Hospitalization for permanent pacemaker implantation in the context of isolated sinus node dysfunction is associated with increased mortality compared with an outpatient strategy

BACKGROUND

Permanent pacemaker (PPM) implantation is a well-established treatment for symptomatic sinus node dysfunction (SND). The optimal timing of this intervention is unclear, with atrioventricular blocks often prioritized in resource stressed waiting lists due to mortality concerns.

METHODS

Mortality data was compared between patients receiving elective outpatient (OP) PPM implantation, and those presenting to hospital for urgent inpatient (IP) management for symptomatic SND. Survival analysis was conducted using Kaplan-Meier plots and compared using the log-rank test. Univariable and multivariable Cox regression, as well as propensity score matching analyses were performed to assess the prognostic effect on 30-day and 1-year all-cause mortality of inpatient implant.

RESULTS

Of the 1269 patients identified with isolated SND, 740 (58%) had PPMs implanted on an OP and 529 (42%) on an IP basis. Mortality was significantly worse in patients where management was driven by hospital admission on an urgent basis (Log-Rank χ2 = 21.6, p < 0.001) and remained an independent predictor of 1-year all-cause mortality (HR 3.40, 95% CI 1.97-5.86, p < 0.001) on multivariable analysis.

CONCLUSIONS

SND is predominantly a disease associated with ageing and comorbid populations, where avoidance of deconditioning, hospitalization acquired infections, and polypharmacy is advantageous. Admission avoidance is therefore the preferable strategy.

P1383Procedural differences during de novo paroxysmal atrial fibrillation ablation with a contact force-sensing ablation catheter between Europe and U.S

Background

Although pulmonary vein isolation (PVI) is considered the standard approach of atrial fibrillation ablation worldwide, procedural practice during the ablation varies by geographical region. Using the same magnetic sensor enabled contact force-sensing ablation catheter for the treatment of de novo paroxysmal atrial fibrillation, a comparison of procedural detail between Europe and U.S operators can provide insights into geographic specific clinical practices. 

Purpose

To characterize and compare procedural differences during paroxysmal atrial fibrillation ablation performed with a magnetic sensor enabled contact force-sensing catheter across European and U.S. centers. 

Methods

Procedural data were prospectively collected in clinical cases performed with a new magnetic sensor enabled, contact force ablation catheter within the first 6 months of use at participating centers in Europe and the U.S. Procedure time, PVI time, PVI confirmation method, fluoroscopy usage and lesion delivery parameters were analyzed based on geographies. 

Results

A total of 131 cases across 35 centers in 11 European countries, and 95 cases across 26 U.S. centers were analyzed. Target geometry was created with the ablation catheter in 94 out of 131 (71.8%) European cases, while only 5 out of 95 U.S. cases (5.3%) reported the use of the ablation catheter for model creation. Although a steerable sheath (64.1% and 67.3%) was commonly used with the ablation catheter in both geographies, difference in the utilization of bidirectional contact force catheter (52.7% and 90.5%) and the automated lesion marking module (76.3% and 81.1%) were observed in European and U.S. cases, respectively. The use of adenosine or isoproterenol to confirm PVI was reported in 25% and 64% of the European and U.S. cases. Average waiting periods were 18.2 minutes and 26.5 minutes from reported European and U.S. cases. Total procedural time, mapping time, and fluoroscopy time were similar between European and U.S. cases. (Table). First pass PVI were 66.4% and 72.6% for European and U.S. cases, respectively.

Conclusion

Total procedural time and RF time were similar between European and U.S. cases during de novo paroxysmal atrial fibrillation ablation using the same ablation catheter. Differences in workflow including the use of a mapping catheter for geometry creation and waiting period were observed between the two geographies.

Summary of procedural details De novo PAF N Procedural time(min) Mapping time (min) PVI time (min) Total RF time (min) Fluoro time( min) Europe 131 144.0 ± 56.9 16.6 ± 17.1 69.8 ± 35.0 33.2 ± 15.6 11.6 ± 10.1 U.S. 95 137.6 ± 64.8 18.1 ± 23.5 58.8 ± 31.5 32.3 ± 22.2 12.0 ± 15.8

P981Comparison of automark utilization and lesion metric target during paroxysmal atrial fibrillation ablation with a contact force-sensing ablation catheter: European and U.S. multicenter Experiences

Background

Accurate delivery of transmural lesion is associated with improved durability of pulmonary vein isolation and reduced reconduction. Lesion quality depends on multiple parameters such as radiofrequency power, tissue-catheter contact, duration of energy application, and catheter tip temperature. Consequently, energy delivery parameters vary based on individual operators’ preferences and procedural needs.

Purpose

To characterize and compare the utilization of automated lesion marking feature and lesion delivery parameters used during paroxysmal atrial fibrillation ablation performed with a magnetic sensor enabled contact force-sensing catheter across European and U.S. centers.

Methods

Procedural data were prospectively collected in clinical cases performed with a new magnetic sensor enabled, contact force ablation catheter within the first 6 months of use at participating centers in Europe and the U.S. Use of bidirectional CF catheters, steerable sheaths, automated lesion marking software and associated lesion delivery parameters during paroxysmal atrial fibrillation ablation were evaluated.

Results

A total of 149 cases across 37 centers in 11 European countries, and 112 cases across 31 U.S. centers were analyzed. A bidirectional contact force catheter (56.4% and 90.2%), a steerable sheath (65.8% and 69.6%), and the automated lesion marking module (77.9% and 90.2%) were used in most European and U.S. cases, respectively. The most commonly reported energy delivery parameters were: lesion index (LSI), Force-Time Integral (FTI), and time from European cases; LSI, average force, and FTI for U.S. cases (Table). Target LSI values were recorded for 126 cases in Europe and 34 in the U.S, ranging from 3 to 6. In anterior/roof segments, most common LSI target values for anterior/roof and posterior/inferior segments were 6 (42.9%) and 5 (51.2%) in Europe, and 5.5 (44.1%) and 5 (54.5%) in the U.S. PVI was confirmed with an average of 20.3 minutes waiting period (69.1%) for European cases and exit block (57.1%) in U.S. cases. First pass PVI were 67.1% and 74.4% for European and U.S. cases, respectively.

Conclusion

Energy delivery parameters and PVI confirmation method varied considerably by geography during paroxysmal atrial fibrillation ablation using the magnetic sensor enabled, contact force ablation catheter. Further study on efficacy implication on these differences in practice should be examined.

Energy delivery parameters used Paroxysmal AF N LSI FTI Time Imp Drop Avg Force Other N/A Europe 149 44.0 % 13.4 % 7.0 % 6.0 % 2.4 % 1.0 % 26.2 % U.S. 112 31.2% 17.9 % 6.2 % 8.0 % 23.2 % 11.7 % 1.8 % Energy delivery parameters used in paroxysmal AF ablation in Europe and U.S.

Effect of catheter ablation on quality of life in patients with atrial fibrillation and its correlation with arrhythmia outcome

Objective

To assess the effect of catheter ablation on atrial fibrillation (AF) symptoms and quality of life (QoL).

Methods

Patients with AF scheduled for ablation were recruited. Pulmonary vein isolation (PVI) was performed and complex fractionated atrial electrogram (CFAE)±linear ablation undertaken in patients in AF despite PVI. QoL and AF symptoms were assessed using SF-36 V2 and Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaires before and 3 months after ablation. Change in QoL scores after ablation was correlated with clinical parameters and the extent of ablation. Magnitude of QoL change was compared between AFEQT and SF-36 physical component summary (PCS) and mental component summary (MCS) scores and correlated with arrhythmia outcome.

Results

80 patients were studied. Summative and individual health scores for both AFEQT (51.5±22.0 vs 81.3±18.2; p<0.01) and SF-36 (PCS 43.3±10.5 vs 47.9±11.3; p<0.01 and MCS 45.0±11.5 vs 51.5±9.4; p<0.01) improved significantly in patients who maintained sinus rhythm after ablation, but not in those with recurrent AF. Improvement in AFEQT (25.4±19) was significantly greater than change in PCS (6.8±6.4; p<0.01) and MCS (8.5±7.9; p<0.01) scores and correlated more closely with arrhythmia outcome (AFEQT r=0.55; PCS r=0.26; MCS r=0.30).

Conclusions

Patients who maintained sinus rhythm after ablation had a significant improvement in AF symptoms and QoL; however, no improvement was observed in patients with recurrent AF. QoL change after ablation did not correlate with baseline clinical parameters or ablation strategy. AF specific QoL scales are more responsive to change and correlate better with ablation outcome.

Characteristics of atrial fibrillation cycle length predict restoration of sinus rhythm by catheter ablation

BACKGROUND

Successful termination of atrial fibrillation (AF) during catheter ablation (CA) is associated with arrhythmia-free follow-up. Preablation factors such as mean atrial fibrillation cycle length (AFCL) predict the likelihood of AF termination during ablation but recurring patterns and AFCL stability have not been evaluated.

OBJECTIVE

To investigate novel predictors of acute and postoperative ablation outcomes from intracardiac electrograms: (1) recurring AFCL patterns and (2) localization index (LI) of the instantaneous fibrillatory rate distribution.

METHODS

Sixty-two patients with AF (32 paroxysmal AF; 45 men; age 57 ± 10 years) referred for CA were enrolled. One-minute electrogram was recorded from coronary sinus (CS; 5 bipoles) and right atrial appendage (HRA; 2 bipoles). Atrial activations were detected automatically to derive the AFCL and instantaneous fibrillatory rate (inverse of AFCL) time series. Recurring AFCL patterns were quantified by using recurrence plot indices (RPIs): percentage determinism, entropy of determinism, and maximum diagonal length. AFCL stability was determined by using the LI. The CA outcome predictivity of individual indices was assessed.

RESULTS

Patients with terminated atrial fibrillation (T-AF) had higher RPI (P < .05 in CS7-8) and LI than did those with nonterminated atrial fibrillation (P < .005 in CS3-4; P < .05 in CS5-6, CS7-8, and HRA). Patients free of arrhythmia after 3-month follow-up had higher RPI and LI (all P < .05 in CS7-8). All indices except percentage determinism predicted T-AF in CS7-8 (area under the curve [AUC] ≥ 0.71; odds ratio [OR] ≥ 4.50; P < .05). The median AFCL and LI predicted T-AF in HRAD (AUC ≥ 0.75; OR ≥ 7.76; P < .05). The RPI and LI predicted 3-month follow-up in CS7-8 (AUC ≥ 0.68; OR ≥ 4.17; P < .05).

CONCLUSIONS

AFCL recurrence and stability indices could be used in selecting patients more likely to benefit from CA.

The clinical significance of antinucleolar antibodies

BACKGROUND

The importance of antinucleolar antibodies seen by indirect immunofluorescence on HEp-2 cells, although associated with systemic sclerosis (SSc), in unselected patients is unknown.

AIMS

To determine the true clinical significance of antinucleolar antibodies in an unselected patient population.

METHODS

Antinucleolar antibody (ANoA) positive samples were identified in the immunology laboratory during routine autoimmune screening tests; case notes were reviewed using a standard proforma.

RESULTS

104 patients with ANoA were identified and ANoA+ samples were subclassified into homogeneous, clumpy and speckled antinucleolar types. SSc was evident in only two (1.8%) patients. Other connective tissue diseases were identified in 33 patients (32%); 22 patients (21%) had evidence of various malignancies. Both disordered liver function and anaemia were seen in 22 patients and were the commonest laboratory abnormalities.

CONCLUSIONS

Neither the presence nor subtype of ANoA is specific for systemic sclerosis. Laboratory comments appended to results should reflect this fact.

beta-Adrenergic subsensitivity induced by chronic administration of terbutaline

The effect of 6-day courses of terbutaline and ephedrine on the metablic and hemodynamic responses to a 4-hour epinephrine infusion were compared in the same five individuals. Terbutaline suppressed the subsequent lactate response to epinephrine more than ephedrine did. The suppression of blood glucose response to epinephrine was similar for the two drugs. Ephedrine profoundly altered the hemodynamic responses to epinephrine causing significantly higher systolic and diastolic blood pressures and slower pulse. Terbutaline did not alter the systolic blood pressure during subsequent epinephrine infusion, and had less effect than ephedrine on the diastolic pressure and heart rate during the infusion. The effect of terbutaline on physiologic responses to exercise was studied, employing both brief strenuous and prolonged moderate treadmill exercice. Following 6 days of terbutaline the blood glucose and lactate levels during and following exercise were consistently but not markedly reduced. There was no effect on hemodynamic responses or on blood levels of free fatty acids, nor did exercise tolerance appear to be reduced. The 6-day course of terbutaline did not alter the bronchial sensitivity to inhaled methacholine as measured by spirometry. We conclude that subsensitivity is a characteristic response in most tissues to chronic exogenous adrenergic stimulation. The failure to demonstrate altered methacholine sensitivity may indicate that the adrenergic receptors of the bronchial smooth muscles are an exception to this rule, or, more likely, may reflect the difficulty in demonstrating partial bronchial adrenergic blockade in normal individuals.