocedurally or within six hours after completed procedure (n=96, 1.8%). Twelve (0.2%) major complications occurred between six hours post-ablation and until discharge the day after procedure. The most common of these were congestive heart failure (n=6) and transient ischemic attack (TIA, n=4). In addition, there were 61 (1.1%) minor complications which occurred in this time span. Factors independently associated with major complications intraprocedurally or within 24 hours were age (p=0.046), body mass index (BMI) ≥30 kg/m2 (p=0.009), significant valvular disease (p=0.001), cardiomyopathy (p<0.001), prior stroke or TIA (p=0.014), first time procedure vs. repeat procedure (p=0.013), cryoablation vs. radiofrequency (p<0.001) and procedure duration (p<0.001).

Conclusion

Very few complications occurred between six hours and until discharge after ablation of atrial fibrillation. Therefore, same-day discharge may be a safe option for a large proportion of patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Region Stockholm funding

Cryoablation as standard treatment of atrial flutter: a prospective, 2-center study (CASTAF)

BACKGROUND

Cryoablation (CRYO) of cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) has been shown to be non-inferior to radiofrequency ablation (RF) in terms of ablation success and is associated with less pain. However, procedural time has been significantly longer with CRYO compared to RF. A possible explanation for this could be that operators had less experience with CRYO than with RF. The purpose of this study was to test the hypothesis that in the hands of experienced operators, cryoablation of CTI-dependent AFL is effective with procedure-time similar to what is reported for RF.

METHODS

This prospective 2-center study included 184 patients with CTI-dependent AFL - median age 66 years (range 28-83), 159 men (86%). Cryoablation was performed using a 9 F, 8 mm tip catheter (Freezor MAX, Medtronic, Inc, MN, USA). Ablation endpoint was bidirectional CTI-block. Pain was evaluated with a visual analogue scale (VAS 0-10). All operators had experience of at least 25 previous CTI-ablations with CRYO.

RESULTS

The acute success rate was 89%. Procedural time including an observation period of 30 min, was 115 ± 36 min which is similar to procedural times for RF in previous studies. Fluoroscopy time was 11 ± 9 min. Cryoablation was perceived as almost pain- free by the patients, VAS (mean) 1.8 ± 1.2. Success rate at 12-month follow-up (FU) was 88% in patients with primary success. No major adverse events occurred.

CONCLUSIONS

Cryoablation of CTI-dependent AFL is effective, with a low level of procedure-related pain. In experienced hands, the procedure time in this prospective non-randomised trial seems to be in the level of reported procedure times for RF. The long-term relapse rate appears to be higher than for RF.

Sinus heart rate post pulmonary vein ablation and long-term risk of recurrences

Aim

To investigate the association of sinus heart rate pre- and post-ablation and recurrence rates in patients undergoing catheter ablation for atrial fibrillation.

Methods

Between January 2012 and December 2017, data of 482 patients undergoing their first pulmonary vein isolation (PVI) were included. All patients were followed-up for 12 months and were screened for any atrial tachyarrhythmia. Sinus heart rate measurements were recorded before (PRE), directly post ablation (POST) and 3 months post ablation (3M).

Results

In the total study population, the mean resting sinus heart rate at PRE (mean 57.9 bpm (95% CI, 57.1–58.7 bpm)) increased by over 10 bpm to POST (mean 69.4 bpm (95% CI, 68.5–70.3 bpm); p<0.001) followed by a slight decrease at 3M (mean 67.3 bpm (95% CI, 66.4–68.2 bpm)) but still remaining higher compared to PRE (p<0.001). This pattern was observed in patients with and without recurrences at PRE, POST and 3M respectively (both p<0.001). However, only at 3M, there was a significant difference in mean heart rate being lower in patients with compared to patients without recurrences (p=0.031). In this regard, patients with a heart rate ≥60 bpm at 3M and a heart rate change ≥11 bpm (PRE to 3M) had a favorable outcome in terms of recurrences compared to the remaining patients (HR 0.61 (95% CI, 0.44–0.84), p=0.002 and HR 0.55 (95% CI, 0.40–0.76), p<0.001, respectively). These variables remained independently associated in multivariable analysis.

Conclusion

Our study confirms the impact of PVI on cardiac autonomic function with a significant heart increase post-ablation. A heart rate ≥60bpm at 3M and a heart rate change ≥11 bpm (PRE to 3M) are associated with a favorable outcome in terms of recurrences.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation

Long-term outcome of patients with invasive electrophysiology procedure related cardiac tamponade

Aims

Iatrogenic cardiac tamponades are a rare but dreaded complication of invasive electrophysiology procedures (EPs). Their long-term impact on clinical outcomes is unknown. This study analyzed the risk of death or serious cardiovascular events in patients suffering from EP related cardiac tamponade requiring pericardiocentesis during long-term follow-up.

Methods and results

Out of 19997 invasive EPs at our university hospital between January 1998 and September 2018, all patients with EP related periprocedural cardiac tamponade were identified (n=60) and matched (1:3 ratio) to a control group (n=180). After a follow-up of 5 years, the composite primary end point - death from any cause, acute myocardial infarction, TIA/stroke and hospitalization for heart failure – occurred in significantly more patients in the tamponade than in the control group (12 patients (20.0%) vs 19 patients (10.6%); Hazard ratio (HR) 2.53 (95% CI, 1.15–5.58); p=0.021). This was mainly driven by a higher incidence of TIA/stroke in the tamponade than in the control group (HR 3.75 (95% CI, 1.01–13.97); p=0.049). Death from any cause, acute myocardial infarction and hospitalization for heart failure did not show a significant difference between the groups. Hospitalization for pericarditis occurred in significantly more patients in the tamponade than in the control group (HR 36.0 (95% CI, 4.68–276.86); p=0.001).

Conclusion

Patients with EP related cardiac tamponade are at higher risk for cerebrovascular events during the first two weeks and hospitalization for pericarditis during the first months after index procedure. Despite the increased risk for early complications tamponade patients have a good long-term prognosis without increased risk for mortality or other serious cardiovascular events.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation

2202Instant analysis of the ECG with a new digital technique during palpitations reduce symptoms, anxiety, depression, and increase HRQOL in women

Background

Palpitation is common, particularly in women, and usually benign caused by premature atrial/ventricular beats or stress-induced sinus tachycardia. Palpitations may cause disturbing symptoms, anxiety, depression, and decreased health related quality of life (HRQOL). Uncommonly, arrhythmias of clinical importance such as atrial fibrillation or paroxysmal supraventricular or ventricular tachycardia may be the cause.

Purposes

To evaluate if instant analysis of underlying heart rhythm during palpitations reduce symptoms, anxiety, depression, and increase HRQOL.

Methods

In all, 913 women (age 56±11 years) with palpitations causing anxiety were recruited from social web sites. Coala Heart Monitor® was used by participants and ECG recorded twice a day and at symptoms for 60 days. The system uses a well-validated algorithm to analyze heart rhythm, is connected to the user's smartphone and provides immediate response to the user. In cases of non-benign arrhythmias, the result was also analyzed manually. Questionnaires addressing symptom (Symptom severity and frequency checklist (SCL), anxiety, depression Hospital anxiety and depression scale (HADS), Generalized Anxiety Disorder (GAD-7) and HRQOL (RAND-36)) were analyzed before and after two months. Exclusion criterium was known atrial fibrillation.

Results

Between June 2018 and November 2018, 280 474 recordings (both chest and thumbs) ECG recordings were automatically analyzed. Frequency and severity of symptoms decreased (frequency from 23.7±8.4 to 19.7±8.5 (p<0.001), severity from 22.7±4.9 to 21±4.4 (p<0.001)). Total anxiety measured by HADS decreased from 6.4±4.2 to 5.7±4.2 (p<0.001) and depression from 5.1±3.9 to 4.6±4.1 (p<0.001). Generalized anxiety disorder decreased from 5.6±4.8 to 4.7±4.6 (p<0.001) and HRQOL increased in all domains (p<0.001). In 83% of recordings during symptomatic palpitation, benign premature atrial or ventricular beats, sinus tachycardia, or normal sinus rhythm were found.

Conclusions

Instant analysis of the ECG with direct response to the user during palpitations reduce symptoms, anxiety, depression, and increase HRQOL in women.

P6574Symptomatic palpitations causing anxiety in women, what are the underlying arrhythmias

Background

Highly symptomatic palpitations are common, particularly in women, and may cause disturbing symptoms including anxiety, depression, and decreased health related quality of life. Palpitation in this context has been considered generally benign and caused by premature atrial or ventricular beats or stress-induced sinus tachycardia. However, how often arrhythmias of clinical importance such as atrial fibrillation and supraventricular or ventricular tachycardia is the cause is unknown.

Purpose

To evaluate to what extent symptomatic palpitation in women is caused by clinically important arrhythmias.

Methods

A new Swedish digital technique was used. The system uses a well-validated algorithm to analyze heart rhythm (both thumbs and chest recordings), is connected to the user's smartphone and provides immediate response to the user. The result is simultaneously available for the supervising physician. In cases of non-benign arrhythmias, the result was also analyzed manually. In all, 909 women (age 56±11 years) with palpitations causing anxiety were included. ECG was recorded twice a day and at symptoms for 60 days. Participants with known atrial fibrillation were excluded.

Results

In all, 6 861 ECG recordings were done due to symptomatic palpitation. Underlying heart rhythms were as follows: normal sinus rhythm (73%), sinus tachycardia (12%), premature atrial beats or ventricular beats (7%), atrial fibrillation (4%), benign sinus bradycardia and second-degree AV block type 1 (4%), and supraventricular tachycardia (1%). In 1% of recordings, quality was too poor for analysis. No ventricular tachycardia was recorded. In all, 19 women with previously undiagnosed atrial fibrillation and 12 women with undiagnosed supraventricular tachycardia were found.

Conclusions

In the great majority of episodes causing symptomatic palpitation in women, the underlying arrhythmia is benign. However, in 5% previously undiagnosed atrial fibrillation or supraventricular tachycardia were found.

Sinus node recovery time assessment revisited: role of pharmacologic blockade of the autonomic nervous system

Sinus node recovery time assessment is used to diagnose clinically significant sinus node dysfunction (SND) when Holter has failed to prove a relationship between sinus bradyarrhythmias and symptoms, but consensus has not been reached as to the value of including assessment after pharmacologic blockade of the autonomic nervous system. This issue was addressed in the present study performed on 52 patients with syncope or presyncope/dizziness (n = 48), sinus bradyarrhythmias (n = 45), or both (n = 41). Group 1 consisted of 13 patients with a proven relationship between symptoms and sinus bradyarrhythmias. Group 2 consisted of 39 patients with suspected SND. The protocol included three pacing periods at two pacing rates and was performed at baseline (n = 52), after single doses of atropine and propranolol (0.02 mg/kg and 0.1 mg/kg, respectively) (n = 41), and again after a second dose (n = 29). The sensitivity of prolonged recovery times was 77% in group 1. Among group 2 patients, 56% had prolonged recovery times at baseline (79% when including the results after the first dose of drugs). The second dose did not contribute diagnostic information, but it caused significant adverse reactions in 7 of 29 patients (P < 0.001). These 7 patients were all older than 60 years. Assessment of sinus node recovery time after pharmacologic blockade of the autonomic nervous system thus increases the sensitivity of the method in patients with suspected SND and normal baseline results. However, only 50% of the initially suggested doses of atropine and propranolol is sufficient and eliminates the risk for significant adverse reactions.

Selective Ik blocker almokalant exhibits class III--specific effects on the repolarization and refractoriness of the human heart: a study of healthy volunteers using right ventricular monophasic action potential recordings

Almokalant, a recently developed potassium-channel blocker, has exhibited properties of a selective class III agent in vitro and in animal experiments. We report the first invasive study in humans in which the electrophysiological characteristics of almokalant were assessed. Thirty-four healthy males received bolus and maintenance infusions of almokalant to two of our target plasma concentrations of 20, 50, 100, and 150 nM. Electrophysiological variables were assessed during stimulation at 100 and 120 beats/min at baseline and at two consecutive targeted levels. Almokalant dose-dependently increased the duration of the monophasic action potential (MAP) above a mean plasma concentration of 60 nM. The duration at 90% repolarization significantly increased by 20% from baseline at 100 beats/min (p < 0.00005), and by 19% at 120 beats/min (p < 0.00005), at a mean plasma concentration of 116 nM. During atrial stimulation, there was a significant increase in the QT interval, amounting to 24% at 100 beats/min (p < 0.00005) and to 30% at 120 beats/min (p = 0.0006), at 124 nM. During right ventricular stimulation in the apical region, the QT interval significantly increased by 17% at 100 beats/min (p < 0.00005), and 13% at 120 beats/min (p < 0.00005). During stimulation from the right ventricular outflow tract, the QT interval increased to a lesser extent and significantly only at 120 beats/min: 9% at 100 beats/min (p = NS) and 6% at 120 beats/min (p = 0.001) at 118 nM. The effective refractory period (ERP) of the atria increased by 18% at 100 beats/min at 119 nM (p = 0.005). The right ventricular ERP increased by 16% at both heart rates (HR) (p < 0.00005) during stimulation from the apical region, and by 11% during stimulation from the outflow tract (p = 0.0001 at 100 beats/min and p = 0.0006 at 120 beats/min). There was no effect on the ERP of the atrioventricular node, (AVN) on the sinus node function or cardiac conduction. Two individuals experienced a transient metallic taste during bolus infusion aiming at 50 and 100 nM, but this side effect did not occur in the group receiving the highest doses. Pronounced T-wave/U-wave (TU) morphology changes were observed in 4 individuals. Almokalant exhibited characteristics of a pure class III agent with no effects on cardiac conduction or sinus node function when given intravenously. Although no proarrhythmias were observed, the development of TU morphology changes and increased spatial dispersion of repolarization after the highest doses warrants further studies regarding the safety profile of the drug.

HLA-B27: an important genetic risk factor for lone aortic regurgitation and severe conduction system abnormalities

PURPOSE

HLA-B27, an immunogenetic marker that is present in 8 percent of the white population around the world, has been found to be an important risk factor for the development of a group of rheumatic disorders, the seronegative spondyloarthropathies. Our objective was to assess the possible role of HLA-B27 and the associated inflammatory disease process in the development of lone aortic regurgitation.

PATIENTS AND METHODS

A group of 91 patients with lone aortic regurgitation were studied by HLA typing and clinical and roentgenologic examination.

RESULTS

The HLA-B27-associated inflammatory disease process was found to be the probable underlying cause in 15 to 20 percent of patients with lone aortic regurgitation of different degrees of severity. Furthermore, HLA-B27 was found in 88 percent of the male patients with the combination of aortic regurgitation and severe conduction system abnormalities.

CONCLUSION

We suggest that this cardiac syndrome should be regarded as an HLA-B27-associated syndrome, sometimes part of ankylosing spondylitis or Reiter's disease, but just as often presenting without obvious rheumatic disease. The marker is thus an important and widely distributed risk factor not only for the development of rheumatic disease but also for acquired aortic regurgitation and sever conduction system abnormalities.