Heart-Focused Anxiety, General Anxiety, Depression and Health-Related Quality of Life in Patients with Atrial Fibrillation Undergoing Pulmonary Vein Isolation

(1) Background: Atrial fibrillation (AF) is associated with anxiety, depression, and chronic stress, and vice versa. The purpose of this study was to evaluate potential effects of pulmonary vein isolation (PVI) on psychological factors. (2) Methods: Psychological assessment was performed before PVI as well as after six months. (3) Results: A total of 118 patients [age 64 ± 9 years, 69% male, left ventricular ejection fraction 57 ± 8%, 56% paroxysmal AF] undergoing PVI were included. After PVI, significant improvements were observed in the mean total heart-focused anxiety (HFA) score, as well as in the Cardiac Anxiety Questionnaire (CAQ) sub-scores: HFA attention, HFA fear, and HFA avoidance scores. Subgroup analyses showed an association of improvement with freedom of documented AF recurrence. Mean scores of general anxiety and depression evaluated by the Hospital Anxiety and Depression Scale (HADS) decreased significantly after PVI in all subgroups regardless of AF recurrence. Further, both physical and mental composite scores of the Short Form Health Survey (SF-12) increased significantly from baseline. (4) Conclusions: PVI results in a significant reduction in HFA. Improvements in general anxiety and depressive symptoms did not seem to be related only to rhythm control per se. Therefore, CAQ may represent a more specific evaluation tool as HADS in patients with AF.

Nutritional support during the hospital stay reduces mortality in patients with different types of cancers: secondary analysis of a prospective randomized trial

BACKGROUND

Nutritional support in patients with cancer aims at improving quality of life. Whether use of nutritional support is also effective in improving clinical outcomes requires further study.

PATIENTS AND METHODS

In this preplanned secondary analysis of patients with cancer included in a prospective, randomized-controlled, Swiss, multicenter trial (EFFORT), we compared protocol-guided individualized nutritional support (intervention group) to standard hospital food (control group) regarding mortality at 30-day (primary endpoint) and other clinical outcomes.

RESULTS

We analyzed 506 patients with a main admission diagnosis of cancer, including lung cancer (n = 113), gastrointestinal tumors (n = 84), hematological malignancies (n = 108) and other types of cancer (n = 201). Nutritional risk based on Nutritional Risk Screening (NRS 2002) was an independent predictor for mortality over 180 days with an (age-, sex-, center-, type of cancer-, tumor activity- and treatment-) adjusted hazard ratio of 1.29 (95% CI 1.09-1.54; P = 0.004) per point increase in NRS. In the 30-day follow-up period, 50 patients (19.9%) died in the control group compared to 36 (14.1%) in the intervention group resulting in an adjusted odds ratio of 0.57 (95% CI 0.35-0.94; P = 0.027). Interaction tests did not show significant differences in mortality across the cancer type subgroups. Nutritional support also significantly improved functional outcomes and quality of life measures.

CONCLUSIONS

Compared to usual hospital nutrition without nutrition support, individualized nutritional support reduced the risk of mortality and improved functional and quality of life outcomes in cancer patients with increased nutritional risk. These data further support the inclusion of nutritional care in cancer management guidelines.

Mapping of an atrial tachycardia after Epicor™ high-intensity focused ultrasound ablation: A case report

BACKGROUND

Surgical techniques, such as the application of high-intensity focused ultrasound (HIFU), can be used for pulmonary vein isolation (PVI).

CASE SUMMARY

We report a case of a 73-year old patient, in whom HIFU failed to achieve PVI but promoted the occurrence of a scar-related atrial tachycardia (AT). Voltage mapping of the left atrium revealed multiple gaps along the ablation line. Coherent mapping with visualization of velocity vectors allowed the correct interpretation and the targeted ablation of the AT.

DISCUSSION

Cardiac surgery can promote scar-related AT. The coherent mapping function could simplify the mapping of scar-related AT in the future.

Inducibility of atrial fibrillation after catheter ablation predicts recurrences of atrial fibrillation: a meta-analysis

BACKGROUND

Pulmonary vein isolation (PVI) is a component of standard care for patients with symptomatic atrial fibrillation (AF). Procedural inducibility of AF following PVI has been suggested as predictor of AF recurrence but is discussed controversially. This meta-analysis aimed at evaluating the relevance of electrophysiological inducibility of AF following PVI for future AF recurrences.

METHODS

A literature search of MEDLINE and Web of Science was performed until April 2020. Prospective trials of PVI in patients with AF and post-procedural atrial stimulation to test for inducibility of AF as well as adequate follow-up for AF recurrence (defined as AF >10 s to >10 min at follow-up) were included. Odds ratios (ORs) were analyzed using random-effects models.

RESULTS

A total of 11 trials with 1544 patients (follow-up 7-39 months, age 56 ± 6 years, predominantly male 74 ± 6%) were included. Inducibility of AF post-PVI was predictive for AF recurrence during follow-up (OR 2.08; 95% CI 1.25 to 3.46). Prediction for AF recurrence at follow-up was better for patients with paroxysmal AF (OR 4.06; 95% CI 1.39 to 11.91), stimulation in the CS (OR 2.82, 95% CI 1.17 to 6.79). A trend towards higher ORs was seen without the use of isoproterenol (OR 2.43; 95% CI 1.17 to 5.07), as well as few stimulations during induction and a short definition of AF in meta-regression analyses.

CONCLUSIONS

Electrophysiological inducibility of AF following PVI was predictive for future recurrence of AF, in particular in patients with paroxysmal AF, stimulation in only CS and no use of isoproterenol.

Remote Monitoring With Appropriate Reaction to Alerts Was Associated With Improved Outcomes in Chronic Heart Failure: Results From the OptiLink HF Study

BACKGROUND

Impedance-based remote monitoring (RM) failed to reduce clinical events in the OptiLink heart failure (HF) trial. However, rates of alert-driven interventions triggered by intrathoracic fluid index threshold crossings (FTC) were low indicating physicians' inappropriate reactions to alerts.

METHODS

We separated appropriate from inappropriate contacts to FTC transmissions in the OptiLink HF trial (Optimization of Heart Failure Management Using OptiVol™ Fluid Status Monitoring and CareLink™). Appropriate contacts had to meet the following criteria: (1) initial telephone contact within 2 working days after FTC transmission, (2) follow-up contacts according to study protocol, and (3) medical intervention initiated after FTC due to cardiac decompensation. We compared time to cardiovascular death or HF hospitalization between RM patients contacted appropriately or inappropriately and patients with usual care.

RESULTS

In the RM group, at least one FTC alert was transmitted in 356 patients (70.5%; n=505). Of note, only 55.5% (n=758) of all transmitted FTCs (n=1365) were followed by an appropriate contact. While 113 patients (31.7%; n=356) have been contacted appropriately after every FTC, in 243 patients (68.3%; n=356) at least one FTC was not responded by an appropriate contact. Compared with usual care, RM with appropriate contacts to FTC alerts independently reduced the risk of the primary end point (hazard ratio, 0.61 [95% CI, 0.39-0.95]; P=0.027).

CONCLUSIONS

RM appropriate reactions to FTC alerts are associated with significantly improved clinical outcomes in patients with advanced HF and implantable cardioverter-defibrillators.

First-in-man experience with ultrasound renal denervation for treatment of recurrent ventricular arrhythmias

Background/Introduction

Ventricular arrhythmias (VA) are common in patients with chronic heart failure (CHF) and can be refractory to drugs and catheter ablation. Promising results of sympathomodulatory treatment have been reported in these patients.

Purpose

This first in man study aims at investigating catheter-based renal denervation (RDN) using ultrasound energy for treatment of refractory VA in patients with CHF.

Methods

Four patients (age 65±10 years, all male, left ventricular ejection fraction 36±7%, global longitudinal strain (GLS) −10±3%) with CHF (n=1 ischemic cardiomyopathy, n=3 non-ischemic cardiomyopathy) and refractory VA were treated with RDN using ultrasound energy. All patients had undergone endo- or epicardial catheter ablation for recurrent ventricular tachycardia (VT) or fibrillation (VF) in the past and were on at least 2 antiarrhythmic drugs. Computer tomography angiography was performed at baseline, duplex ultrasound of renal arteries, ambulatory blood pressure monitoring (ABPM) and ICD interrogations were performed before, 1 day and 3 months post RDN.

Results

Bilateral RDN using an ultrasound-based catheter were performed with at least 2 sonications in each main branch of the left and right renal artery. In this analysis, mean follow-up time was 113±12 days. All RDN procedures were performed without any complications. No renal artery stenoses during follow-up. Arrhythmic burden (measured as VT/VF episodes) within 3 months before RDN requiring ICD therapy was reduced from 3 [1.5–54.5] episodes of anti-tachycardia pacing (ATP) and 0.5 [0–1.25] adequate ICD shocks to 1 [0.75–1] episode of ATP. There were no adequate ICD shocks after 3 months. Mean 24-hour ABP before RDN was 94±8/65±9 mmHg with no change in BP following 3 months (SBP 92±1 mmHg, DBP 62±6 mmHg after 3 months). There was no change in left ventricular GLS (−10±3% before, −9±4% after RDN) or ejection fraction (36±7% before and after RDN).

Conclusions

RDN using ultrasound energy in patients with CHF and refractory VA was safely performed with no changes in blood pressure and reduced the arrhythmic burden after 3 months follow-up.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): ReCor Medical Inc.

Research in Atrial Fibrillation: A Scientometric Analysis Using the Novel Web Application SciPE

OBJECTIVES

This study sought to determine the quantity and quality of publications in AF research using large-scale scientometric data analyses.

BACKGROUND

Research in atrial fibrillation (AF) has increased over time. The increasing number of research papers makes it harder to identify relevant research work.

METHODS

All 21,603 publications from 1945 to 2018 were retrieved from Web of Science and analyzed regarding geographical distribution of scientific output and international research cooperation.

RESULTS

The total number of AF publications has significantly increased since the millennium change, from 3,063 (14.2%) in 1945 to 1999 to 18,540 (85.8%) publications in 2000 to 2018. AF research grew 10-fold compared with overall medical research since 1990 (ratio of AF publications to all publications: 0.02% (n = 99 of 410,701) in 1990 vs. 0.2% (n = 1,967 of 1,172,649) in 2018; p < 0.05). Quantitatively, the United States contributed 25.9% of AF research, followed by Japan (8.0%), Germany (7.8%), China (7.3%), and the United Kingdom (5.9%). In the all-time modified h-index, the United States ranked first (13.3% of all nations), followed by Canada (8.5%) and the United Kingdom (6.3%). In relation to population, Denmark was the best-rated nation, with the lowest number of inhabitants per publication (11,457), followed by Sweden (18,426) and the Netherlands (25,749), and per modified h-index (90,746), followed by Sweden (170,602) and the Netherlands (218,203). Measuring publications per research institute, Denmark again ranked first, with 19.2 publications per institute, followed by Italy (14.9) and Sweden (13.8). An intensive cooperation between nations was apparent.

CONCLUSIONS

This study showed an increase in publication activity in AF research. The United States was the leading country in quantity of research efforts. Related to population and research institutes, Denmark ranked first.

Simultaneous islet-kidney vs pancreas-kidney transplantation in type 1 diabetes mellitus: a 5 year single centre follow-up

AIMS/HYPOTHESIS

The aim of this study was to compare the long-term outcomes--in terms of glucose control, renal function and procedure-related complications--of simultaneous islet-kidney (SIK) transplantation with those of simultaneous pancreas-kidney (SPK) transplantation in patients with type 1 diabetes mellitus.

METHODS

HbA1c, need for insulin, GFR and complication rate were compared between 13 recipients of SIK and 25 recipients of SPK transplants at the same institution. The mean follow-up was 41 months.

RESULTS

Two primary organ non-functions occurred in the SIK group. HbA1c did not differ at any time point during follow-up in the SIK group compared with the SPK group (mean during follow-up 6.3 vs 5.9%). Similarly, kidney function over time was not different between the two groups. A higher rate of insulin independence following SPK transplantation (after 1 year 96 vs 31% in the SIK group) was counterbalanced by a higher rate of serious adverse events (40% relaparotomies vs 0% in the SIK group).

CONCLUSIONS/INTERPRETATION

The endogenous insulin production achieved by islet transplantation, combined with optimal insulin therapy, was sufficient for maintaining near-normal glucose levels. In terms of glucose control, islet transplantation provides results comparable to those achieved with pancreas transplantation. However, SPK results in a higher rate of insulin independence, albeit at the cost of more surgical complications. These results have led to a new paradigm in islet transplantation at our institution, where the primary goal is not insulin independence, but good glucose control and avoidance of severe hypoglycaemia.

Inaccurate Self-Monitoring of Blood Glucose Readings in Patients on Chronic Ambulatory Peritoneal Dialysis with Icodextrin

Patients on chronic ambulant peritoneal dialysis (CAPD) are increasingly likely to be treated with a new solution of corn starch-derived glucose polymers called icodextrin. This solution involves a very low carbohydrate absorption leading to a better glycemic control in diabetic patients. However these glucose polymers pass to the blood and are metabolized to oligosaccharids which interfere with blood glucose in distinct capillary glucose analyzers leading to overestimation of glycemia. We assessed the accuracy of glucose measurements with the three most commonly used glucose analyzers compared to venous plasma glucose measurement at our institution in 8 patients (4 patients with type 2 diabetes) on CAPD using icodextrin. Glycemia was measured simultaneously in plasma of venous blood using a reference laboratory method and in capillary blood using Accu-Chek sensor (Rotkreuz, Switzerland) (glucose dehydrogenase method), Glucotrend 2 (Rotkreuz, Switzerland) (glucose-dye-oxyreductase method) and Ascensia elite (Zurich, Switzerland) (glucose oxidase method) glucose analyzers. Only glucose readings with Ascensia elite correspond correctly with venous plasma glucose results (+0.3 mmol/l; n. s.), whereas glycemia was significantly overestimated by Accu-Chek sensor (+4.3 mmol/l; p<0.0001) and Glucotrend 2 glucose analyzers (+3.7 mmol/l; p<0.0001). Thus we conclude that distinct glucose analyzers overestimate real blood glucose concentration and are not suitable for monitoring glycemia in patients on CAPD with icodextrin. On the basis of our results, these patients should use glucose analyzers using glucose oxidase methods. All glucose analyzers should be cross-checked with a laboratory reference method before the application in patients on CAPD with icodextrin is recommended.

Thyrotoxicosis-induced Prinzmetal Variant Angina

We describe a postmenopausal women with new onset of variant angina caused by thyrotoxicosis due to Graves' disease. During exercise bicycle ergometry at 50 Watts, the patient developed typical angina with ST segment elevation in the precordial leads. A coronary angiogram revealed normal coronary arteries. Graves' disease with overt hyperthyroidism was diagnosed. After achieving an euthyroid state with administration of propylthiouracil, the symptoms resolved completely and the patient had a normal exercise capacity without electrocardiographic changes. Thus, we conclude that in patients with thyrotoxicosis, variant angina and normal coronary arteries, restoration of normal thyroid function may be curative.

Inseltransplantation bei Typ 1 Diabetes mellitus

Der Traum, die durch einen Autoimmunpozess zerstörten Inseln des Pankreas (genauer der Betazellen) ersetzen zu können, rückte im Juli 2000 durch eine bahnbrechende Studie über Inseltransplantation einen beträchtlichen Schritt näher. In Edmonton konnte gezeigt werden, dass dank Transplantation von Inseln bei nicht urämischen Patienten mit Typ 1 Diabetes das Erreichen einer vollkommenen Insulinunabhängigkeit zur Regel wird. Der Erfolg, der inzwischen an vielen anderen Orten der Welt repliziert werden konnte, ist dadurch zu erklären, dass die Inseln von mehreren Spendern und eine steroidfreie Immunsuppression verwendet wurde. Dank dieses «Edmonton Protokolls» konnte die Insulinunabhängigkeit ein Jahr nach Transplantation auf 80% gesteigert werden. Es wurde aber auch festgestellt, dass beim längeren Follow-up dieser Prozentsatz deutlich absinkt. Aus diesem Grunde müsste von Zeit zu Zeit eine Inseltransplantation wiederholt werden, um die Insulinunabhängigkeit aufrecht erhalten zu können. Wegen dem ausgeprägten Organmangel kam es zu einem Paradigmenwechsel: Das Hauptziel, welches mit der Inseltransplantation verfolgt wird, ist nicht mehr unbedingt eine Insulinunabhängigkeit, sondern eine gute Blutzuckerkontrolle unter Vermeidung von schweren Hypoglykämien. Dieses Ziel kann bei 80–90% aller Patienten, welche eine Inseltransplantation erhielten, erfüllt werden, auch wenn geringe Dosen von Insulin injiziert werden müssen. Die lebenslang notwendige Immunsuppression hingegen limitiert diese praktisch komplikationslose Therapieform auf Patienten, welche eine andere Organtransplantation benötigen oder trotz optimierter Diabetesbehandlung lebensbedrohliche Hypoglykämien erleiden. Die häufigste Indikation bei uns sind Patienten mit einer chronischen dialysepflichtigen Niereninsuffizienz und einem Typ 1 Diabetes mellitus. Diese Patienten sollten auf die Möglichkeit einer kombinierten Insel-Nierentransplantation oder Pankreas-Nierentransplantation aufmerksam gemacht werden. Die Wahl, ob eine Insel- oder Pankreastransplantation in Frage kommt, hängt in allererster Linie vom Alter und vom Ausmaß der Begleiterkrankungen, vor allem kardiovaskulärer Art, ab, die wiederum mit Diabetesdauer, Alter und Qualität der Blutzuckereinstellung zusammenhängen.

Increased myocardial blood flow during acute exposure to simulated altitudes

BACKGROUND

Although only poor data exist on changes in myocardial blood flow (MBF) under acute hypoxia, patients with known coronary artery disease are advised not to exceed a moderate altitude exposure of about 2000 m above sea level.

METHODS AND RESULTS

We measured MBF with positron emission tomography using O-15--labeled water in 8 healthy human volunteers (aged 26 +/- 3 years [mean +/- SD]) at baseline (450 m above sea level, Zurich, Switzerland) and during acute hypoxic hypoxemia induced by inhalation of 2 hypoxic gas mixtures corresponding to altitudes of 2000 and 4500 m. MBF remained unchanged at 2000 m (increase of 10%, not significant) but increased significantly at 4500 m (62%, P <.001), exceeding the relative increase in rate pressure product.

CONCLUSIONS

Our results may explain why exposure to an altitude of 2000 m (corresponding to the cabin pressure in most airplanes during flight) is clinically well tolerated, even by patients with reduced coronary flow reserve, such as those with coronary artery disease. However, at an altitude of 4500 m, MBF increases significantly, supporting the recommendation that patients with impaired flow reserve avoid exposure to higher altitudes.

Effects of hypobaric hypoxia on vascular endothelial growth factor and the acute phase response in subjects who are susceptible to high-altitude pulmonary oedema

In order to investigate whether vascular endothelial growth factor (VEGF) and inflammatory pathways are activated during acute hypobaric hypoxia in subjects who are susceptible to high-altitude pulmonary oedema (HAPE-S), seven HAPE-S and five control subjects were exposed to simulated altitude corresponding to 4000 m in a hypobaric chamber for 1 day. Peripheral venous blood was taken at 450 m (Zürich level) and at 4000 m, and levels of erythropoietin (EPO), VEGF, interleukin-6 (IL-6) and the acute-phase proteins complement C3 (C3), alpha1-antitrypsin (alpha1AT), transferrin (Tf) and C-reactive protein (CRP) were measured. Peripheral arterial oxygen saturation (SaO2) was recorded. Chest radiography was performed before and immediately after the experiment. EPO increased during altitude exposure, correlating with SaO2, in both groups (r = -0.86, P < 0.001). Venous serum VEGF did not show any elevation despite a marked decrease in SaO2 in the HAPE-S subjects [mean (SD) HAPE-S: 69.6 (9.1)%; controls: 78.7 (5.2)%]. C3 and alpha1AT levels increased in HAPE-S during hypobaric hypoxia [from 0.94 (0.11) g/l to 1.07 (0.13) g/l, and from 1.16 (0.08) g/l to 1.49 (0.27) g/l, respectively; P < 0.05], but remained within the clinical reference ranges. No significant elevations of IL-6, Tf or CRP were observed in either group. The post-exposure chest radiography revealed no signs of oedema. We conclude that VEGF is not up-regulated in HAPE-S and thus does not seem to increase critically pulmonary vascular permeability during the 1st day at high altitude. Furthermore, our data provide evidence against a clinically relevant inflammation in the initial phase of exposure to hypoxia in HAPE-S, although C3 and alpha1AT are mildly induced.

Changes of cerebral blood flow during short-term exposure to normobaric hypoxia

Decreased arterial partial oxygen pressure (PaO2) below a certain level presents a strong stimulus for increasing cerebral blood flow. Although several field studies examined the time course of global cerebral blood flow (gCBF) changes during hypoxia at high altitude, little was known about the regional differences in the flow pattern. Positron emission tomography (PET) with [(15)O]H2O was used on eight healthy volunteers to assess regional cerebral blood flow (rCBF) during short-term exposure to hypoxia corresponding to simulated altitudes of 3,000 and 4,500 m. Scans at the simulated altitudes were preceded and followed by baseline scans at the altitude of Zurich (450 m, baseline-1 and baseline-2). Each altitude stage lasted 20 minutes. From baseline to 4,500 m, gCBF increased from 34.4 +/- 5.9 to 41.6 +/- 9.0 mL x minute(-1) x 100 g(-1) (mean +/- SD), whereas no significant change was noted at 3,000 m. During baseline-2 the flow values returned to those of baseline-1. Statistical parametric mapping identified the hypothalamus as the only region with excessively increased blood flow at 4,500 m (+32.8% +/- 21.9% relative to baseline-1). The corresponding value for the thalamus, the structure with the second largest increase, was 19.2% +/- 16.3%. Compared with the rest of the brain, an excessive increase of blood flow during acute exposure to hypoxia is found in the hypothalamus. The functional implications are at present unclear. Further studies of this finding should elucidate its meaning and especially focus on a potential association with the symptoms of acute mountain sickness.