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Crowley R, Chieng D, Sugumar H, Ling LH, Segan L, William J, Prabhu S, Voskoboinik A, Wong G, Morton JB, Lee G, McLellan AJ, Wong M, Pathak RK, Sterns L, Ginks M, Sanders P, Kalman JM, Kistler PM. Catheter ablation for persistent atrial fibrillation: patterns of recurrence and impact on quality of life and health care utilisation. Eur Heart J 2024:ehae291. [PMID: 38759110 DOI: 10.1093/eurheartj/ehae291] [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: 11/22/2023] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND AND AIMS Patterns of atrial fibrillation (AF) recurrence post catheter ablation for persistent AF are not well described. This study aimed to describe the pattern of AF recurrence seen following catheter ablation for persistent AF (PsAF) and the implications for healthcare utilisation and quality of life. METHODS This was a post-hoc analysis of the CAPLA study, an international, multi-centre study that randomised patients with symptomatic PsAF to pulmonary vein isolation plus posterior wall isolation or pulmonary vein isolation alone. Patients underwent twice daily single lead ECG, implantable device monitoring or three monthly Holter monitoring. RESULTS 154 of 333 (46.2%) patients (median age 67.3 years, 28% female) experienced AF recurrence at 12-month follow-up. Recurrence was paroxysmal in 97 (63%) patients and persistent in 57 (37%). Recurrence type did not differ between randomisation groups (p=0.508). Median AF burden was 27.4% in PsAF recurrence and 0.9% in paroxysmal AF (PAF) recurrence (p<0.001). Patients with PsAF recurrence had lower baseline left ventricular ejection fraction (PsAF 50% vs PAF 60%, p<0.001) and larger left atrial volume (PsAF 54.2±19.3 ml/m² vs PAF 44.8±11.6 ml/m², p=0.008). Healthcare utilisation was significantly higher in PsAF (45 patients [78.9%]) vs PAF recurrence (45 patients [46.4%], p<0.001) and lowest in those without recurrence (17 patients [9.5%], p<0.001). Patients without AF recurrence had greater improvements in quality of life as assessed by the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire (Δ33.3±25.2 points) compared to those with PAF (Δ24.0±25.0 points, p=0.012) or PsAF (Δ13.4±22.9 points, p<0.001) recurrence. CONCLUSIONS AF recurrence is more often paroxysmal after catheter ablation for PsAF irrespective of ablation strategy. Recurrent PsAF was associated with higher AF burden, increased healthcare utilisation and antiarrhythmic drug use. The type of AF recurrence and AF burden may be considered important endpoints in clinical trials investigating ablation of PsAF.
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Affiliation(s)
- Rose Crowley
- The Alfred Hospital, Melbourne, Australia
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - David Chieng
- The Alfred Hospital, Melbourne, Australia
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Hariharan Sugumar
- The Alfred Hospital, Melbourne, Australia
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Australia
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Louise Segan
- The Alfred Hospital, Melbourne, Australia
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Jeremy William
- The Alfred Hospital, Melbourne, Australia
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Australia
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Alfred Hospital, Melbourne, Australia
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Monash University, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Geoffrey Wong
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph B Morton
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Alex J McLellan
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Wong
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Peter M Kistler
- The Alfred Hospital, Melbourne, Australia
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Monash University, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
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2
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Segan L, Chieng D, Sugumar H, Ling LH, Azzopardi S, Nderitu Z, Voskoboinik A, Morton JB, McLellan AJ, Lee G, Wong M, Kalman JM, Kistler PM, Prabhu S. Impact of Baseline Left Atrial Size on Outcomes Following Catheter Ablation for AF in Patients With Left Ventricular Systolic Dysfunction. Circ Arrhythm Electrophysiol 2024; 17:e012783. [PMID: 38629285 DOI: 10.1161/circep.124.012783] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Affiliation(s)
- Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
- St Vincent's Hospital, Melbourne, Australia (H.S., A.J.M.L.)
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
| | - Sonia Azzopardi
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
| | - Ziporah Nderitu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
| | - Joseph B Morton
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
| | - Alex J McLellan
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- St Vincent's Hospital, Melbourne, Australia (H.S., A.J.M.L.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
| | - Geoffrey Lee
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
| | - Michael Wong
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
- Western Health, Melbourne, Australia (M.W.)
| | - Jonathan M Kalman
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
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Dawson LP, Ball J, Wilson A, Voskoboinik A, Nehme Z, Horrigan M, Emerson L, Kaye D, Stub D. Population trends in the incidence and outcomes of atrial fibrillation presentations to emergency departments in Victoria, Australia. Heart Rhythm 2024; 21:693-695. [PMID: 38219891 DOI: 10.1016/j.hrthm.2024.01.010] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 01/16/2024]
Affiliation(s)
- Luke P Dawson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Andrew Wilson
- Department of Health Services, Safer Care Victoria, Melbourne, Victoria, Australia; Ambulance Victoria, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Mark Horrigan
- St Vincent's Health, Melbourne, Victoria, Australia; Austin Health, Melbourne, Victoria, Australia
| | - Lance Emerson
- Department of Health Services, Safer Care Victoria, Melbourne, Victoria, Australia
| | - David Kaye
- The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
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4
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Bloom JE, Nehme E, Paratz ED, Dawson L, Nelson AJ, Ball J, Eliakundu A, Voskoboinik A, Anderson D, Bernard S, Burrell A, Udy AA, Pilcher D, Cox S, Chan W, Mihalopoulos C, Kaye D, Nehme Z, Stub D. Healthcare and economic cost burden of emergency medical services treated non-traumatic shock using a population-based cohort in Victoria, Australia. BMJ Open 2024; 14:e078435. [PMID: 38684259 PMCID: PMC11057314 DOI: 10.1136/bmjopen-2023-078435] [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: 09/28/2023] [Accepted: 04/02/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES We aimed to assess the healthcare costs and impact on the economy at large arising from emergency medical services (EMS) treated non-traumatic shock. DESIGN We conducted a population-based cohort study, where EMS-treated patients were individually linked to hospital-wide and state-wide administrative datasets. Direct healthcare costs (Australian dollars, AUD) were estimated for each element of care using a casemix funding method. The impact on productivity was assessed using a Markov state-transition model with a 3-year horizon. SETTING Patients older than 18 years of age with shock not related to trauma who received care by EMS (1 January 2015-30 June 2019) in Victoria, Australia were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome assessed was the total healthcare expenditure. Secondary outcomes included healthcare expenditure stratified by shock aetiology, years of life lived (YLL), productivity-adjusted life-years (PALYs) and productivity losses. RESULTS A total of 21 334 patients (mean age 65.9 (±19.1) years, and 9641 (45.2%) females were treated by EMS with non-traumatic shock with an average healthcare-related cost of $A11 031 per episode of care and total cost of $A280 million. Annual costs remained stable throughout the study period, but average costs per episode of care increased (Ptrend=0.05). Among patients who survived to hospital, the average cost per episode of care was stratified by aetiology with cardiogenic shock costing $A24 382, $A21 254 for septic shock, $A19 915 for hypovolaemic shock and $A28 057 for obstructive shock. Modelling demonstrated that over a 3-year horizon the cohort lost 24 355 YLLs and 5059 PALYs. Lost human capital due to premature mortality led to productivity-related losses of $A374 million. When extrapolated to the entire Australian population, productivity losses approached $A1.5 billion ($A326 million annually). CONCLUSION The direct healthcare costs and indirect loss of productivity among patients with non-traumatic shock are high. Targeted public health measures that seek to reduce the incidence of shock and improve systems of care are needed to reduce the financial burden of this syndrome.
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Affiliation(s)
- Jason E Bloom
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Emily Nehme
- Research & Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | | | - Luke Dawson
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Adam J Nelson
- Victorian Heart Institute, Clayton, North Carolina, Australia
| | - Jocasta Ball
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Amminadab Eliakundu
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David Anderson
- Ambulance Victoria, Doncaster, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | | | | | - Andrew A Udy
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | | | - Shelley Cox
- Research & Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - William Chan
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
- Western Health, St Albans, Victoria, Australia
| | | | - David Kaye
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Research & Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Dion Stub
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
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William J, Nanayakkara S, Chieng D, Sugumar H, Ling LH, Patel H, Mariani J, Prabhu S, Kistler PM, Voskoboinik A. Predictors of pacemaker requirement in patients receiving implantable loop recorders for unexplained syncope: A systematic review and meta-analysis. Heart Rhythm 2024:S1547-5271(24)00284-4. [PMID: 38508296 DOI: 10.1016/j.hrthm.2024.03.038] [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: 02/12/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Implantable loop recorders (ILRs) are increasingly used to evaluate patients with unexplained syncope. Identification of all predictors of bradycardic syncope and consequent permanent pacemaker (PPM) insertion is of substantial clinical interest as patients in the highest risk category may benefit from upfront pacemaker insertion. OBJECTIVE We performed a systematic review and meta-analysis to identify risk predictors for PPM insertion in ILR recipients with unexplained syncope. METHODS An electronic database search (MEDLINE, Embase, Scopus, Cochrane) was performed in June 2023. Studies evaluating ILR recipients with unexplained syncope and recording risk factors for eventual PPM insertion were included. A random effects model was used to calculate the pooled odds ratio (OR) for clinical and electrocardiographic characteristics with respect to future PPM requirement. RESULTS Eight studies evaluating 1007 ILR recipients were included; 268 patients (26.6%) underwent PPM insertion during study follow-up. PPM recipients were older (mean age, 70.2 ± 15.4 years vs 61.6 ± 19.7 years; P < .001). PR prolongation on baseline electrocardiography was a significant predictor of PPM requirement (pooled OR, 2.91; 95% confidence interval, 1.63-5.20). The presence of distal conduction system disease, encompassing any bundle branch or fascicular block, yielded a pooled OR of 2.88 for PPM insertion (95% confidence interval, 1.53-5.41). Injurious syncope and lack of syncopal prodrome were not significant predictors of PPM insertion. Sinus node dysfunction accounted for 62% of PPM insertions, whereas atrioventricular block accounted for 26%. CONCLUSION Approximately one-quarter of ILR recipients for unexplained syncope require eventual PPM insertion. Advancing age, PR prolongation, and distal conduction disease are the strongest predictors for PPM requirement.
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Affiliation(s)
- Jeremy William
- The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - David Chieng
- The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Hariharan Sugumar
- The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Hitesh Patel
- The Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Peter M Kistler
- The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia.
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6
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Hogarty JP, Comella A, Nanayakkara S, William J, Stub D, Mariani JA, Patel HC, Kistler PM, Kaye DM, Voskoboinik A. Influence of Impaired Conduction on Exercise Hemodynamics in Patients With Preserved Ejection Fraction. JACC Heart Fail 2024; 12:588-590. [PMID: 37921802 DOI: 10.1016/j.jchf.2023.09.021] [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] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/04/2023]
Affiliation(s)
| | | | | | | | - Dion Stub
- The Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
| | | | | | - Peter M Kistler
- The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - David M Kaye
- The Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia.
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7
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Morton MB, William J, Kistler PM, Prabhu S, Sugumar H, Brink OVD, Patel H, Mariani J, Voskoboinik A. Caudal fluoroscopic guidance for the insertion of transvenous pacing leads. J Cardiovasc Electrophysiol 2024; 35:433-437. [PMID: 38205869 DOI: 10.1111/jce.16183] [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: 10/16/2023] [Revised: 12/12/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Pneumothorax is a well-recognized complication of cardiac implantable electronic device (CIED) insertion. While AP fluoroscopy alone is the most commonly imaging technique for subclavian or axillary access, caudal fluoroscopy (angle 40°) is routinely used at our institution. The caudal view provides additional separation of the first rib and clavicle and may reduce the risk of pneumothorax. We assessed outcomes at our institution of AP and caudal fluoroscopic guided pacing lead insertion. METHODS Retrospective cohort study of consecutive patients undergoing transvenous lead insertion for pacemakers, defibrillators, and cardiac resynchronization therapy devices between 2011 and 2023. Both de novo and lead replacement/upgrade procedures were included. Data were extracted from operative, radiology, and discharge reports. All patients underwent postprocedure chest radiography. RESULTS Three thousand two hundred fifty-two patients underwent insertion of pacing leads between February 2011 and March 2023. Mean age was 71.1 years (range 16-102) and 66.7% were male. Most (n = 2536; 78.0%) procedures used caudal guidance to obtain venous access, while 716 (22.0%) procedures used AP guidance alone. Pneumothoraxes occurred in five (0.2%) patients in the caudal group and five (0.7%) patients in the AP group (p = .03). Subclavian contrast venography was performed less frequently in the caudal group (26.2% vs. 42.7%, p < .01). CONCLUSION Caudal fluoroscopy for axillary/subclavian access is associated with a lower rate of pneumothorax and contrast venography compared with an AP approach.
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Affiliation(s)
- Matthew B Morton
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeremy William
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter M Kistler
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sandeep Prabhu
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Hariharan Sugumar
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Hitesh Patel
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Justin Mariani
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
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8
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Segan L, Chieng D, Crowley R, William J, Sugumar H, Ling LH, Hawson J, Prabhu S, Voskoboinik A, Morton JB, Lee G, Sterns LD, Ginks M, Sanders P, Kalman JM, Kistler PM. Sex-specific outcomes after catheter ablation for persistent AF. Heart Rhythm 2024:S1547-5271(24)00125-5. [PMID: 38336190 DOI: 10.1016/j.hrthm.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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Sex-specific outcomes after catheter ablation (CA) for atrial fibrillation (AF) have reported conflicting findings. OBJECTIVE We examined the impact of female sex on outcomes in patients with persistent AF (PsAF) from the Catheter Ablation for Persistent Atrial Fibrillation: A Multicentre Randomized Trial of Pulmonary Vein Isolation vs PVI with Posterior Left Atrial Wall Isolation (CAPLA) randomized trial. METHODS A total of 338 patients with PsAF were randomized to pulmonary vein isolation (PVI) or PVI with posterior wall isolation (PWI). The primary outcome was arrhythmia recurrence at 12 months. Clinical and electroanatomical characteristics, arrhythmia recurrence, and quality of life were compared between women and men. RESULTS Seventy-nine women (23.4%; PVI 37; PVI + PWI 42) and 259 men (76.6%; PVI 131; PVI + PWI 128) underwent AF ablation. Women were older {median age 70.4 (interquartile range [IQR] 64.8-74.6) years vs 64.0 (IQR 56.7-69.7) years; P < .001} and had more advanced left atrial electroanatomical remodeling. At 12 months, arrhythmia-free survival was lower in women (44.3% vs 56.8% in men; hazard ratio 1.44; 95% confidence interval 1.02-2.04; log-rank, P = .036). PWI did not improve arrhythmia-free survival at 12 months (hazard ratio 1.02; 95% confidence interval 0.74-1.40; log-rank, P = .711). The median AF burden was 0% in both groups (women: IQR 0.0%-2.2% vs men: IQR 0.0%-2.8%; P = .804). Health care utilization was comparable between women (36.7%) and men (30.1%) (P = .241); however, women were more likely to undergo a repeat procedure (17.7% vs 6.9%; P = .007). Women reported more severe baseline anxiety (average Hospital Anxiety and Depression Scale [HADS] anxiety score 7.5 ± 4.9 vs 6.3 ± 4.3 in men; P = .035) and AF-related symptoms (baseline Atrial Fibrillation Effect on Quality-of-Life Questionnaire [AFEQT] score 46.7 ± 20.7 vs 55.9 ± 23.0 in men; P = .002), with comparable improvements in psychological symptoms (change in HADS anxiety score -3.8 ± 4.6 vs -3.0 ± 4.5; P = .152 (change in HADS depression score -2.9 ± 5.0 vs -2.6 ± 4.0; P = .542) and greater improvement in AFEQT score compared with men at 12 months (change in AFEQT score +45.9 ± 23.1 vs +39.2 ± 24.8; P = .048). CONCLUSION Women undergoing CA for PsAF report more significant symptoms and poorer quality of life at baseline than men. Despite higher arrhythmia recurrence and repeat procedures in women, the AF burden was comparably low, resulting in significant improvements in quality of life and psychological well-being after CA in both sexes.
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Affiliation(s)
- Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Rose Crowley
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Jeremy William
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Joshua Hawson
- University of Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Mulgrave Private Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Joseph B Morton
- University of Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Laurence D Sterns
- Royal Jubilee Hospital, Department of Cardiology, Vancouver Island, British Columbia, Canada
| | - Matthew Ginks
- John Radcliffe Hospital, Department of Cardiology, Oxford, United Kingdom
| | - Prashanthan Sanders
- Royal Adelaide Hospital, Department of Cardiology, Adelaide, South Australia, Australia
| | - Jonathan M Kalman
- University of Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Department of Cardiology, Melbourne, Victoria, Australia; Melbourne Private Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia; Melbourne Private Hospital, Department of Cardiology, Melbourne, Victoria, Australia.
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9
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Higuchi S, Voskoboinik A, Im SI, Lee A, Olgin J, Arbil A, Afzal J, Marcus GM, Stillson C, Bibby D, Abraham T, Wilson E, Gerstenfeld EP. Frequent Premature Atrial Contractions Lead to Adverse Atrial Remodeling and Atrial Fibrillation in a Swine Model. Circulation 2024; 149:463-474. [PMID: 37994608 PMCID: PMC10872765 DOI: 10.1161/circulationaha.123.065874] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/26/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Frequent premature atrial complexes (PACs) are associated with future incident atrial fibrillation (AF), but whether PACs contribute to development of AF through adverse atrial remodeling has not been studied. This study aimed to explore the effect of frequent PACs from different sites on atrial remodeling in a swine model. METHODS Forty swine underwent baseline electrophysiologic studies and echocardiography followed by pacemaker implantations and paced PACs (50% burden) at 250-ms coupling intervals for 16 weeks in 4 groups: (1) lateral left atrium (LA) PACs by the coronary sinus (Lat-PAC; n=10), (2) interatrial septal PACs (Sep-PAC; n=10), (3) regular LA pacing at 130 beats/min (Reg-130; n=10), and (4) controls without PACs (n=10). At the final study, repeat studies were performed, followed by tissue histology and molecular analyses focusing on fibrotic pathways. RESULTS Lat-PACs were associated with a longer P-wave duration (93.0±9.0 versus 74.2±8.2 and 58.8±7.6 ms; P<0.001) and greater echocardiographic mechanical dyssynchrony (57.5±11.6 versus 35.7±13.0 and 24.4±11.1 ms; P<0.001) compared with Sep-PACs and controls, respectively. After 16 weeks, Lat-PACs led to slower LA conduction velocity (1.1±0.2 versus 1.3±0.2 [Sep-PAC] versus 1.3±0.1 [Reg-130] versus 1.5±0.2 [controls] m/s; P<0.001) without significant change in atrial ERP. The Lat-PAC group had a significantly increased percentage of LA fibrosis and upregulated levels of extracellular matrix proteins (lysyl oxidase and collagen 1 and 8), as well as TGF-β1 (transforming growth factor-β1) signaling proteins (latent and monomer TGF-β1 and phosphorylation/total ratio of SMAD2/3; P<0.05). The Lat-PAC group had the longest inducible AF duration (terminal to baseline: 131 [interquartile range 30, 192] seconds versus 16 [6, 26] seconds [Sep-PAC] versus 22 [11, 64] seconds [Reg-130] versus -1 [-16, 7] seconds [controls]; P<0.001). CONCLUSIONS In this swine model, frequent PACs resulted in adverse atrial structural remodeling with a heightened propensity to AF. PACs originating from the lateral LA produced greater atrial remodeling and longer induced AF duration than the septal-origin PACs. These data provide evidence that frequent PACs can cause adverse atrial remodeling as well as AF, and that the location of ectopic PACs may be clinically meaningful.
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Affiliation(s)
- Satoshi Higuchi
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Aleksandr Voskoboinik
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Sung Il Im
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Adam Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Jeffrey Olgin
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Ayla Arbil
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Junaid Afzal
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Gregory M Marcus
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Carol Stillson
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Dwight Bibby
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Theodore Abraham
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Emily Wilson
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco
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10
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Hawson J, Anderson RD, Das SK, Al-Kaisey A, Chieng D, Segan L, Watts T, Campbell T, Morton J, McLellan A, Sparks P, Lee A, Gerstenfeld EP, Hsia HH, Voskoboinik A, Pathik B, Kumar S, Kistler PM, Kalman J, Lee G. Optimal Annotation of Local Activation Time in Ventricular Tachycardia Substrate Mapping. JACC Clin Electrophysiol 2024; 10:206-218. [PMID: 38099880 DOI: 10.1016/j.jacep.2023.10.014] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Accurate annotation of electrogram local activation time (LAT) is critical to the functional assessment of ventricular tachycardia (VT) substrate. Contemporary methods of annotation include: 1) earliest bipolar electrogram (LATearliest); 2) peak bipolar electrogram (LATpeak); 3) latest bipolar electrogram (LATlatest); and 4) steepest unipolar -dV/dt (LAT-dV/dt). However, no direct comparison of these methods has been performed in a large dataset, and it is unclear which provides the optimal functional analysis of the VT substrate. OBJECTIVES This study sought to investigate the optimal method of LAT annotation during VT substrate mapping. METHODS Patients with high-density VT substrate maps and a defined critical site for VT re-entry were included. All electrograms were annotated using 5 different methods: LATearliest, LATpeak, LATlatest, LAT-dV/dt, and the novel steepest unipolar -dV/dt using a dynamic window of interest (LATDWOI). Electrograms were also tagged as either late potentials and/or fractionated signals. Maps, utilizing each annotation method, were then compared in their ability to identify critical sites using deceleration zones. RESULTS Fifty cases were identified with 1,.813 ± 811 points per map. Using LATlatest, a deceleration zone was present at the critical site in 100% of cases. There was no significant difference with LATearliest (100%) or LATpeak (100%). However, this number decreased to 54% using LAT-dV/dt and 76% for LATDWOI. Using LAT-dV/dt, only 33% of late potentials were correctly annotated, with the larger far field signals often annotated preferentially. CONCLUSIONS Annotation with LAT-dV/dt and LATDWOI are suboptimal in VT substrate mapping. We propose that LATlatest should be the gold standard annotation method, as this allows identification of critical sites and is most suited to automation.
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Affiliation(s)
- Joshua Hawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Souvik K Das
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Ahmed Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - David Chieng
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Louise Segan
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital and Westmead Applied Research Centre, Westmead, New South Wales, Australia
| | - Joseph Morton
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alexander McLellan
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Paul Sparks
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Adam Lee
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Edward P Gerstenfeld
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Henry H Hsia
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Aleksandr Voskoboinik
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Bhupesh Pathik
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital and Westmead Applied Research Centre, Westmead, New South Wales, Australia; Western Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Peter M Kistler
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia.
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11
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Roccisano L, Voskoboinik A, Mariani J, Marwick TH, Patel HC. Cardiac Resynchronisation Therapy: How Medicare Criteria Might Inadvertently Promote Disparate Healthcare. Heart Lung Circ 2024; 33:e10-e11. [PMID: 38453294 DOI: 10.1016/j.hlc.2023.11.026] [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: 10/31/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 03/09/2024]
Affiliation(s)
- Laura Roccisano
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia.
| | - Aleksandr Voskoboinik
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Justin Mariani
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Central Clinical School, Monash University, Melbourne, Vic, Australia
| | | | - Hitesh C Patel
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
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12
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Ranasinghe MP, Koh Y, Vogrin S, Nelson CL, Cohen ND, Voskoboinik A, Nanayakkara S, Haikerwal D, Mateevici C, Wharton J, Casey E, Papapostolou S, Costello B. Early Discharge to Clinic-Based Therapy of Patients Presenting With Decompensated Heart Failure (EDICT-HF): Study Protocol for a Multi-Centre Randomised Controlled Trial. Heart Lung Circ 2024; 33:78-85. [PMID: 38158264 DOI: 10.1016/j.hlc.2023.11.021] [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: 10/25/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Acute decompensated heart failure involves a high rate of mortality and complications. Management typically involves a multi-day hospital admission. However, patients often lose part of their function with each successive admission, and are at a high risk for hospital-associated complications such as nosocomial infection. This study aims to determine the safety and efficacy of the management of patients presenting with acute decompensated heart failure to clinic-based therapy vs usual inpatient care using a reproducible management pathway. METHOD An investigator-initiated, prospective, non-inferiority, 1:1 randomised-controlled trial, stratified by left ventricular ejection fraction including 460 patients with a minimum follow-up of 7 days. This is a multi-centre study to be performed in centres across Victoria, Australia. Participants will be patients with either heart failure with reduced ejection fraction (HFrEF) or heart failure with preserved ejection fraction (HFpEF), admitted for acute decompensation of heart failure. INTERVENTION Early discharge to an outpatient-based Heart Failure Rapid Access Clinical Review (RACER) in addition to frequent medical/nursing at-home review for patients admitted with decompensated heart failure. RESULTS The primary endpoint will be a non-inferiority assessment of re-hospitalisation at 30 days. Secondary outcomes include superiority assessment of hospitalisation at 30 days, a composite clinical endpoint of major adverse cardiac and cerebrovascular event (MACCE), hospital re-admission or mortality at 3 months, achievement of guideline-directed medical therapy, patient assessment of symptoms (visual-analogue scale quantified as area under curve and Kansas City Cardiomyopathy Questionnaire-12 [KCCQ-12]), attendance at 3-month outpatient follow-up, number of bed stays/clinics attended, proportion of patients free from congestion, change in serum creatinine level, treatment for electrolyte disturbances, time to transition from intravenous to oral diuretics, and health economics analysis (cost-benefit analysis, cost-utility analysis, incremental cost-effectiveness ratio). CONCLUSIONS The Early Discharge to Clinic-Based Therapy of Patients Presenting with Decompensated Heart Failure (EDICT-HF) trial will help determine whether earlier discharge to out-of-hospital care is non-inferior to the usual practice of inpatient care, in patients with heart failure admitted to hospital for acute decompensation, as an alternative model of care.
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Affiliation(s)
- Mark P Ranasinghe
- Western Health, Department of Cardiology, Melbourne, Vic, Australia; The University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Vic, Australia
| | - Youlin Koh
- Western Health, Department of Cardiology, Melbourne, Vic, Australia
| | - Sara Vogrin
- The University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Vic, Australia
| | - Craig L Nelson
- Western Health, Division of Chronic and Complex Care, Melbourne, Vic, Australia; Western Health, Department of Nephrology, Melbourne, Vic, Australia
| | - Neale D Cohen
- Baker Heart and Diabetes Institute, Diabetes Clinical Research, Melbourne, Vic, Australia
| | - Aleksandr Voskoboinik
- Western Health, Department of Cardiology, Melbourne, Vic, Australia; Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia
| | | | - Deepak Haikerwal
- Western Health, Department of Cardiology, Melbourne, Vic, Australia
| | - Cristina Mateevici
- Western Health, Ambulatory Care Unit, Melbourne, Vic, Australia; Western Health, Department of Infectious Diseases, Melbourne, Vic, Australia
| | - James Wharton
- Western Health, Ambulatory Care Unit, Melbourne, Vic, Australia
| | - Erin Casey
- Western Health, Division of Chronic and Complex Care, Melbourne, Vic, Australia
| | - Stavroula Papapostolou
- Western Health, Department of Cardiology, Melbourne, Vic, Australia; Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia
| | - Ben Costello
- Western Health, Department of Cardiology, Melbourne, Vic, Australia.
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13
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William J, Voskoboinik A. PVC Triggers in Early Repolarization Syndrome: A New Wave of Knowledge. JACC Clin Electrophysiol 2024; 10:13-15. [PMID: 38267166 DOI: 10.1016/j.jacep.2023.12.001] [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: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Jeremy William
- Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia.
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14
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Segan L, Chieng D, Prabhu S, Hunt A, Watts T, Klys B, Voskoboinik A, Sugumar H, Ling LH, Lee G, Morton J, Pathak RK, Chandh Raja D, Sterns L, Ginks M, Sanders P, Kalman JM, Kistler PM. Posterior Wall Isolation Improves Outcomes for Persistent AF With Rapid Posterior Wall Activity: CAPLA Substudy. JACC Clin Electrophysiol 2023; 9:2536-2546. [PMID: 37702654 DOI: 10.1016/j.jacep.2023.08.018] [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: 08/04/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is less effective in persistent atrial fibrillation (PerAF) than in paroxysmal atrial fibrillation (AF). However, the CAPLA (Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA randomized clinical trial) of PVI vs posterior wall isolation (PWI) did not support empiric PWI in PerAF. We examined pulmonary vein (PV) and posterior wall (PW) electrical characteristics to determine if select patients may benefit from additional PWI. OBJECTIVES This study sought to determine the impact of PV and PW electrical characteristics on AF ablation outcomes in the CAPLA randomized study. METHODS Participants in spontaneous AF at the time of ablation were included from the CAPLA study. The mean, shortest, and longest PV, PW, and left atrial (LA) appendage cycle length measurements were annotated preablation using a multipolar catheter for 100 consecutive cycles. Next, cardioversion was performed with a high-density LA voltage map completed. Cox proportional hazards regression was utilized to determine clinical and electroanatomic predictors of AF recurrence overall and according to ablation strategy. Follow-up included twice daily single-lead electrocardiograms or continuous monitoring for 12 months. RESULTS A total of 151 patients (27% female, age 65 ± 9 years, 18% long-standing PerAF, LA volume index 52 ± 16 mL/m2, median AF duration 5 months [IQR: 2-10 months]) were in AF on the day of procedure and were randomized to PVI alone (50%) or PVI+PWI (50%) according to the CAPLA randomized clinical trial protocol. Baseline clinical, echocardiographic, and electroanatomic parameters were comparable between groups (all P > 0.05) including PV and PW characteristics. After 12 months, freedom from AF off antiarrhythmic drug therapy was 51.7% in PVI and 49.7% in PVI+PWI (log-rank P = 0.564). Rapid PW activity was defined as less than the median of the shortest PW cycle length (140 ms) and rapid PV activity was defined as less than the median of the shortest PV cycle length (126 ms). In those with rapid PW activity, the addition of PWI was associated with greater arrhythmia-free survival (56.4%) vs PVI alone (38.6%) (HR: 0.78; 95% CI: 0.67-0.94; log-rank P = 0.030). Moreover, in those undergoing PVI only, the risk of AF recurrence was higher in those with rapid PW activity (55.3% vs 46.5% in slower PW activity; HR: 1.50, 95%CI 1.11-2.26; log-rank P = 0.036). Rapid PV activity and PV cycle length (individual PVs or average of all 4 PVs) were not associated with outcome (all P > 0.05) regardless of ablation strategy. There was no correlation between PW cycle length and posterior low voltage (r = -0.06, P = 0.496). The addition of PWI did not improve arrhythmia-free survival in subgroups with LA enlargement (LA volume index >34 mL/m2) (HR: 0.69; 95% CI: 0.39-1.25; P = 0.301), posterior low-voltage zone (HR: 1.06; 95% CI: 0.68-1.66; P = 0.807), or long-standing PerAF (HR: 1.10; 95% CI: 0.71-1.72; P = 0.669). CONCLUSIONS Rapid PW activity is associated with an increased risk of AF recurrence post-catheter ablation. The addition of PWI in this subgroup was associated with a significant improvement in freedom from AF compared with PVI alone. The presence of rapid PW activity may identify patients with PerAF likely to benefit from PWI.
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Affiliation(s)
- Louise Segan
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - David Chieng
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Sandeep Prabhu
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | | | - Troy Watts
- Royal Melbourne Hospital, Melbourne, Australia
| | - Brian Klys
- Melbourne Private Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Hariharan Sugumar
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Liang-Han Ling
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Geoff Lee
- University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Joseph Morton
- University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Rajeev K Pathak
- Canberra Hospital, Canberra, Australia; Australian National University, Canberra, Australia
| | - Deep Chandh Raja
- Canberra Hospital, Canberra, Australia; Australian National University, Canberra, Australia
| | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | - Prashanthan Sanders
- Royal Adelaide Hospital, Adelaide, Australia; Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Peter M Kistler
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia.
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15
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Koh Y, Kwok C, Voskoboinik A, Kalman JM, Wong M. Serotonin antidepressants and atrial fibrillation burden from cardiac implantable electronic devices. J Arrhythm 2023; 39:876-883. [PMID: 38045466 PMCID: PMC10692859 DOI: 10.1002/joa3.12948] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/16/2023] [Accepted: 10/17/2023] [Indexed: 12/05/2023] Open
Abstract
Objective Depression and anxiety show a bidirectional relationship with atrial fibrillation (AF). Antidepressant use is associated with a reduction in the incidence of AF. However, no studies have examined the relationship between antidepressant use and AF burden (time in AF). This retrospective cohort study examined cardiac implantable device-detected AF episodes and their relationship with antidepressant use, among other treatment factors. Methods Consecutive patients from the Western Health Cardiology Department attending pacemaker checks between 2015 and 2021 were included. Patients with permanent AF were excluded, yielding 285 patients with no or paroxysmal AF, with a total of 772 patient encounters. Generalized estimating equations were used to model two processes: binary AF (present/absent) and the number of days in AF for patients with AF. Results Each yearly increase with age was associated with an increase in the odds of developing AF (OR 1.03 [1.00-1.05], p = .027). Male gender conferred a reduction in AF incidence (OR 0.30 [0.13-0.68], p = .004). Digoxin use was associated with incident AF (OR 4.43 [1.07-18.4], p = .04). Sotalol and heart-failure beta blocker use were associated with a decrease in AF burden (IRR 0.30 [0.12-0.78], p = .013 and 0.33 [0.14-0.81], p = .015). Selective serotonin reuptake inhibitor antidepressant use was associated with reduced AF burden (IRR 0.27 [0.09-0.81], p = .019), as was selective serotonin/noradrenaline reuptake inhibitor use (IRR 0.07 [0.03-0.15], p < .001). Conclusions Older age, female gender and digoxin are associated with a higher odds of developing incident AF. Sotalol, heart failure beta blockers and serotonin-based antidepressants are associated with reduced AF burden. Further prospective study into the effects of antidepressants on atrial arrhythmias is warranted.
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Affiliation(s)
- Youlin Koh
- Department of CardiologyWestern HealthSt AlbansVictoriaAustralia
- Department of CardiologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Cecilia Kwok
- Department of CardiologyWestern HealthSt AlbansVictoriaAustralia
| | - Aleksandr Voskoboinik
- Department of CardiologyWestern HealthSt AlbansVictoriaAustralia
- Department of CardiologyAlfred HealthMelbourneVictoriaAustralia
| | - Jonathan M. Kalman
- Department of CardiologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Michael Wong
- Department of CardiologyWestern HealthSt AlbansVictoriaAustralia
- Department of CardiologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
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16
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Morton MB, Mariani JA, Kistler PM, Patel H, Voskoboinik A. Transvenous versus subcutaneous implantable cardioverter defibrillators in young cardiac arrest survivors. Intern Med J 2023; 53:1956-1962. [PMID: 37929818 DOI: 10.1111/imj.16259] [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: 05/16/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023]
Abstract
Secondary prevention implantable cardioverter defibrillators (ICDs) are indicated in young patients presenting with aborted sudden cardiac death (SCD) because of ventricular arrhythmias. Transvenous-ICDs (TV-ICDs) are effective, established therapies supported by evidence. The significant morbidity associated with transvenous leads led to the development of the newer subcutaneous-ICD (S-ICD). This review discusses the clinical considerations when selecting an ICD for the young patient presenting with out-of-hospital cardiac arrest. The major benefits of TV-ICDs are their ability to pace (antitachycardia pacing [ATP], bradycardia support and cardiac resynchronisation therapy [CRT]) and the robust evidence base supporting their use. Other benefits include a longer battery life. Significant complications associated with transvenous leads include pneumothorax and tamponade during insertion and infection and lead failure in the long term. Comparatively, S-ICDs, by virtue of having no intravascular leads, prevent these complications. S-ICDs have been associated with a higher incidence of inappropriate shocks. Patients with an indication for bradycardia pacing, CRT or ATP (documented ventricular tachycardia) are seen as unsuitable for a S-ICD. If venous access is unsuitable or undesirable, S-ICDs should be considered given the patient is appropriately screened. There is a need for further randomised controlled trials to directly compare the two devices. TV-ICDs are an effective therapy for preventing SCD limited by significant lead-related complications. S-ICDs are an important development hindered largely by an inability to pace. Young patients stand to gain the most from a S-ICD as the cumulative risk of lead-related complications is high. A clinical framework to aid decision-making is presented.
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Affiliation(s)
- Matthew B Morton
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Justin A Mariani
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Peter M Kistler
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Hitesh Patel
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
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17
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Chieng D, Sugumar H, Hunt A, Ling LH, Segan L, Al-Kaisey A, Hawson J, Prabhu S, Voskoboinik A, Wong G, Morton JB, Lee G, Ginks M, Sterns L, Sanders P, Kalman JM, Kistler PM. Impact of Posterior Left Atrial Voltage on Ablation Outcomes in Persistent Atrial Fibrillation: CAPLA Substudy. JACC Clin Electrophysiol 2023; 9:2291-2299. [PMID: 37715741 DOI: 10.1016/j.jacep.2023.08.002] [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: 05/21/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is less effective in patients with persistent atrial fibrillation (PsAF). Adjunctive ablation targeting low voltage areas (LVAs) may improve arrhythmia outcomes. OBJECTIVES This study aims to compare the outcomes of adding posterior wall isolation (PWI) to PVI, vs PVI alone in PsAF patients with posterior wall LVAs. METHODS The CAPLA (Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation) study was a multicenter, randomized trial involving PsAF patients randomized 1:1 to either PVI alone or PVI with PWI. Voltage mapping performed during pacing pre-ablation was reviewed offline, with LVA defined as bipolar voltage of <0.5 mV. The primary endpoint was freedom from any documented atrial arrhythmia of >30 seconds off antiarrhythmic medication at 12 months after a single ablation procedure in patients with posterior LVA. RESULTS A total of 210 patients (average 64.6 ± 9.2 years,73.3% males, median atrial fibrillation duration 4.5 months [IQR: 2 to 8 months]) underwent multipolar left atrial mapping during coronary sinus pacing with posterior LVA present in 69 (32.9%). Patients with posterior LVA were more likely to have LVA in other atrial regions (91.7% vs 57.1%; P < 0.01), larger left atrial diameter (4.8 cm vs 4.4 cm; P < 0.01), and significantly increased risk of atrial arrhythmia recurrence at 12 months (LVA: 56.5% vs no LVA: 41.4%; HR: 1.51; 95% CI: 1.01-2.27; P = 0.04) compared to no posterior LVA. However, the addition of PWI to PVI did not significantly improve freedom from atrial arrhythmia recurrence over PVI alone (PVI with PWI: 44.8% vs PVI: 41.9%; HR: 0.95; 95% CI: 0.51-1.79; P = 0.95). CONCLUSIONS In patients with PsAF undergoing catheter ablation, posterior LVA was associated with a significant increase in atrial arrhythmia recurrence. However, the addition of PWI in those with posterior LVA did not reduce atrial arrhythmia recurrence over PVI alone.
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Affiliation(s)
- David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | | | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Ahmed Al-Kaisey
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Joshua Hawson
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Mulgrave Private Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Geoffrey Wong
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph B Morton
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | | | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; Monash Health, Melbourne, Australia
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia; Monash Health, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia.
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18
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William J, Chieng D, Sugumar H, Ling LH, Segan L, Crowley R, Al-Kaisey A, Hawson J, Prabhu S, Voskoboinik A, Wong G, Morton JB, Lee G, McLellan AJ, Wong M, Pathak RK, Sterns L, Ginks M, Reid CM, Sanders P, Kalman JM, Kistler PM. The Role of Posterior Wall Isolation in Catheter Ablation for Persistent Atrial Fibrillation and Systolic Heart Failure: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2023; 8:1077-1082. [PMID: 37755920 PMCID: PMC10534992 DOI: 10.1001/jamacardio.2023.3208] [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: 05/16/2023] [Accepted: 07/30/2023] [Indexed: 09/28/2023]
Abstract
Importance Catheter ablation for patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) is associated with improved left ventricular ejection fraction (LVEF) and survival compared with medical therapy. Nonrandomized studies have reported improved success with posterior wall isolation (PWI). Objective To determine the impact of pulmonary vein isolation (PVI) with PWI vs PVI alone on outcomes in patients with HFrEF. Design, Setting, and Participants This was an ad hoc secondary analysis of the CAPLA trial, a multicenter, prospective, randomized control trial that involved 11 centers in 3 countries (Australia, Canada, and UK). CAPLA featured 338 patients with persistent AF randomized to either PVI plusPWI or PVI alone. This substudy included patients in the original CAPLA study who had symptomatic HFrEF (LVEF <50% and New York Heart Association class ≥II). Interventions Pulmonary vein isolation with PWI vs PVI alone. Main Outcomes and Measures The primary end point was freedom from any documented atrial arrhythmia greater than 30 seconds, after a single ablation procedure, without the use of antiarrhythmic drug (AAD) therapy at 12 months. Results A total of 98 patients with persistent AF and symptomatic HFrEF were identified (mean [SD] age, 62.1 [9.8] years; 79.5% men; and mean [SD] LVEF at baseline, 34.6% [7.9%]). After 12 months, 58.7% of patients with PVI plus PWI were free from recurrent atrial arrhythmia without the use of AAD therapy vs 61.5% with PVI alone (hazard ratio, 1.02; 95% CI, 0.54-1.91; P = .96). There were no significant differences in freedom from atrial arrhythmia with or without AAD therapy after multiple procedures (PVI plus PWI vs PVI alone, 60.9% vs 65.4%; P = .73) or AF burden (median, 0% in both groups; P = .78). Mean LVEF improved substantially in PVI plus PWI (∆ LVEF, 19.3% [13.0%; P < .01) and PVI alone (18.2% [14.1%; P < .01), with no difference between groups (P = .71). Normalization of LV function occurred in 65.2% of patients in the PVI plus PWI group and 50.0% of patients with PVI alone (P = .13). Conclusions and Relevance The results of this study indicate that addition of PWI to PVI did not improve freedom from arrhythmia recurrence or recovery of LVEF in patients with persistent AF and symptomatic HFrEF. Catheter ablation was associated with significant improvements in systolic function, irrespective of ablation strategy used. These results caution against the routine inclusion of PWI in patients with HFrEF undergoing first-time catheter ablation for persistent AF. Trial Registration http://anzctr.org.au Identifier: ACTRN12616001436460.
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Affiliation(s)
- Jeremy William
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - David Chieng
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Hariharan Sugumar
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Liang-Han Ling
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Louise Segan
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Rose Crowley
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Ahmed Al-Kaisey
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Joshua Hawson
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Geoffrey Wong
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph B. Morton
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Alex J. McLellan
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Wong
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Rajeev K. Pathak
- Canberra Heart Rhythm Centre, Canberra Hospital, Australian Capital Territory, Australia
| | - Laurence Sterns
- Cardiac Electrophysiology Department, Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | - Matthew Ginks
- Division of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - Prashanthan Sanders
- Department of Cardiac Electrophysiology and Pacing, Royal Adelaide Hospital, Adelaide, Australia
| | - Jonathan M. Kalman
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Peter M. Kistler
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
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19
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Segan L, Chieng D, Sugumar H, Voskoboinik A, Ling LH, Costello B, Azzopardi S, Nderitu Z, Parameswaran R, Amerena J, McLellan AJ, Lee G, Morton J, Joseph S, Wong M, Taylor A, Kalman JM, Kistler PM, Prabhu S. The impact of age on ablation outcomes in AF-mediated cardiomyopathy. J Cardiovasc Electrophysiol 2023; 34:2065-2075. [PMID: 37694615 DOI: 10.1111/jce.16052] [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: 05/11/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION The absence of ventricular scar in patients with atrial fibrillation (AF) and systolic heart failure (HF) predicts left ventricular (LV) recovery following AF ablation. It is unknown whether age impacts the degree of LV recovery, reverse remodeling, or AF recurrence following catheter ablation (CA) among this population. OBJECTIVES To evaluate the impact of age on LV recovery and AF recurrence in a population with AF and systolic HF without fibrosis (termed AF-mediated cardiomyopathy) following CA. METHODS Consecutive patients undergoing CA between 2013 and 2021 with LV ejection fraction (LVEF) < 45% and absence of cardiac magnetic resonance imaging (CMR) detected LV myocardial fibrosis were stratified by age (<65 vs. ≥65 years). Following CA, participants underwent remote rhythm monitoring for 12 months with repeat CMR for HF surveillance. RESULTS The study population consisted of 70 patients (10% female, mean LVEF 33 ± 9%), stratified into younger (age < 65 years, 63%) and older (age ≥ 65 years, 37%) cohorts. Baseline comorbidities, LVEF (34 ± 9 vs. 33 ± 8 ≥65 years, p = .686), atrial and ventricular dimensions (left atrial volume index: 55 ± 21 vs. 56 ± 14 mL/m2 age ≥ 65, p = .834; indexed left ventricular end-diastolic volume: 108 ± 40 vs. 104 ± 28 mL/m2 age ≥ 65, p = .681), pharmacotherapy and ablation strategy (pulmonary vein isolation in all; posterior wall isolation in 27% vs. 19% age ≥ 65, p = .448; cavotricuspid isthmus in 9% vs. 11.5% age ≥ 65) were comparable (all p > .05) albeit a higher CHADS2 VASc score in the older cohort (2.7 ± 0.9 vs. 1.6 ± 0.6 age < 65, p < .001). Freedom from AF was comparable (hazard ratio: 0.65, 95% confidence interval: 0.38-1.48, LogRank p = .283) as was AF burden [0% (interquartile range, IQR: 0.0-2.1) vs. age ≥ 65: [0% (IQR 0.0-1.7), p = .516], irrespective of age. There was a significant improvement in LV systolic function in both groups (ΔLVEF + 21 ± 14% vs. +21 ± 12% age ≥ 65, p = .913), with LV recovery in the vast majority (73% vs. 69%, respectively, p = .759) at 13 (IQR: 12-16) months. This was accompanied by comparable improvements in functional status (New York Heart Association class p = .851; 6-min walk distance 50 ± 61 vs. 93 ± 134 m in age ≥ 65, p = .066), biomarkers (ΔN-terminal-pro brain natriuretic peptide -139 ± 246 vs. -168 ± 181 age ≥ 65,p = .629) and HF symptoms (Short Form-36 survey Δphysical component summary p = .483/Δmental component summary, p = .841). CONCLUSION In patients undergoing CA for AF with systolic HF in the absence of ventricular scar, comparable improvements in ventricular function, symptoms, and freedom from AF are achieved irrespective of age.
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Affiliation(s)
- Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
- Western Health, Melbourne, Australia
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Ben Costello
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Western Health, Melbourne, Australia
| | - Sonia Azzopardi
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Ziporah Nderitu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Ramanathan Parameswaran
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
- Barwon Health, Geelong, Australia
| | | | - Alex J McLellan
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph Morton
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Michael Wong
- University of Melbourne, Melbourne, Australia
- Western Health, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
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20
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Segan L, Canovas R, Nanayakkara S, Chieng D, Prabhu S, Voskoboinik A, Sugumar H, Ling LH, Lee G, Morton J, LaGerche A, Kaye DM, Sanders P, Kalman JM, Kistler PM. New-onset atrial fibrillation prediction: the HARMS2-AF risk score. Eur Heart J 2023; 44:3443-3452. [PMID: 37350480 DOI: 10.1093/eurheartj/ehad375] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 04/03/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023] Open
Abstract
AIMS Lifestyle risk factors are a modifiable target in atrial fibrillation (AF) management. The relative contribution of individual lifestyle risk factors to AF development has not been described. Development and validation of an AF lifestyle risk score to identify individuals at risk of AF in the general population are the aims of the study. METHODS AND RESULTS The UK Biobank (UKB) and Framingham Heart Study (FHS) are large prospective cohorts with outcomes measured >10 years. Incident AF was based on International Classification of Diseases version 10 coding. Prior AF was excluded. Cox proportional hazards regression identified independent AF predictors, which were evaluated in a multivariable model. A weighted score was developed in the UKB and externally validated in the FHS. Kaplan-Meier estimates ascertained the risk of AF development. Among 314 280 UKB participants, AF incidence was 5.7%, with median time to AF 7.6 years (interquartile range 4.5-10.2). Hypertension, age, body mass index, male sex, sleep apnoea, smoking, and alcohol were predictive variables (all P < 0.001); physical inactivity [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.96-1.05, P = 0.80] and diabetes (HR 1.03, 95% CI 0.97-1.09, P = 0·38) were not significant. The HARMS2-AF score had similar predictive performance [area under the curve (AUC) 0.782] to the unweighted model (AUC 0.802) in the UKB. External validation in the FHS (AF incidence 6.0% of 7171 participants) demonstrated an AUC of 0.757 (95% CI 0.735-0.779). A higher HARMS2-AF score (≥5 points) was associated with a heightened AF risk (score 5-9: HR 12.79; score 10-14: HR 38.70). The HARMS2-AF risk model outperformed the Framingham-AF (AUC 0.568) and ARIC (AUC 0.713) risk models (both P < 0.001) and was comparable to the CHARGE-AF risk score (AUC 0.754, P = 0.73). CONCLUSION The HARMS2-AF score is a novel lifestyle risk score which may help identify individuals at risk of AF in the general community and assist population screening.
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Affiliation(s)
- Louise Segan
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
| | - Rodrigo Canovas
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- CSIRO Health and Biosecurity, Australian e-Health Research Centre, 343 Royal Parade, Parkville, Melbourne, VIC 3052, Australia
| | - Shane Nanayakkara
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, VIC 3800, Australia
| | - David Chieng
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
| | - Sandeep Prabhu
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
| | - Hariharan Sugumar
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
| | - Liang-Han Ling
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
| | - Geoff Lee
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne, VIC 3050, Australia
| | - Joseph Morton
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne, VIC 3050, Australia
| | - Andre LaGerche
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
| | - David M Kaye
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, VIC 3800, Australia
| | - Prashanthan Sanders
- Department of Cardiology, Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide, Port Rd, Adelaide, SA 5000, Australia
| | - Jonathan M Kalman
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne, VIC 3050, Australia
| | - Peter M Kistler
- Department of Cardiology, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Clinical Research, The Baker Heart and Diabetes Research Institute, 75 Commercial Rd, Melbourne, VIC 3004, Australia
- Department of Medicine, Nursing and Health Sciences, University of Melbourne, Parkville, Melbourne, VIC 3010, Australia
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne, VIC 3050, Australia
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21
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Al-Kaisey AM, Parameswaran R, Bryant C, Anderson RD, Hawson J, Chieng D, Segan L, Voskoboinik A, Sugumar H, Wong GR, Finch S, Joseph SA, McLellan A, Ling LH, Morton J, Sparks P, Sanders P, Lee G, Kistler PM, Kalman JM. Atrial Fibrillation Catheter Ablation vs Medical Therapy and Psychological Distress: A Randomized Clinical Trial. JAMA 2023; 330:925-933. [PMID: 37698564 PMCID: PMC10498333 DOI: 10.1001/jama.2023.14685] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/25/2023] [Accepted: 07/12/2023] [Indexed: 09/13/2023]
Abstract
Importance The impact of atrial fibrillation (AF) catheter ablation on mental health outcomes is not well understood. Objective To determine whether AF catheter ablation is associated with greater improvements in markers of psychological distress compared with medical therapy alone. Design, Setting, and Participants The Randomized Evaluation of the Impact of Catheter Ablation on Psychological Distress in Atrial Fibrillation (REMEDIAL) study was a randomized trial of symptomatic participants conducted in 2 AF centers in Australia between June 2018 and March 2021. Interventions Participants were randomized to receive AF catheter ablation (n = 52) or medical therapy (n = 48). Main Outcomes and Measures The primary outcome was Hospital Anxiety and Depression Scale (HADS) score at 12 months. Secondary outcomes included follow-up assessments of prevalence of severe psychological distress (HADS score >15), anxiety HADS score, depression HADS score, and Beck Depression Inventory-II (BDI-II) score. Arrhythmia recurrence and AF burden data were also analyzed. Results A total of 100 participants were randomized (mean age, 59 [12] years; 31 [32%] women; 54% with paroxysmal AF). Successful pulmonary vein isolation was achieved in all participants in the ablation group. The combined HADS score was lower in the ablation group vs the medical group at 6 months (8.2 [5.4] vs 11.9 [7.2]; P = .006) and at 12 months (7.6 [5.3] vs 11.8 [8.6]; between-group difference, -4.17 [95% CI, -7.04 to -1.31]; P = .005). Similarly, the prevalence of severe psychological distress was lower in the ablation group vs the medical therapy group at 6 months (14.2% vs 34%; P = .02) and at 12 months (10.2% vs 31.9%; P = .01), as was the anxiety HADS score at 6 months (4.7 [3.2] vs 6.4 [3.9]; P = .02) and 12 months (4.5 [3.3] vs 6.6 [4.8]; P = .02); the depression HADS score at 3 months (3.7 [2.6] vs 5.2 [4.0]; P = .047), 6 months (3.4 [2.7] vs 5.5 [3.9]; P = .004), and 12 months (3.1 [2.6] vs 5.2 [3.9]; P = .004); and the BDI-II score at 6 months (7.2 [6.1] vs 11.5 [9.0]; P = .01) and 12 months (6.6 [7.2] vs 10.9 [8.2]; P = .01). The median (IQR) AF burden in the ablation group was lower than in the medical therapy group (0% [0%-3.22%] vs 15.5% [1.0%-45.9%]; P < .001). Conclusion and Relevance In this trial of participants with symptomatic AF, improvement in psychological symptoms of anxiety and depression was observed with catheter ablation, but not medical therapy. Trial Registration ANZCTR Identifier: ACTRN12618000062224.
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Affiliation(s)
- Ahmed M. Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ramanathan Parameswaran
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Christina Bryant
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Robert D. Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Joshua Hawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - David Chieng
- Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia
- Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Louise Segan
- Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia
- Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia
- Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Hariharan Sugumar
- Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia
- Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Geoffrey R. Wong
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Sue Finch
- School of Mathematics and Statistics, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen A. Joseph
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Alex McLellan
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Liang-Han Ling
- Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia
- Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Joseph Morton
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Paul Sparks
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter M. Kistler
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia
- Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Jonathan M. Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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22
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William J, Shembrey J, Quine E, Perrin M, Ridley D, Parameswaran R, Kistler PM, Voskoboinik A. Polymorphic Ventricular Tachycardia Storm After Coronary Artery Bypass Graft Surgery: A Form of 'Angry Purkinje Syndrome'. Heart Lung Circ 2023; 32:986-992. [PMID: 37210317 DOI: 10.1016/j.hlc.2023.04.298] [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: 02/23/2023] [Revised: 03/30/2023] [Accepted: 04/24/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Polymorphic ventricular tachycardia (PMVT) is a highly lethal arrhythmia which is commonly caused by acute myocardial ischaemia. PMVT mediated by short-coupled ventricular ectopy patients with ischaemic heart disease but in the absence of acute ischaemia may relate to transient peri-infarct Purkinje fibre irritability and has been termed 'Angry Purkinje Syndrome'. METHODS We present a case series of three patients with PMVT storm 3-5 days following coronary artery bypass graft surgery (CABG). In all three cases, recurrent episodes of PMVT were initiated by monomorphic ventricular ectopy with a short coupling interval. Acute coronary ischaemia was excluded in all three patients with a coronary angiogram and graft study. Two out of three of the patients commenced oral quinidine sulphate with subsequent rapid suppression of arrhythmia. Implantable cardiac defibrillators were implanted in all three patients and revealed no recurrence of PMVT following hospital discharge. CONCLUSION The Angry Purkinje Syndrome is a rare but important cause of ventricular tachycardia storm after CABG surgery and is mediated by short-coupled ventricular ectopy in the absence of acute myocardial ischaemia. This arrhythmia may be highly responsive to quinidine.
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Affiliation(s)
- Jeremy William
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, University Hospital Geelong, Geelong, Vic, Australia
| | - Jack Shembrey
- Department of Cardiology, University Hospital Geelong, Geelong, Vic, Australia
| | - Edward Quine
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, University Hospital Geelong, Geelong, Vic, Australia
| | - Mark Perrin
- Department of Cardiology, University Hospital Geelong, Geelong, Vic, Australia
| | - Daryl Ridley
- Department of Cardiology, University Hospital Geelong, Geelong, Vic, Australia
| | | | - Peter M Kistler
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
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23
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William J, Voskoboinik A. Epicardial Involvement in Roof-Dependent Macro-Re-Entrant Tachycardia: Finding the Missing Link. JACC Clin Electrophysiol 2023; 9:1540-1542. [PMID: 37204353 DOI: 10.1016/j.jacep.2023.04.003] [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: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Jeremy William
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia.
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24
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Segan L, Nanayakkara S, Spear E, Shirwaiker A, Chieng D, Prabhu S, Sugumar H, Ling L, Kaye DM, Kalman JM, Voskoboinik A, Kistler PM. Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS-AF Score. J Am Heart Assoc 2023; 12:e029259. [PMID: 37301743 PMCID: PMC10356043 DOI: 10.1161/jaha.122.029259] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 02/02/2023] [Accepted: 04/13/2023] [Indexed: 06/12/2023]
Abstract
Background Transesophageal echocardiography-guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. Methods and Results We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS-AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P>0.05). CHADS2VASc, though significant on univariate analysis (P<0.001), was not significant after adjustment (P=0.12). The novel CLOTS-AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m2), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752-0.887). The weighted CLOTS-AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. Conclusions The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.
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Affiliation(s)
- Louise Segan
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Shane Nanayakkara
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | | | | | - David Chieng
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Sandeep Prabhu
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Hariharan Sugumar
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Liang‐Han Ling
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - David M. Kaye
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Jonathan M. Kalman
- University of MelbourneMelbourneAustralia
- Royal Melbourne HospitalMelbourneAustralia
| | - Aleksandr Voskoboinik
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Peter M. Kistler
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
- Monash UniversityMelbourneAustralia
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25
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Chieng D, Sugumar H, Segan L, Tan C, Vizi D, Nanayakkara S, Al-Kaisey A, Hawson J, Prabhu S, Voskoboinik A, Finch S, Morton JB, Lee G, Mariani J, La Gerche A, Taylor AJ, Howden E, Kistler PM, Kalman JM, Kaye DM, Ling LH. Atrial Fibrillation Ablation for Heart Failure With Preserved Ejection Fraction: A Randomized Controlled Trial. JACC Heart Fail 2023; 11:646-658. [PMID: 36868916 DOI: 10.1016/j.jchf.2023.01.008] [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] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/23/2022] [Accepted: 01/04/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Patients with heart failure with preserved ejection fraction (HFpEF) frequently develop atrial fibrillation (AF). There are no randomized trials examining the effects of AF ablation on HFpEF outcomes. OBJECTIVES The aim of this study is to compare the effects of AF ablation vs usual medical therapy on markers of HFpEF severity, including exercise hemodynamics, natriuretic peptide levels, and patient symptoms. METHODS Patients with concomitant AF and HFpEF underwent exercise right heart catheterization and cardiopulmonary exercise testing. HFpEF was confirmed with pulmonary capillary wedge pressure (PCWP) of 15 mm Hg at rest or ≥25 mm Hg on exercise. Patients were randomized to AF ablation vs medical therapy, with investigations repeated at 6 months. The primary outcome was change in peak exercise PCWP on follow-up. RESULTS A total of 31 patients (mean age: 66.1 years; 51.6% females, 80.6% persistent AF) were randomized to AF ablation (n = 16) vs medical therapy (n = 15). Baseline characteristics were comparable across both groups. At 6 months, ablation reduced the primary outcome of peak PCWP from baseline (30.4 ± 4.2 to 25.4 ± 4.5 mm Hg; P < 0.01). Improvements were also seen in peak relative VO2 (20.2 ± 5.9 to 23.1 ± 7.2 mL/kg/min; P < 0.01), N-terminal pro-B-type natriuretic peptide levels (794 ± 698 to 141 ± 60 ng/L; P = 0.04), and MLHF (Minnesota Living with Heart Failure) score (51 ± -21.9 to 16.6 ± 17.5; P < 0.01). No differences were detected in the medical arm. Following ablation, 50% no longer met exercise right heart catheterization-based criteria for HFpEF vs 7% in the medical arm (P = 0.02). CONCLUSIONS AF ablation improves invasive exercise hemodynamic parameters, exercise capacity, and quality of life in patients with concomitant AF and HFpEF.
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Affiliation(s)
- David Chieng
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Hariharan Sugumar
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Louise Segan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Caleb Tan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Donna Vizi
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Shane Nanayakkara
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Ahmed Al-Kaisey
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Joshua Hawson
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Sue Finch
- University of Melbourne, Melbourne, Australia
| | - Joseph B Morton
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Justin Mariani
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Andre La Gerche
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Andrew J Taylor
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Erin Howden
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Peter M Kistler
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia.
| | - Liang-Han Ling
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia.
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26
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De Silva K, Haqqani H, Mahajan R, Qian P, Chik W, Voskoboinik A, Kistler PM, Lee G, Jackson N, Kumar S. Catheter Ablation vs Antiarrhythmic Drug Therapy for Treatment of Premature Ventricular Complexes: A Systematic Review. JACC Clin Electrophysiol 2023; 9:873-885. [PMID: 37380322 DOI: 10.1016/j.jacep.2023.01.035] [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: 09/01/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 06/30/2023]
Abstract
There is variability in treatment modalities for premature ventricular complexes (PVCs), including use of antiarrhythmic drug (AAD) therapy or catheter ablation (CA). This study reviewed evidence comparing CA vs AADs for the treatment of PVCs. A systematic review was performed from the Medline, Embase, and Cochrane Library databases, as well as the Australian and New Zealand Clinical Trials Registry, U.S. National Library of Medicine ClinicalTrials database, and the European Union Clinical Trials Register. Five studies (1 randomized controlled trial) enrolling 1,113 patients (57.9% female) were analyzed. Four of five studies recruited mainly patients with outflow tract PVCs. There was significant heterogeneity in AAD choice. Electroanatomic mapping was used in 3 of 5 studies. No studies documented intracardiac echocardiography or contact force-sensing catheter use. Acute procedural endpoints varied (2 of 5 targeted elimination of all PVCs). All studies had significant potential for bias. CA seemed superior to AADs for PVC recurrence, frequency, and burden. One study reported long-term symptoms (CA superior). Quality of life or cost-effectiveness was not reported. Complication and adverse event rates were 0% to 5.6% for CA and 9.5% to 21% for AADs. Future randomized controlled trials will assess CA vs AADs for patients with PVCs without structural heart disease (ECTOPIA [Elimination of Ventricular Premature Beats with Catheter Ablation versus Optimal Antiarrhythmic Drug Treatment]), with impaired LVEF (PAPS [Prospective Assessment of Premature Ventricular Contractions Suppression in Cardiomyopathy] Pilot), and with structural heart disease (CAT-PVC [Catheter Ablation Versus Amiodarone for Therapy of Premature Ventricular Contractions in Patients With Structural Heart Disease]). In conclusion, CA seems to reduce recurrence, burden, and frequency of PVCs compared with AADs. There is a lack of data on patient- and health care-specific outcomes such as symptoms, quality of life, and cost-effectiveness. Several upcoming trials will offer important insights for management of PVCs.
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Affiliation(s)
- Kasun De Silva
- Department of Cardiology, Westmead Hospital, New South Wales, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Haris Haqqani
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Rajiv Mahajan
- University of Adelaide Precinct, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Pierre Qian
- Department of Cardiology, Westmead Hospital, New South Wales, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - William Chik
- Department of Cardiology, Westmead Hospital, New South Wales, Australia
| | - Aleksandr Voskoboinik
- Baker Heart and Diabetes Research Institute, Alfred Hospital Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter M Kistler
- Baker Heart and Diabetes Research Institute, Alfred Hospital Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Nicholas Jackson
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia; University of Newcastle, Newcastle, New South Wales, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, New South Wales, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia.
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27
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Al-Kaisey AM, Parameswaran R, Bryant C, Anderson RD, Hawson J, Chieng D, Voskoboinik A, Sugumar H, West D, Azzopardi S, Finch S, Wong G, Joseph SA, McLellan A, Ling LH, Sanders P, Lee G, Kistler PM, Kalman JM. Impact of Catheter Ablation on Cognitive Function in Atrial Fibrillation: A Randomized Control Trial. JACC Clin Electrophysiol 2023:S2405-500X(23)00157-3. [PMID: 37227345 DOI: 10.1016/j.jacep.2023.02.020] [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: 10/13/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Early postoperative cognitive dysfunction (POCD) has been reported following atrial fibrillation (AF) ablation. However, whether POCD is persistent long-term is unknown. OBJECTIVES The purpose of this study was to determine if AF catheter ablation is associated with persistent cognitive dysfunction at 12-month follow-up. METHODS This is a prospective study of 100 patients with symptomatic AF who failed at least 1 antiarrhythmic drug randomized to either ongoing medical therapy or AF catheter ablation and followed up for 12 months. Changes in cognitive performance were assessed using 6 cognitive tests administered at baseline and during follow-up (3, 6, and 12 months). RESULTS A total of 96 participants completed the study protocol. Mean age was 59 ± 12 years (32% women, 46% with persistent AF). The prevalence of new cognitive dysfunction in the ablation arm compared with the medical arm was as follows: at 3 months: 14% vs 2%; P = 0.03; at 6 months: 4% vs 2%; P = NS; and at 12 months: 0% vs 2%; P = NS. Ablation time was an independent predictor of POCD (P = 0.03). A significant improvement in cognitive scores was seen in 14% of the ablation arm patients at 12 months compared with no patients in the medical arm (P = 0.007). CONCLUSIONS POCD was observed following AF ablation. However, this was transient with complete recovery at 12-month follow-up.
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Affiliation(s)
- Ahmed M Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Heart Centre, Alfred Hospital, Melbourne, Australia
| | - Ramanathan Parameswaran
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Heart Centre, Alfred Hospital, Melbourne, Australia
| | - Christina Bryant
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia; Clinical Psychology, Royal Women's Hospital, Melbourne, Australia
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Joshua Hawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - David Chieng
- Heart Centre, Alfred Hospital, Melbourne, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Heart Centre, Alfred Hospital, Melbourne, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Hariharan Sugumar
- Heart Centre, Alfred Hospital, Melbourne, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Danielle West
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Sonia Azzopardi
- Heart Centre, Alfred Hospital, Melbourne, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Sue Finch
- School of Mathematics and Statistics, University of Melbourne, Melbourne, Australia
| | - Geoffrey Wong
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Stephen A Joseph
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Alex McLellan
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Liang-Han Ling
- Heart Centre, Alfred Hospital, Melbourne, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Peter M Kistler
- Department of Medicine, University of Melbourne, Melbourne, Australia; Heart Centre, Alfred Hospital, Melbourne, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia.
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Bloom JE, Partovi A, Bernard S, Okyere D, Heritier S, Mahony E, Eliakundu AL, Dawson LP, Voskoboinik A, Anderson D, Ball J, Chan W, Kaye DM, Nehme Z, Stub D. Use of a novel smartphone-based application tool for enrolment and randomisation in pre-hospital clinical trials. Resuscitation 2023; 187:109787. [PMID: 37028747 DOI: 10.1016/j.resuscitation.2023.109787] [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] [Received: 11/23/2022] [Revised: 03/11/2023] [Accepted: 03/25/2023] [Indexed: 04/08/2023]
Abstract
The effective recruitment and randomisation of patients in pre-hospital clinical trials presents unique challenges. Owing to the time critical nature of many pre-hospital emergencies and limited resourcing, the use of traditional methods of randomisation that may include centralised telephone or web-based systems are often not practicable or feasible. Previous technological limitations have necessitated that pre-hospital trialists strike a compromise between implementing pragmatic, deliverable study designs, and robust enrolment and randomisation methodologies. In this commentary piece, we present a novel smartphone-based solution that has the potential to align pre-hospital clinical trial recruitment processes to that of best-in-practice in-hospital and ambulatory care setting studies. Running title: Smartphone application based randomisation in pre-hospital clinical trials.
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Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia; Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | | | - Stephen Bernard
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Daniel Okyere
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Emily Mahony
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Amminadab L Eliakundu
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David Anderson
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia; Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia.
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29
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William J, Xiao X, Shirwaiker A, Patel H, Prabhu S, Ling LH, Sugamar H, Mariani J, Kistler P, Voskoboinik A. Diagnostic evaluation of unexplained ventricular tachyarrhythmias in younger adults. J Cardiovasc Electrophysiol 2023; 34:959-966. [PMID: 36802117 DOI: 10.1111/jce.15868] [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: 11/28/2022] [Revised: 02/07/2023] [Accepted: 02/12/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND The diagnostic work-up for cardiac arrest from ventricular tachyarrhythmias occurring in younger adults and structurally normal hearts is variable and often incomplete. METHODS We reviewed records for all recipients of a secondary prevention implantable cardiac defibrillator (ICD) younger than 60 years at a single quaternary referral hospital from 2010 to 2021. Patients with unexplained ventricular arrhythmias (UVA) were identified as those with no structural heart disease on echocardiogram, no obstructive coronary disease, and no clear diagnostic features on ECG. We specifically evaluated the adoption rate of five modalities of "second-line" cardiac investigations: cardiac magnetic resonance imaging (CMR), exercise ECG, flecainide challenge, electrophysiology study (EPS), and genetic testing. We also evaluated patterns of antiarrhythmic drug therapy and device-detected arrhythmias and compared them with secondary prevention ICD recipients with a clear etiology found on initial assessment. RESULTS One hundred and two recipients of a secondary prevention ICD under the age of 60 were analyzed. Thirty-nine patients (38.2%) were identified with UVA and were compared with the remaining 63 patients with VA of clear etiology (61.8%). UVA patients were younger (35.6 ± 13.0 vs. 46.0 ± 8.6 years, p < .001) and were more often female (48.7% vs. 28.6%, p = .04). CMR was performed in 32 patients with UVA (82.1%), whereas flecainide challenge, stress ECG, genetic testing, and EPS were only performed in a minority of patients. Overall, the use of a second-line investigation suggested an etiology in 17 patients with UVA (43.5%). Compared to patients with VA of clear etiology, UVA patients had lower rates of antiarrhythmic drug prescription (64.1% vs. 88.9%, p = .003) and had a higher rate of device-delivered tachy-therapies (30.8% vs. 14.3%, p = .045). CONCLUSION In this real-world analysis of patients with UVA, the diagnostic work-up is often incomplete. While CMR was increasingly utilized at our institution, investigations for channelopathies and genetic causes appear to be underutilized. Implementation of a systematic protocol for work-up of these patients requires further study.
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Affiliation(s)
- Jeremy William
- The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | | | | | | | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Australia.,The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Australia.,The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Hariharan Sugamar
- The Alfred Hospital, Melbourne, Australia.,The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | | | - Peter Kistler
- The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia.,The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia.,The Baker Heart and Diabetes Research Institute, Melbourne, Australia
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30
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Bennett RG, Campbell T, Garikapati K, Kotake Y, Turnbull S, Kanawati J, Wong MS, Qian P, Thomas SP, Chow CK, Kovoor P, Robert Denniss A, Chik W, Marschner S, Kistler P, Haqqani H, Rowe M, Voskoboinik A, Lee G, Jackson N, Sanders P, Roberts-Thomson K, Chan KH, Sy R, Pathak R, Kanagaratnam L, Chia K, El-Sokkari I, Hallani H, Kanthan A, Burgess D, Kumar S. A Prospective, Multicentre Randomised Controlled Trial Comparing Catheter Ablation Versus Antiarrhythmic Drugs in Patients With Structural Heart Disease Related Ventricular Tachycardia: The CAAD-VT Trial Protocol. Heart Lung Circ 2023; 32:184-196. [PMID: 36599791 DOI: 10.1016/j.hlc.2022.09.006] [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] [Received: 04/10/2022] [Revised: 07/20/2022] [Accepted: 09/08/2022] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Randomised trials have shown that catheter ablation (CA) is superior to medical therapy for ventricular tachycardia (VT) largely in patients with ischaemic heart disease. Whether this translates to patients with all forms and stages of structural heart disease (SHD-e.g., non-ischaemic heart disease) is unclear. This trial will help clarify whether catheter ablation offers superior outcomes compared to medical therapy for VT in all patients with SHD. OBJECTIVE To determine in patients with SHD and spontaneous or inducible VT, if catheter ablation is more efficacious than medical therapy in control of VT during follow-up. DESIGN Randomised controlled trial including 162 patients, with an allocation ratio of 1:1, stratified by left ventricular ejection fraction (LVEF) and geographical region of site, with a median follow-up of 18-months and a minimum follow-up of 1 year. SETTING Multicentre study performed in centres across Australia. PARTICIPANTS Structural heart disease patients with sustained VT or inducible VT (n=162). INTERVENTION Early treatment, within 30 days of randomisation, with catheter ablation (intervention) or initial treatment with antiarrhythmic drugs only (control). MAIN OUTCOMES, MEASURES, AND RESULTS Primary endpoint will be a composite of recurrent VT, VT storm (≥3 VT episodes in 24 hrs or incessant VT), or death. Secondary outcomes will include each of the individual primary endpoints, VT burden (number of VT episodes in the 6 months preceding intervention compared to the 6 months after intervention), cardiovascular hospitalisation, mortality (including all-cause mortality, cardiac death, and non-cardiac death) and LVEF (assessed by transthoracic echocardiography from baseline to 6-, 12-, 24- and 36-months post intervention). CONCLUSIONS AND RELEVANCE The Catheter Ablation versus Anti-arrhythmic Drugs for Ventricular Tachycardia (CAAD-VT) trial will help determine whether catheter ablation is superior to antiarrhythmic drug therapy alone, in patients with SHD-related VT. TRIAL REGISTRY Australian New Zealand Clinical Trials Registry (ANZCTR) TRIAL REGISTRATION ID: ACTRN12620000045910 TRIAL REGISTRATION URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377617&isReview=true.
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Affiliation(s)
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Kartheek Garikapati
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Juliana Kanawati
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Mary S Wong
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Pierre Qian
- Department of Cardiology, Westmead Hospital, Department of Cardiology, Blacktown Hospital, Sydney, NSW, Australia
| | - Stuart P Thomas
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Clara K Chow
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Pramesh Kovoor
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - A Robert Denniss
- Department of Cardiology, Westmead Hospital, Department of Cardiology, Blacktown Hospital, Sydney, NSW, Australia
| | - William Chik
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Simone Marschner
- Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Peter Kistler
- Department of Cardiology, The Alfred Hospital, Sydney, NSW, Australia
| | - Haris Haqqani
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia
| | - Matthew Rowe
- Department of Cardiology, Gold Coast University Hospital, Brisbane, Qld, Australia
| | | | - Geoffrey Lee
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Nicholas Jackson
- Department of Cardiology, John Hunter Hospital, Newcastle, NSW, Australia
| | | | | | - Kim Hoe Chan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Raymond Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Rajeev Pathak
- Department of Cardiology, Canberra Hospital, ACT, Australia
| | - Logan Kanagaratnam
- Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Karin Chia
- Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ihab El-Sokkari
- Department of Cardiology, Nepean Hospital, Sydney, NSW, Australia
| | - Hisham Hallani
- Department of Cardiology, Nepean Hospital, Sydney, NSW, Australia
| | - Ajita Kanthan
- Department of Cardiology, Blacktown Hospital, Sydney, NSW, Australia
| | - David Burgess
- Department of Cardiology, Blacktown Hospital, Sydney, NSW, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia.
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Kistler PM, Chieng D, Sugumar H, Ling LH, Segan L, Azzopardi S, Al-Kaisey A, Parameswaran R, Anderson RD, Hawson J, Prabhu S, Voskoboinik A, Wong G, Morton JB, Pathik B, McLellan AJ, Lee G, Wong M, Finch S, Pathak RK, Raja DC, Sterns L, Ginks M, Reid CM, Sanders P, Kalman JM. Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial. JAMA 2023; 329:127-135. [PMID: 36625809 PMCID: PMC9856612 DOI: 10.1001/jama.2022.23722] [Citation(s) in RCA: 94] [Impact Index Per Article: 94.0] [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] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison. OBJECTIVE To compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation. DESIGN, SETTING, AND PARTICIPANTS Investigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022. INTERVENTIONS The PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone. MAIN OUTCOMES AND MEASURES Primary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications. RESULTS Among 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, -1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone. CONCLUSIONS AND RELEVANCE In patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12616001436460.
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Affiliation(s)
- Peter M. Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
- Monash Health, Melbourne, Australia
- Melbourne Private Hospital, Melbourne, Australia
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Sonia Azzopardi
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Ahmed Al-Kaisey
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Robert D. Anderson
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joshua Hawson
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Mulgrave Private Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Geoffrey Wong
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph B. Morton
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Bhupesh Pathik
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Alex J. McLellan
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
- St Vincent’s Private Hospital Fitzroy, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Wong
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
- Epworth Hospital Richmond, Melbourne, Australia
| | - Sue Finch
- University of Melbourne, Melbourne, Australia
| | - Rajeev K. Pathak
- Canberra Hospital, Australian Capital Territory, Australia
- Australian National University, Australian Capital Territory, Australia
| | - Deep Chandh Raja
- Canberra Hospital, Australian Capital Territory, Australia
- Australian National University, Australian Capital Territory, Australia
| | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | | | | | - Jonathan M. Kalman
- University of Melbourne, Melbourne, Australia
- Monash Health, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
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32
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Chieng D, Canovas R, Segan L, Sugumar H, Voskoboinik A, Prabhu S, Ling LH, Lee G, Morton JB, Kaye DM, Kalman JM, Kistler PM. The impact of coffee subtypes on incident cardiovascular disease, arrhythmias, and mortality: long-term outcomes from the UK Biobank. Eur J Prev Cardiol 2022; 29:2240-2249. [PMID: 36162818 DOI: 10.1093/eurjpc/zwac189] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/09/2022] [Accepted: 08/24/2022] [Indexed: 01/11/2023]
Abstract
AIMS Epidemiological studies report the beneficial effects of habitual coffee consumption on incident arrhythmia, cardiovascular disease (CVD), and mortality. However, the impact of different coffee preparations on cardiovascular outcomes and survival is largely unknown. The aim of this study was to evaluate associations between coffee subtypes on incident outcomes, utilizing the UK Biobank. METHODS AND RESULTS Coffee subtypes were defined as decaffeinated, ground, and instant, then divided into 0, <1, 1, 2-3, 4-5, and >5 cups/day, and compared with non-drinkers. Cardiovascular disease included coronary heart disease, cardiac failure, and ischaemic stroke. Cox regression modelling with hazard ratios (HRs) assessed associations with incident arrhythmia, CVD, and mortality. Outcomes were determined through ICD codes and death records. A total of 449 563 participants (median 58 years, 55.3% females) were followed over 12.5 ± 0.7 years. Ground and instant coffee consumption was associated with a significant reduction in arrhythmia at 1-5 cups/day but not for decaffeinated coffee. The lowest risk was 4-5 cups/day for ground coffee [HR 0.83, confidence interval (CI) 0.76-0.91, P < 0.0001] and 2-3 cups/day for instant coffee (HR 0.88, CI 0.85-0.92, P < 0.0001). All coffee subtypes were associated with a reduction in incident CVD (the lowest risk was 2-3 cups/day for decaffeinated, P = 0.0093; ground, P < 0.0001; and instant coffee, P < 0.0001) vs. non-drinkers. All-cause mortality was significantly reduced for all coffee subtypes, with the greatest risk reduction seen with 2-3 cups/day for decaffeinated (HR 0.86, CI 0.81-0.91, P < 0.0001); ground (HR 0.73, CI 0.69-0.78, P < 0.0001); and instant coffee (HR 0.89, CI 0.86-0.93, P < 0.0001). CONCLUSION Decaffeinated, ground, and instant coffee, particularly at 2-3 cups/day, were associated with significant reductions in incident CVD and mortality. Ground and instant but not decaffeinated coffee was associated with reduced arrhythmia.
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Affiliation(s)
- David Chieng
- Clinical Electrophysiology Research Laboratory, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne 3004, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
| | - Rodrigo Canovas
- Cambridge Baker Systems Genomics Initiaive, 75 Commercial Road, Melbourne 3004, Australia
- Baker Department of Cardiometabolic Health, 75 Commercial Road, Melbourne 3004, Australia
| | - Louise Segan
- Clinical Electrophysiology Research Laboratory, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne 3004, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
| | - Hariharan Sugumar
- Clinical Electrophysiology Research Laboratory, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne 3004, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
| | - Aleksandr Voskoboinik
- Clinical Electrophysiology Research Laboratory, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne 3004, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
| | - Sandeep Prabhu
- Clinical Electrophysiology Research Laboratory, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne 3004, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
| | - Liang-Han Ling
- Clinical Electrophysiology Research Laboratory, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne 3004, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
| | - Geoffrey Lee
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
- Royal Melbourne Hospital, 300 Grattan Street, Melbourne 3010, Australia
| | - Joseph B Morton
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
- Royal Melbourne Hospital, 300 Grattan Street, Melbourne 3010, Australia
| | - David M Kaye
- Clinical Electrophysiology Research Laboratory, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne 3004, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
- Department of Medicine, Faculty of Medicine, Monash University, Melbourne 3800, Australia
| | - Jonathan M Kalman
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
- Royal Melbourne Hospital, 300 Grattan Street, Melbourne 3010, Australia
- Department of Medicine, Faculty of Medicine, Monash University, Melbourne 3800, Australia
| | - Peter M Kistler
- Clinical Electrophysiology Research Laboratory, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne 3004, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne 3004, Australia
- Department of Medicine, University of Melbourne, Parkville 3010, Australia
- Department of Medicine, Faculty of Medicine, Monash University, Melbourne 3800, Australia
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33
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Chieng D, Segan L, Sugumar H, Al-Kaisey A, Hawson J, Moore BM, Nam MCY, Voskoboinik A, Prabhu S, Ling LH, Ng JF, Brown G, Lee G, Morton J, Debinski H, Kalman JM, Kistler PM. Higher power short duration vs. lower power longer duration posterior wall ablation for atrial fibrillation and oesophageal injury outcomes: a prospective multi-centre randomized controlled study (Hi-Lo HEAT trial). Europace 2022; 25:417-424. [PMID: 36305561 PMCID: PMC9934996 DOI: 10.1093/europace/euac190] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Radiofrequency (RF) ablation for pulmonary vein isolation (PVI) in atrial fibrillation (AF) is associated with the risk of oesophageal thermal injury (ETI). Higher power short duration (HPSD) ablation results in preferential local resistive heating over distal conductive heating. Although HPSD has become increasingly common, no randomized study has compared ETI risk with conventional lower power longer duration (LPLD) ablation. This study aims to compare HPSD vs. LPLD ablation on ETI risk. METHODS AND RESULTS Eighty-eight patients were randomized 1:1 to HPSD or LPLD posterior wall (PW) ablation. Posterior wall ablation was 40 W (HPSD group) or 25 W (LPLD group), with target AI (ablation index) 400/LSI (lesion size index) 4. Anterior wall ablation was 40-50 W, with a target AI 500-550/LSI 5-5.5. Endoscopy was performed on Day 1. The primary endpoint was ETI incidence. The mean age was 61 ± 9 years (31% females). The incidence of ETI (superficial ulcers n = 4) was 4.5%, with equal occurrence in HPSD and LPLD (P = 1.0). There was no difference in the median value of maximal oesophageal temperature (HPSD 38.6°C vs. LPLD 38.7°C, P = 0.43), or the median number of lesions per patient with temperature rise above 39°C (HPSD 1.5 vs. LPLD 2, P = 0.93). Radiofrequency ablation time (23.8 vs. 29.7 min, P < 0.01), PVI duration (46.5 vs. 59 min, P = 0.01), and procedure duration (133 vs. 150 min, P = 0.05) were reduced in HPSD. After a median follow-up of 12 months, AF recurrence was lower in HPSD (15.9% vs. LPLD 34.1%; hazard ratio 0.42, log-rank P = 0.04). CONCLUSION Higher power short duration ablation was associated with similarly low rates of ETI and shorter total/PVI RF ablation times when compared with LPLD ablation. Higher power short duration ablation is a safe and efficacious approach to PVI.
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Affiliation(s)
- David Chieng
- Clinical Electrophysiology Research, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne, Victoria 3004, Australia,Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia,School of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia,Department of Cardiology, Cabrini Hospital, 181/183 Wattletree Road, Malvern, Victoria 3144, Australia
| | - Louise Segan
- Clinical Electrophysiology Research, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne, Victoria 3004, Australia,Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia,School of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia,Department of Cardiology, Cabrini Hospital, 181/183 Wattletree Road, Malvern, Victoria 3144, Australia
| | - Hariharan Sugumar
- Clinical Electrophysiology Research, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne, Victoria 3004, Australia,Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia,School of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia,Department of Cardiology, Cabrini Hospital, 181/183 Wattletree Road, Malvern, Victoria 3144, Australia
| | - Ahmed Al-Kaisey
- School of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia,Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Joshua Hawson
- School of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia,Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Benjamin M Moore
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia,Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Michael C Y Nam
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia,Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Aleksandr Voskoboinik
- Clinical Electrophysiology Research, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne, Victoria 3004, Australia,Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia,School of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia,Department of Cardiology, Cabrini Hospital, 181/183 Wattletree Road, Malvern, Victoria 3144, Australia
| | - Sandeep Prabhu
- Clinical Electrophysiology Research, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne, Victoria 3004, Australia,Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia,School of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Liang-Han Ling
- Clinical Electrophysiology Research, Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne, Victoria 3004, Australia,Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia,School of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia,Department of Cardiology, Cabrini Hospital, 181/183 Wattletree Road, Malvern, Victoria 3144, Australia
| | - Jer Fuu Ng
- Department of Gastroenterology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Gregor Brown
- Department of Gastroenterology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Joseph Morton
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Henry Debinski
- Department of Cardiology, Cabrini Hospital, 181/183 Wattletree Road, Malvern, Victoria 3144, Australia
| | - Jonathan M Kalman
- School of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia,Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia,School of Medicine, Monash University, Wellington Road, Clayton, Victoria 3800, Australia
| | - Peter M Kistler
- Corresponding author. Tel: +61 0390762000; fax: +61 0390762461. E-mail address:
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Segan L, Canovas R, Nanayakkara S, Chieng D, Prabhu S, Ling LH, Voskoboinik A, Sugumar H, Lee G, Morton J, Kalman J, Kistler P. Development and validation of the HARMS2-AF lifestyle risk score to predict incident AF. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2278] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Lifestyle risk factors (RFs) are a modifiable target in atrial fibrillation (AF) management. However, the relative contribution of individual lifestyle RFs to AF incidence has not been described.
Purpose
Development and validation of a novel AF-lifestyle risk score to determine AF risk in the general population.
Methods
The UK Biobank (UKB) is a large prospective cohort with outcomes measured >10 years. In the UKB, we performed regression analysis of AF lifestyle RFs which were then evaluated in a multivariable model and a weighted score was developed. Next, the risk score was externally validated in the Framingham Heart Study (FHS) population. Kaplan-Meier estimates ascertained the 10-year risk of AF development.
Results
In the UKB, AF incidence was 5.3% among 302,926 participants, with a median time to AF 7.3 years (IQR 4.3–9.8). Hypertension, sleep apnoea, male sex, age, obesity (BMI>30 kg/m2), alcohol and smoking were predictive variables (all p<0.001); physical inactivity (OR 1.02,95% CI 0.97–1.10, p=0.3), diabetes (OR 0.98,95% CI 0.91–1.06, p=0.2) and BMI 27–30 kg/m2 (OR 1.02, 95% CI 0.97–1.07, p=0.424) were not significant. The HARMS2-AF score (Figure 1) had similar predictive performance (AUC=0.782, LogLoss 0.178, Brier Score 0.046) to the unweighted regression model (AUC 0.808) in the UKB. Validation in the FHS (AF incidence 6.7% of 7206 participants) maintained excellent predictive performance with an AUC of 0.747 (95% CI 0.724–0.769, Figure 2). A higher HARMS2-AF score (>5 points) was associated with a heightened 10-year AF risk (score 5–9: OR 9.35, score 10–14: OR 33.34).
Conclusions
The HARMS2-AF score is a novel lifestyle risk score which may help identify individuals at risk of AF and assists in general population screening.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- L Segan
- The Alfred Hospital , Melbourne , Australia
| | - R Canovas
- Baker Heart and Diabetes Institute , Melbourne , Australia
| | | | - D Chieng
- The Alfred Hospital , Melbourne , Australia
| | - S Prabhu
- The Alfred Hospital , Melbourne , Australia
| | - L H Ling
- The Alfred Hospital , Melbourne , Australia
| | | | - H Sugumar
- The Alfred Hospital , Melbourne , Australia
| | - G Lee
- Royal Melbourne Hospital, Department of Cardiology , Melbourne , Australia
| | - J Morton
- Royal Melbourne Hospital, Department of Cardiology , Melbourne , Australia
| | - J Kalman
- Royal Melbourne Hospital, Department of Cardiology , Melbourne , Australia
| | - P Kistler
- The Alfred Hospital , Melbourne , Australia
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Chieng D, Sugumar H, Segan L, Al-Kaisey A, Hawson J, Prabhu S, Voskoboinik A, Morton JB, Lee G, Mariani J, La Gerche A, Kistler PM, Kalman JM, Kaye DM, Ling LH. Catheter ablation in atrial fibrillation and heart failure with preserved ejection fraction improves peak pulmonary capillary wedge pressure, exercise capacity and quality of life: RCT STALL HFpEF. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.607] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Atrial fibrillation (AF) frequently accompanies heart failure with preserved ejection fraction (HFpEF). AF exacerbates HFpEF through adverse haemodynamic effects. In turn, HFpEF promotes AF through adverse left atrial remodelling. Observational data suggest sinus rhythm restoration improves outcomes in patients with AF and HFpEF. However, there are no randomised data examining the effects of rhythm control with catheter-based AF ablation on HFpEF outcomes.
Purpose
To compare the effects of AF ablation versus usual medical therapy on markers of HFpEF severity, including exercise haemodynamics, natriuretic peptide levels and patient symptoms.
Methods
Patients with symptomatic AF and HFpEF underwent exercise right heart catheterization (RHC) and cardiopulmonary exercise testing (CPET). HFpEF diagnosis was based on left ventricular ejection fraction (LVEF) ≥50%, elevated natriuretic peptide and echocardiographic diastolic impairment. HFpEF was confirmed on exercise RHC based on peak exercise pulmonary capillary wedge pressure (PCWP) of ≥25mmHg. Patients were randomised to AF ablation versus medical therapy, with investigations repeated at 6 months. The primary outcome was change in PCWP on follow-up.
Results
31 patients aged 66.1±7.5 years were randomized to AF ablation (16) versus medical therapy (15), with 51.6% female and 80.6% persistent AF. Baseline characteristics were comparable across groups. Paired analyses of ablation cohort showed significant reductions in peak PCWP (29.6±3.7 vs 25.9±4.6 mmHg, p<0.01), PCWP indexed for workload (39.0±57.9 vs 33.0±50.5 mmHg/W/kg, p<0.01), and BNP (146.2±80.5 vs 82.2±75.4 pg/mL, p=0.01); and increased resting cardiac output (4.6±0.9 vs 5.6±1.2 L/min, p=0.01), peak cardiac output (9.6±4.2 vs 10.4±3.7 L/min, p=0.02), peak (30s averaged) VO2 (1875.1±759.2 vs 2193.7±878.1 mL/min, p<0.01), peak absolute VO2 (1937.3±739.3 vs 2216.3±861.9 mL/min, p<0.01), peak (30s averaged) relative VO2 (19.4±5.9 vs 22.9±7.4 ml/kg/min) and peak workload (162.0±81.1 vs 184.4±83.4 W, p<0.01). Quality of life scores improved: AFEQT (45.3±20.9 vs 75±20.7, p<0.01) and MLHF (53±23.3 vs 17.5±22.8, p<0.01). Reversal of HFpEF by PCWP criteria occurred in 31.2% following AF ablation, and 50% among those free from arrhythmia recurrence. In the medical arm, there were no significant differences in RHC, CPET, and natriuretic peptide outcomes on follow-up versus baseline. Repeated measures mixed ANOVA testing showed significant time-randomisation interaction on peak VO2, absolute peak VO2, peak relative VO2, AFEQT/ MLHF scores, suggesting that significant improvements in these parameters were related to AF ablation.
Conclusion
In patients with concomitant AF and HFpEF, AF ablation improves invasive exercise haemodynamic parameters, increases exercise capacity, and enhances quality of life. Successful AF ablation may reverse the clinical syndrome of HFpEF in a subset of cases.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- D Chieng
- Baker Heart and Diabetes Institute , Melbourne , Australia
| | - H Sugumar
- Baker Heart and Diabetes Institute , Melbourne , Australia
| | - L Segan
- Baker Heart and Diabetes Institute , Melbourne , Australia
| | - A Al-Kaisey
- Royal Melbourne Hospital, Cardiology , Melbourne , Australia
| | - J Hawson
- Royal Melbourne Hospital, Cardiology , Melbourne , Australia
| | - S Prabhu
- Baker Heart and Diabetes Institute , Melbourne , Australia
| | - A Voskoboinik
- Baker Heart and Diabetes Institute , Melbourne , Australia
| | - J B Morton
- Royal Melbourne Hospital, Cardiology , Melbourne , Australia
| | - G Lee
- Royal Melbourne Hospital, Cardiology , Melbourne , Australia
| | - J Mariani
- The Alfred Hospital , Melbourne , Australia
| | - A La Gerche
- Baker Heart and Diabetes Institute , Melbourne , Australia
| | - P M Kistler
- Baker Heart and Diabetes Institute , Melbourne , Australia
| | - J M Kalman
- Royal Melbourne Hospital, Cardiology , Melbourne , Australia
| | - D M Kaye
- Baker Heart and Diabetes Institute , Melbourne , Australia
| | - L H Ling
- Baker Heart and Diabetes Institute , Melbourne , Australia
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Segan L, Nanayakkara S, Spear E, Shirwaiker A, Chieng D, Sugumar H, Ling LH, Prabhu S, Lee G, Morton J, Kalman J, Voskoboinik A, Kistler P. Clinical risk prediction for left atrial appendage thrombus among patients with atrial fibrillation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.568] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Exclusion of left atrial appendage thrombus (LAAT) by transoesophageal echocardiography (TOE) is recommended in patients with inadequate anticoagulation prior to direct cardioversion (DCR) or catheter ablation for atrial fibrillation/flutter (AF/AFL). LAAT risk factors in this population remain poorly defined.
Purpose
Determine LAAT predictors in AF/AFL patients undergoing pre-procedural TOE.
Methods
We evaluated available clinical and transthoracic echocardiographic (TTE) parameters in AF/AFL patients undergoing TOE between 1999–2022 in our institution in Melbourne, Australia. Regression analysis identified predictors of LAAT, which were applied to a weighted score developed in the derivation cohort (70%) and validated in the remaining 30%.
Results
Of 627 patients (age 62±12 years, 27% female, AF 84%,AFL 16%, left ventricular ejection fraction (LVEF) 44±20%), 24% had LAAT and 13.8% dense spontaneous echo contrast precluding DCR. Anticoagulation was NOAC 56.5%, warfarin 32.1% and none in 11.4%. In the LAAT cohort, thrombus resolution occurred in 39% on serial transoesophageal imaging with a median time to resolution of 131 days (IQR 54–398).
Diabetes (p=0.004), prior stroke (p=0.009), coronary disease (p=0.015), renal impairment (p<0.001) and CHADS2VASc >2 (73% vs. 55%, p<0.001) were higher in the LAAT cohort. Age (p=0.093), gender (p=0.689), BMI (p=0.828), anticoagulant type (p=0.316) and diabetes (p=0.107) were not univariate predictors, whereas anticoagulation duration (<30 days), creatinine and TTE markers of remodeling (LVEF, LAVI, RVSP and TAPSE) were independent predictors on univariate and multivariate regression; CHADS2VASc was not significant after adjustment (p=0.090). The weighted risk model included continuous (age, creatinine, LVEF, LAVI, TAPSE and RVSP) and categorical (anticoagulation duration) variables with excellent predictive performance: AUC 0.872 (95% CI 0.798–0.946), PPV 91%, NPV 70% and accuracy 80%.
Conclusion
A novel LAAT risk model comprising clinical and echocardiographic parameters enhances risk prediction over CHADS2VASc in AF/AFL and may guide the need for pre-procedural TOE imaging.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- L Segan
- The Alfred Hospital , Melbourne , Australia
| | | | - E Spear
- Monash Health, General Medicine , Melbourne , Australia
| | | | - D Chieng
- The Alfred Hospital , Melbourne , Australia
| | - H Sugumar
- The Alfred Hospital , Melbourne , Australia
| | - L H Ling
- The Alfred Hospital , Melbourne , Australia
| | - S Prabhu
- The Alfred Hospital , Melbourne , Australia
| | - G Lee
- Royal Melbourne Hospital, Department of Cardiology , Melbourne , Australia
| | - J Morton
- Royal Melbourne Hospital, Department of Cardiology , Melbourne , Australia
| | - J Kalman
- Royal Melbourne Hospital, Department of Cardiology , Melbourne , Australia
| | | | - P Kistler
- The Alfred Hospital , Melbourne , Australia
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Stephens AF, Šeman M, Nehme Z, Voskoboinik A, Smith K, Gregory SD, Stub D. Ex vivo evaluation of personal protective equipment in hands-on defibrillation. Resusc Plus 2022; 11:100284. [PMID: 35942482 PMCID: PMC9356271 DOI: 10.1016/j.resplu.2022.100284] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Andrew F. Stephens
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
- Corresponding author at: Lab 2, Level 3, Baker Heart and Diabetes Institute, 75 Commercial Rd, 3004, Australia.
| | - Michael Šeman
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, AU
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Health, Melbourne, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Australia
- Electrophysiology Research, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, AU
| | - Shaun D. Gregory
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, Alfred Health, Melbourne, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, AU
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Nalliah CJ, Wong GR, Lee G, Voskoboinik A, Kee K, Goldin J, Watts T, Linz D, Parameswaran R, Sugumar H, Prabhu S, McLellan A, Ling LH, Joseph SA, Morton JB, Kistler P, Sanders P, Kalman JM. Impact of CPAP on the Atrial Fibrillation Substrate in Obstructive Sleep Apnea: The SLEEP-AF Study. JACC Clin Electrophysiol 2022; 8:869-877. [PMID: 35863812 DOI: 10.1016/j.jacep.2022.04.015] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Observational studies report that obstructive sleep apnea (OSA) is associated with an increasingly remodeled atrial substrate in atrial fibrillation (AF). However, the impact of OSA management on the electrophysiologic substrate has not been evaluated. OBJECTIVES In this study, the authors sought to determine the impact of OSA management on the atrial substrate in AF. METHODS We recruited 24 consecutive patients referred for AF management with at least moderate OSA (apnea-hypopnea index [AHI] ≥15). Participants were randomized in a 1:1 ratio to commence continuous positive airway pressure (CPAP) or no therapy (n = 12 CPAP; n = 12 no CPAP). All participants underwent invasive electrophysiologic study (high-density right atrial mapping) at baseline and after a minimum of 6 months. Outcome variables were atrial voltage (mV), conduction velocity (m/s), atrial surface area <0.5 mV (%), proportion of complex points (%), and atrial effective refractory periods (ms). Change between groups over time was compared. RESULTS Clinical characteristics and electrophysiologic parameters were similar between groups at baseline. Compliance with CPAP therapy was high (device usage: 79% ± 19%; mean usage/day: 268 ± 91 min) and resulted in significant AHI reduction (mean reduction: 31 ± 23 events/h). There were no differences in blood pressure or body mass index between groups over time. At follow-up, the CPAP group had faster conduction velocity (0.86 ± 0.16 m/s vs 0.69 ± 0.12 m/s; P (time × group) = 0.034), significantly higher voltages (2.30 ± 0.57 mV vs 1.94 ± 0.72 mV; P < 0.05), and lower proportion of complex points (8.87% ± 3.61% vs 11.93% ± 4.94%; P = 0.011) compared with the control group. CPAP therapy also resulted in a trend toward lower proportion of atrial surface area <0.5 mV (1.04% ± 1.41% vs 4.80% ± 5.12%; P = 0.065). CONCLUSIONS CPAP therapy results in reversal of atrial remodeling in AF and provides mechanistic evidence advocating for management of OSA in AF.
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Affiliation(s)
- Chrishan J Nalliah
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia
| | - Geoffrey R Wong
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Kirk Kee
- Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia; Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Jeremy Goldin
- Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia; Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Ramanathan Parameswaran
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia
| | - Hariharan Sugumar
- Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Alex McLellan
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia
| | - Liang-Han Ling
- Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Stephen A Joseph
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia
| | - Joseph B Morton
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia
| | - Peter Kistler
- Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Physiology, University of Melbourne, Melbourne, Australia.
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Shirwaiker A, William J, Mariani JA, Kistler PM, Patel HC, Voskoboinik A. Long-Term Implications of Pacemaker Insertion in Younger Adults: A Single Centre Experience. Heart Lung Circ 2022; 31:993-998. [PMID: 35219598 DOI: 10.1016/j.hlc.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/09/2021] [Revised: 01/07/2022] [Accepted: 01/09/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The long-term implications of pacemaker insertion in younger adults are poorly described in the literature. METHODS We performed a retrospective analysis of consecutive younger adult patients (18-50 yrs) undergoing pacemaker implantation at a quaternary hospital between 1986-2020. Defibrillators and cardiac resynchronisation therapy devices were excluded. All clinical records, pacemaker checks and echocardiograms were reviewed. RESULTS Eighty-one (81) patients (median age 41.0 yrs IQR=35-47.0, 53% male) underwent pacemaker implantation. Indications were complete heart block (41%), sinus node dysfunction (33%), high grade AV block (11%) and tachycardia-bradycardia syndrome (7%). During a median 7.9 (IQR=1.1-14.9) years follow-up, nine patients (11%) developed 13 late device-related complications (generator or lead malfunction requiring reoperation [n=11], device infection [n=1] and pocket revision [n=1]). Five (5) of these patients were <40 years old at time of pacemaker insertion. At long-term follow-up, a further nine patients (11%) experienced pacemaker-related morbidity from inadequate lead performance managed with device reprogramming. Sustained ventricular tachycardia was detected in two patients (2%). Deterioration in ventricular function (LVEF decline >10%) was observed in 14 patients (17%) and seven of these patients required subsequent biventricular upgrade. Furthermore, four patients (5%) developed new tricuspid regurgitation (>moderate-severe). Of 69 patients with available long-term pacing data, minimal pacemaker utilisation (pacing <5% at all checks) was observed in 13 (19%) patients. CONCLUSIONS Pacemaker insertion in younger adults has significant long-term implications. Clinicians should carefully consider pacemaker insertion in this cohort given risk of device-related complications, potential for device under-utilisation and issues related to lead longevity. In addition, patients require close follow-up for development of structural abnormalities and arrhythmias.
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Affiliation(s)
| | | | - Justin A Mariani
- Heart Centre, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Peter M Kistler
- Heart Centre, Alfred Health, Melbourne, Vic, Australia; The Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; The University of Melbourne, Melbourne, Vic, Australia
| | - Hitesh C Patel
- Heart Centre, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia; The Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Aleksandr Voskoboinik
- Heart Centre, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia; The Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia.
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Xiao X, William J, Kistler PM, Joseph S, Patel HC, Vaddadi G, Kalman JM, Mariani JA, Voskoboinik A. Prediction of Pacemaker Requirement in Patients With Unexplained Syncope: The DROP Score. Heart Lung Circ 2022; 31:999-1005. [PMID: 35370087 DOI: 10.1016/j.hlc.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/05/2021] [Revised: 01/18/2022] [Accepted: 03/04/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Implantable loop recorders (ILR) are increasingly utilised in the evaluation of unexplained syncope. However, they are expensive and do not protect against future syncope. OBJECTIVES To compare patients requiring permanent pacemaker (PPM) implantation during ILR follow-up with those without abnormalities detected on ILR in order to identify potential predictors of benefit from upfront pacing. METHODS We analysed 100 consecutive patients receiving ILR: Group 1 (n=50) underwent PPM insertion due to bradyarrhythmias detected on ILR; Group 2 (n=50) had no arrhythmias detected on ILR over >3 years follow-up. Baseline clinical characteristics, syncope history, electrocardiographic and echocardiographic parameters were assessed to identify predictors of ultimate requirement for pacing. RESULTS Group 1 (64% male, median age 70.8 years; IQR 65.5-78.8) were older than Group 2 (58% male, median 60.2 years; IQR 44.0-73.0 p=0.001) and were less likely to have related historical factors such as overheating, posture and exercise (98% vs 70% p<0.001). PR interval was also longer in Group 1 (192±51 vs 169±23 p=0.006) with greater prevalence of distal conduction system disease (30% vs 4.3% p=0.002). Significant univariate predictors for PPM insertion were distal conduction disease (p=0.007), first degree atrioventricular (AV) block (p=0.003), absence of precipitating factors (p=0.004), and age >65 years (p=0.001). Injury sustained, recurrent syncope, history of atrial fibrillation (AF) or heart failure, left atrial (LA) size and left ventricular ejection fraction (LVEF) were not predictive. These significant predictors were incorporated into the DROP score1 (0-4). Using time-to-event analysis, no patients with a score of 0 progressed to pacing, while higher scores (3-4) strongly predicted pacing requirement (log-rank p<0.001). CONCLUSION The DROP score may be helpful in identifying patients likely to benefit from upfront permanent pacemaker (PPM) insertion following unexplained syncope. Larger prospective studies are required to validate this tool.
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Affiliation(s)
- Xiaoman Xiao
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Jeremy William
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Peter M Kistler
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia; The Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia
| | - Stephen Joseph
- Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia
| | - Hitesh C Patel
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia; The Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Gautam Vaddadi
- Department of Cardiology, Northern Health, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia
| | - Jonathan M Kalman
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Justin A Mariani
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia; The Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia.
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Koh Y, Voskoboinik A, Neil C. Arrhythmias and Their Electrophysiological Mechanisms in Takotsubo Syndrome: A Narrative Review. Heart Lung Circ 2022; 31:1075-1084. [PMID: 35562239 DOI: 10.1016/j.hlc.2022.03.010] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/19/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Takotsubo syndrome (TTS), an acute and usually reversible condition, is associated with both tachy- and bradyarrhythmias. Such arrhythmias can be life-threatening, e.g. ventricular tachycardia and fibrillation, and associated with cardiac arrest. Others, such as atrioventricular block, persist and require long-term device therapy. In this narrative review, we aim to provide a summary of the current literature on arrhythmias in TTS and their clinical sequelae. METHODS PubMed and Medline databases were searched with various permutations of TTS, arrhythmias and beta-adrenoceptors. After application of exclusion criteria and review, 84 articles were included. RESULTS Although there are no specific electrocardiograph (ECG) findings in TTS to differentiate it from ST-elevation myocardial infarction, suggestive patterns include small QRS amplitude, ST segment elevation without reciprocal ST depression and prolonged QT interval. Atrial tachyarrhythmias (incidence of 5-15%) are associated with a more unwell patient cohort. Ventricular arrhythmias (incidence 4-14%) are often associated with prolonged QT interval and are a cause of sudden death in TTS. Bradyarrhythmias are less common (incidence 1.3-2.5%), but have been reported with TTS, and usually persist beyond the acute phase. CONCLUSIONS Takotsubo syndrome, though considered primarily a disease of the myocardium, carries multiple arrhythmic manifestations that affect short- and long-term prognosis. The management of such arrhythmias represents a constantly evolving area of research.
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Affiliation(s)
- Y Koh
- Department of Cardiology, Western Health, Melbourne, Vic, Australia.
| | - A Voskoboinik
- Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | - C Neil
- Department of Cardiology, Western Health, Melbourne, Vic, Australia
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Segan L, Nanayakkara S, Canovas R, Chieng D, Sugumar H, Voskoboinik A, Ling LH, Prabhu S, Kalman JM, Kistler PM. PO-670-03 IMPACT OF LIFESTYLE RISK FACTORS ON THE INCIDENCE OF AF: A LARGE POPULATION-BASED STUDY. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.407] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kistler PM, Chieng D, Canovas R, Morton JB, Lee G, Ling LH, Prabhu S, Voskoboinik A, Sugumar H, Segan L, Kalman JM. PO-654-01 REGULAR COFFEE INTAKE IS SAFE AND IMPROVES SURVIVAL IN PEOPLE WITH UNDERLYING ARRHYTHMIA AND/OR CARDIOVASCULAR DISEASE. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.262] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Chieng D, Canovas R, Segan L, Sugumar H, Voskoboinik A, Prabhu S, Ling LH, Lee G, Morton JB, Kalman JM, Kistler PM. CE-544-04 HABITUAL COFFEE CONSUMPTION AND INCIDENCE OF ARRHYTHMIAS: A LARGE POPULATION STUDY. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.770] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Segan L, Nanayakkara S, Canovas R, Chieng D, Sugumar H, Voskoboinik A, Ling LH, Prabhu S, Kalman JM, Kistler PM. CE-543-02 DEVELOPMENT OF THE HARMS2-AF LIFESTYLE RISK SCORE TO PREDICT INCIDENT AF. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.748] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Rowe K, Xiao X, Bloom JE, Shirwaiker A, Kistler PM, Marasco S, Voskoboinik A. PO-655-06 PREDICTORS OF LATE ATRIAL FIBRILLATION RECURRENCE FOLLOWING CARDIAC SURGERY. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.276] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Chieng D, Sugumar H, Segan L, Al-Kaisey A, Moore BM, Yuan Nam MC, Prabhu S, Voskoboinik A, Ling LH, Kalman JM, Kistler PM. CA-535-02 HIGH POWER SHORT DURATION (HPSD) VERSUS LOWER POWER LONGER DURATION (LPLD) ATRIAL FIBRILLATION ABLATION: A PROSPECTIVE MULTICENTRE RANDOMISED CONTROLLED STUDY. THE HI-LO HEAT STUDY. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.728] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Voskoboinik A. Posterior Wall Isolation for Atrial Fibrillation: Time to Curb Our Enthusiasm? JACC Clin Electrophysiol 2022; 8:593-594. [PMID: 35589171 DOI: 10.1016/j.jacep.2022.01.025] [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] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Aleksandr Voskoboinik
- Alfred Hospital, Prahran, Victoria, Australia; Baker Heart and Diabetes Institute, Prahran, Victoria, Australia; Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Western Health, St Albans, Victoria, Australia.
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Chieng D, Sugumar H, Canovas R, Segan L, Ling LH, Voskoboinik A, Al-Kaisey A, Lee G, Prabhu S, Morton JB, Kalman JM, Kistler PM. PO-668-04 IMPACT OF DECAFFEINATED, GROUND AND INSTANT COFFEE SUBTYPES ON THE INCIDENCE OF ARRHYTHMIAS: LONG TERM OUTCOMES FROM THE UK BIOBANK. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.390] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Voskoboinik A, Nehme Z, Kistler PM, Stub D, Smith K. First time use of manual pressure augmentation for ventricular fibrillation arrest in the community. Resuscitation 2022; 174:31-32. [PMID: 35331802 DOI: 10.1016/j.resuscitation.2022.03.018] [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: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Aleksandr Voskoboinik
- Alfred Health, Melbourne, Australia; Western Health, Melbourne, Australia; Monash University, Melbourne, Australia; The Baker Heart and Diabetes Institute, Melbourne, Australia.
| | - Ziad Nehme
- Monash University, Melbourne, Australia; Ambulance Victoria, Melbourne, Australia
| | - Peter M Kistler
- Alfred Health, Melbourne, Australia; The Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Dion Stub
- Alfred Health, Melbourne, Australia; Western Health, Melbourne, Australia; Monash University, Melbourne, Australia; The Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Karen Smith
- Monash University, Melbourne, Australia; Ambulance Victoria, Melbourne, Australia
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