Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Oesophageal protection during AF ablation: real world registry data and mechanisms behind the therapeutic effect of tissue cooling

Funding Acknowledgements

Type of funding sources: None.

Background

Oesophageal protection using a dedicated device to provide controlled active thermal protection of the oesophagus during atrial fibrillation ablation has been shown to be effective at reducing endoscopically detected oesophageal lesions. Real world registry data of this device and established evidence on the effect of cooling on localized tissue after thermal injury have been under review.

Purpose

To determine the safety of an oesophageal temperature control device by a review of real-world registry data on its clinical use during catheter ablation procedures and to clarify basic mechanisms of its therapeutic action by a literature review of scientific studies on cooling in the context of thermal injury.

Methods

The United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE), FDA Medical and Radiation Emitting Device Recalls, the Medicines and Healthcare products Regulatory Agency (MHRA) Medical Device Alerts and SwissMedic records of Field Safety Corrective Actions (FSCA) databases were reviewed for any device-related adverse events. A systematic literature review was conducted to clarify the findings from studies investigating the physiological processes behind the therapeutic effect of cooling after tissue thermal injury.

Results

Of over 20,000 oesophageal temperature control devices clinically used, 7976 were recorded as having been used for the purpose of oesophageal protection during left atrial catheter ablations. No adverse events occurred related to its use during left atrial catheter ablations. No case of clinically significant oesophageal injury was reported in a patient who had been protected by the oesophageal temperature control device. 208 research articles retrieved from PubMed and MEDLINE that met the search criteria were reviewed. The common finding in all the studies was that cooling had an anti-inflammatory and restorative effect via modulation of several immune-mediated pathways, local cellular function and genetic expression.

Conclusions

There have been no adverse events reported to date in real world clinical use of an oesophageal temperature control device during left atrial catheter ablations, for the purpose of active thermal protection. Literature review data suggests that there are complex biophysical and cellular effects from cooling that leads to its therapeutic effect but further work is required to define the mechanisms of action of thermal protection in this specific context.

Transvenous lead revision for cardiac perforation: a single centre experience

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac perforation is an uncommon but life-threatening complication of cardiac implantable electronic device (CIED) implantation. Management strategy commonly relies on diagnostic Computed Tomography (CT) imaging and cardiac surgery. Emerging evidence has indicated a diversion from this approach. Transvenous culprit lead revision has been shown to be safe and efficacious in limited series.

We sought to evaluate the outcomes of transvenous lead revision in patients with cardiac perforation.

Method

Data was collected retrospectively of patients admitted to a single tertiary centre with CIED-related cardiac perforation between December 2013 – October 2019. Transvenous lead revision was performed as standard with cardiac surgery on standby. Patient demographics, use of CT imaging, method of removal and 30-day outcomes were recorded.

Results

Of the 46 recorded CIED-related cardiac perforations, the majority occurred in female patients (63%) and hypertensives (61%), whilst a proportion had cancer (20%) and ischaemic heart disease (30%). The culprit in most cases was a standard pacing lead (92%) of an active fixation (98%) in the right ventricle (80%) positioned at the ventricular apex (65%). The median time to presentation from implant was 14 days [IQR 4-50 days] with chest pain (44%); abnormal pacing indices was highly prevalent (95%) whilst a pericardial effusion was noted in the majority of cases (57%). CT scanning was performed in 19 cases (41%) for various indications but deemed essential in only 4, all of which had non-diagnostic pacing indices and imaging. Chest X-ray (CXR) found clear perforation, lead displacement or pleural effusion in 74% of cases, whilst an echocardiogram found these in 64% of cases. The culprit lead was replaced in the majority of cases (87%) under local anaesthesia (76%) with surgical backup. The median hospital stay was 7 days [IQR 3-10 days] with zero procedural and 30-day mortality.

Conclusion

Transvenous lead revision for CIED-related cardiac perforation is safe and efficacious. CT modality for diagnostic purposes is useful in providing incremental value in a minority of cases; patients with non-diagnostic pacing parameters and non-CT imaging benefit most from this.

A registry review of 2532 catheter ablations for atrial fibrillation using active thermal protection

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Dr Leung has received research support from Attune Medical (Chicago, IL). Dr Gallagher has received research funding from Attune Medical (Chicago, IL).

Background

  Thermal injury to the oesophagus causes a spectrum of adverse effects after ablation for atrial fibrillation (AF); at the most severe end, atrio-oesophageal fistula carries a high mortality rate. Controlled active thermal protection in the oesophagus during ablation is the most promising method of oesophageal protection. Randomized evidence from the IMPACT trial (NCT03819946) showed an 83.4% reduction in endoscopically detected oesophageal lesions compared to standard care when an oesophageal temperature control device was used to control the local temperature. The IMPACT patients who were randomized to the use of the device had no adverse event related to its use.  Real world registry data on applications of this device have not previously been available. 

Purpose

To determine the safety of an oesophageal temperature control device by review of real-world registry data on its clinical use and any reported device-related adverse events.

Methods

  We reviewed the following databases for any reported oesophageal temperature control device-related complications: The United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE), FDA Medical and Radiation Emitting Device Recalls, the Medicines and Healthcare products Regulatory Agency (MHRA) Medical Device Alerts and SwissMedic records of Field Safety Corrective Actions (FSCA). An internal registry (post-marketing follow up) database maintained by the manufacturer of the device was used to quantify the number used for each indication.  Reported events were reviewed and catalogued for description and identification of any events related to its use in the cardiac electrophysiology lab. The IMPACT study patients were reviewed for any device-related events.

Results

  Of the 13, 284 oesophageal temperature control devices used, 2532 were recorded as having been used for the purpose of oesophageal protection during catheter ablation for AF.  A total of 5 events associated with the device were identified, all from the MAUDE database.  Three were from 2017, one from 2018, and one from 2019.  All involved its use in critical care or trauma patients and were related to user error or contraindicated patient selection; none resulted in serious harm to the patient. No adverse events occurred related to its use in the cardiac electrophysiology lab. No case of clinically significant oesophageal injury was reported in a patient who had been protected by the oesophageal temperature control device.

Conclusions

Real world registry data has shown no adverse events reported to date in over 2500 uses of an oesophageal temperature control device in the cardiac electrophysiology lab, for the purpose of active thermal protection. This data supports the randomized trial evidence of its clinical effectiveness. Abstract Figure. Oesophageal active thermal protection

Patient outcomes after AF ablation using Ablation Index technology with oesophageal protection: insight from the IMPACT study

Background

Atrio-oesophageal fistula formation accounts for the majority of AF ablation-related morbidity and mortality. Thermal injury to the oesophagus can be significantly reduced by application of oesophageal cooling for protection during AF ablation. The effect of this method of oesophageal protection in patients receiving radiofrequency (RF) ablation guided by Ablation Index technology is currently unknown.

Objective

To investigate the ability of a temperature control device to protect the oesophagus from ablation-related thermal injury in patients receiving AF ablation guided by Ablation Index technology.

Methods

The IMPACT study is a single-centre, prospective, double-blind randomized controlled trial, which investigated the ability of a controlled method of oesophageal cooling to protect the oesophagus from ablation-related thermal injury. The EnsoETM device was used to deliver oesophageal cooling. This method was compared in a 1:1 randomization to a control group of standard practice utilizing a single-sensor temperature probe. In the study group, the device was used to keep the luminal temperature at 4°C during RF ablation. All participants received AF ablation using Ablation Index technology at posterior and anterior settings (30W at 350–400 and 40W at 450–500, respectively). Endoscopic examination was performed within 7 days post-ablation and oesophageal injury was graded. The patient and the endoscopist were blinded to the randomization. Structured clinical follow up occurred after 3 months post-ablation; both patient and follow up clinician were blinded.

Results

We recruited 188 patients, of whom 120 underwent endoscopic evaluation. Thermal injury to the mucosa was significantly more common in the control group than in those receiving oesophageal protection (12/60 versus 2/60; P=0.008). There was no difference between groups in RF time, lesion duration, force, power and combined ablation index (P value range= 0.2–0.9). Procedure and fluoroscopy duration were similar (P=0.97, P=0.91 respectively). The majority of those who passed through the 1st follow up evaluation (n=136) did not have gastrointestinal or chest pain symptoms post ablation and there was no difference between the randomized groups. Only 4.4% overall had severe symptoms and they were poorly correlated against those who sustained mucosal lesions. AF recurrence was similar in both groups (8% vs 8.8%). There were 2 cases of vascular trauma needing intervention in the control group and 1 case of conservatively managed pericardial effusion in the protected group only. Clinical and endoscopy findings did not report any EnsoETM device-related trauma.

Conclusion

Thermal protection of the oesophagus significantly reduces ablation-related thermal injury compared to standard care when ablation is performed using radiofrequency with Ablation Index technology. This method of oesophageal protection is safe and does not compromise the efficacy of the ablation procedure.

Endoscopy findings and patient symptoms.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): 1. Public hospital: St. George's NHS Foundation Trust; 2. Private company: Attune Medical (Chicago, IL)

Angiogenesis and the tumour hypoxia response in prostate cancer: a review

The formation of new blood vessels, angiogenesis, is a highly-regulated active process that is critical for the development of the normal and malignant prostate. The vascular endothelial growth factor (VEGF) system assumes a critical role in the angiogenic process. Angiogenesis is a prerequisite for the expansion of solid tumours beyond 1-3 mm3 and is stimulated in response to a hypoxic environment. This review discusses the process of angiogenesis and the key angiogenic mediator, VEGF, and their role in tumour progression and metastasis. A better understanding of the mechanisms behind angiogenesis will ultimately lead to the development of new anti-angiogenic agents in the management of prostate cancer.

The evolution of the doctor-patient relationship

The doctor-patient relationship has undergone a transition throughout the ages. Prior to the last two decades, the relationship was predominantly between a patient seeking help and a doctor whose decisions were silently complied with by the patient. In this paternalistic model of the doctor-patient relationship, the doctor utilises his skills to choose the necessary interventions and treatments most likely to restore the patient's health or ameliorate his pain. Any information given to the patient is selected to encourage them to consent to the doctor's decisions. This description of the asymmetrical or imbalanced interaction between doctor and patient [Parsons T. The social system. Free Press, New York, 1951.](1) has been challenged during the last 20 years. Critics have proposed a more active, autonomous and thus patient-centred role for the patient who advocates greater patient control, reduced physician dominance, and more mutual participation. This patient-centred approach has been described as one where "the physician tries to enter the patient's world, to see the illness through the patient's eyes" [McWhinney I. The need for a transformed clinical method. In: Stewart M, Roter D, Communicating with medical patients. London: Sage, 1989.](2), and has become the predominant model in clinical practice today.

Evaluation of the mechanisms of damage to flexible ureteroscopes and suggestions for ureteroscope preservation

AIM

To investigate the causes and costs of flexible ureteroscope damage, and to develop recommendations to limit damage.

METHODS

The authors analysed repair figures and possible causes of damage to 35 instruments sent for repair to a leading UK supplier over a 1-year period, and calculated cost figures for maintenance of the instruments as opposed to repair and replacement costs.

RESULTS

All damages were handling-induced and therefore did not fall under the manufacturer's warranty: 28 % were damaged by misfiring of the laser inside the instrument; 72 %, mainly crushing and stripping of the ureteroscope shaft tube, were likely to have occurred during out-of-surgery handling, washing and disinfection. Seventeen (4 %) instruments were not repaired and consequently taken out of service due to the extensive costs involved. Eighteen (51 %) ureteroscopes were repaired at an average cost of 10 833 USD.

CONCLUSION

Damages to flexible ureteroscopes bear considerable costs. Most damages occur during handling between surgical procedures. Thorough adherence to handling procedures, and courses for theater staff and surgeons on handling flexible instruments may help to reduce these damages and prove a cost-saving investment. The authors provide a list of recommended procedural measures that may help to prevent such damages.

The risks and benefits of cyclo-oxygenase-2 inhibitors in prostate cancer: A review

Cyclo-oxygenase (COX), also referred to as prostaglandin (PG) endoperoxidase synthase, is a key enzymatic mediator in the production of arachidonic acids to PGs and eicosanoids. Two isoforms of COX exist, namely COX-1 and COX-2, which have distinct physiological functions and tissue distribution. Epidemiological studies suggest that regular consumption of aspirin and/or other non-steroidal anti-inflammatory drugs (NSAIDs), which inhibit COX, could notably reduce the risk of developing many cancers. COX-2 expression has been shown to increase in many cancers and cancer cell lines, including human prostate adenocarcinoma. COX-2 may also be upregulated in proliferative inflammatory atrophy (PIA) of the prostate, a pre-neoplastic lesion. The COX-2 pathway may therefore be a useful target for chemoprevention of prostate cancer, and there is much interest in exploring this with the use of COX-2 inhibitor drugs such as celecoxib. While there is concern regarding the cardiovascular toxicities of coxibs, there is no evidence that there is any increased risk with the use of celecoxib in the short-term neoadjuvant setting.

Why Do Orthopaedic Surgeons Ignore the Medial Patellofemoral Ligament?

The medial patellofemoral ligament (MPFL) is a condensation of the medial capsule of the knee joint. In the past two decades dissection studies have shown that it extends from the superomedial border of the patella to the femoral epicondyle, at or immediately above the adductor tubercle. MRI and operative studies have revealed that it is almost invariably damaged by lateral patellofemoral dislocation. Current surgical management of such dislocations may involve imbricating the torn medial capsule and parapatellar retinaculum back onto the medial border of the patella. If the medial patellofemoral ligament is torn at or near the femoral attachment, as the latest MRI and operative studies demonstrate it frequently is, then this medial reefing procedure will not be successful in restoring normal anatomy and function. Here we review the anatomy and function of the MPFL, its role in patellar dislocation and as well as surgical treatment for patellar dislocation.

Immunocytochemical analysis of connexin expression in the healthy and diseased cardiovascular system

Gap junctions play essential roles in the normal function of the heart and arteries, mediating the spread of the electrical impulse that stimulates synchronized contraction of the cardiac chambers, and contributing to co-ordination of activities between cells of the arterial wall. In common with other multicellular systems, cardiovascular tissues express multiple connexin isotypes that confer distinctive channel properties. This review highlights how state-of-the-art immunocytochemical and cellular imaging techniques, as part of a multidisciplinary approach in gap junction research, have advanced our understanding of connexin diversity in cardiovascular cell function in health and disease. In the heart, spatially defined patterns of expression of three connexin isotypes-connexin43, connexin40, and connexin45-underlie the precisely orchestrated patterns of current flow governing the normal cardiac rhythm. Derangement of gap junction organization and/or reduced expression of connexin43 are associated with arrhythmic tendency in the diseased human ventricle, and high levels of connexin40 in the atrium are associated with increased risk of developing atrial fibrillation after coronary by-pass surgery. In the major arteries, endothelial gap junctions may simultaneously express three connexin isotypes, connexin40, connexin37, and connexin43; underlying medial smooth muscle, by contrast, predominantly expresses connexin43, with connexin45 additionally expressed at restricted sites. In normal arterial smooth muscle, the abundance of connexin43 gap junctions varies according to vascular site, and shows an inverse relationship with desmin expression and positive correlation with the quantity of extracellular matrix. Increased connexin43 expression between smooth muscle cells is closely linked to phenotypic transformation in early human coronary atherosclerosis and in the response of the arterial wall to injury. Current evidence thus suggests that gap junctions in both their guises, as pathways for cell-to-cell signaling in the vessel wall and as pathways for impulse conduction in the heart, contribute to the initial pathogenesis and eventual clinical manifestation of human cardiovascular disease.

Altered connexin expression in human congestive heart failure

Congestive heart failure is associated with a high risk of life-threatening ventricular re-entrant arrhythmias. Down-regulation of the principal gap-junctional protein of the ventricular myocytes, connexin43, has previously been implicated in arrhythmia in ischaemic heart disease, but it is not known whether connexin43 is similarly reduced in heart failure due to idiopathic dilated cardiomyopathy, whether disease-related connexin43 down-regulation occurs at the level of transcription or translation, or whether the expression of other connexin isotypes is altered in congestive heart failure. We therefore investigated the expression of the four connexins expressed in the heart-connexins 43, 40, 45 and 37-at the mRNA and protein levels in explanted hearts from transplant patients with end-stage heart failure (NYHA class 4) by immunoconfocal analysis, and northern and western blotting. Connexin43 mRNA and protein were markedly downregulated in the left ventricle in end-stage heart failure due both to ischaemic cardiomyopathy and idiopathic dilated cardiomyopathy. Connexin43 content was spatially heterogeneous in the diseased ventricle. Connexin40 mRNA was increased in the ischaemic group, more so in the left ventricle than the right. This correlated with an increased depth of connexin40 protein expression in myocytes at the endocardial surface. Connexin45 mRNA and protein, present only in very low quantities, followed a similar trend to connexin43, while connexin37 (exclusively expressed in endothelium) showed no change. Our findings show that congestive heart failure is associated with significantly reduced levels of the principal gap junction protein, connexin43, in the left ventricle, potentially contributing to enhanced arrhythmogenicity and contractile dysfunction. This down-regulation is due predominantly to a reduced transcript steady-state level. Elevated connexin40 may represent a compensatory response that improves the spread of depolarization in the otherwise compromised ischaemic ventricle.

Comparison of connexin 43, 40 and 45 expression patterns in the developing human and mouse hearts

The mouse is currently widely used as a model organism in the analysis of gene function but how developmentally regulated patterns of connexin gene expression in the mouse compare with those in the human is unclear. Here we compare the patterns of connexin expression in the heart during the development of the mouse (from embryonic day 12.5 to 6 weeks postpartum) and the human (at 9 weeks gestation and adult stage). The extent of connexin43 expression in the ventricles progressively increased during development of the mouse heart. The developmental pattern of expression for connexins 40 and 45 in the mouse heart was similar, but not identical, and in the ventricles showed a progressive and preferential expression in the conduction system. In general, these dynamic changes of connexins 43, 40 and 45 during mouse cardiac development appear to be mirrored in the human.

Differential expression of connexin43 and desmin defines two subpopulations of medial smooth muscle cells in the human internal mammary artery

Upregulation of connexin43-gap junctions is associated with transition of contractile vascular smooth muscle cells (SMCs) to the synthetic state. To determine whether phenotypically distinct subpopulations of medial SMCs differentially express connexin43, we investigated the human distal internal mammary artery, a structurally heterogeneous vessel with features ranging from elastic to elastomuscular to muscular. Immunoconfocal microscopy combined with quantitative analysis and complemented by in situ hybridization showed that SMCs in the elastic medial regions expressed high levels of connexin43 but low levels of desmin, whereas those of muscular medial regions expressed low levels of connexin43 but high levels of desmin. Ultrastructurally, SMCs of both regions were of the contractile phenotype, but the former cells were irregular in shape with relatively prominent synthetic organelles whereas the latter were spindle shaped with fewer synthetic organelles. Vimentin, smooth muscle alpha-actin, calponin, h-caldesmon, and myosin heavy chains (SM1 and SM2) were equally highly expressed by most cells in both subpopulations. The connexin43/desmin expression pattern of SMCs in regions of intimal thickening resembled those of elastic medial regions. These findings refine the view suggested from previous studies that high levels of connexin43 expression are associated with SMCs of a less contractile/more synthetic phenotype. In the internal mammary artery, the 2 subpopulations of SMCs with markedly different connexin43 expression levels both represent a differentiated contractile phenotype, but the subpopulation showing high levels of connexin43-gap junctions is characterized by low levels of desmin and structural features that reflect a more synthetic tendency.