The dynamic nature of ventricular tachycardia initiation

Initiation of ventricular tachycardia (VT) or ventricular fibrillation (VF) requires heterogeneity of the substrate. This heterogeneity has a stable/fixed component (structural or functional) and a dynamic component. The latter explains the random and sudden destabilization of the substrate and the initiation of VT or VF by a ventricular extra stimulus trigger. The main mechanisms of dynamic heterogeneity are discussed at the cellular level (action potential duration alternans and restitution and intracellular calcium cycling instability) and at the tissue level (conduction velocity restitution and concordant and discordant alternans). Better knowledge of dynamic factors in arrhythmogenesis has an overwhelming impact on both predicting malignant arrhythmias and changing the antiarrhythmic drug paradigm from suppressing triggers to modifying dynamic instability factors.

Transseptal Leftventricular Endocardial Pacing is an Alternative Technique in Cardiac Resynchronization Therapy. One Year Experience in a High Volume Center

INTRODUCTION

In patients receiving cardiac resynchronization therapy (CRT), failure rate to implant the left ventricular (LV) lead by the traditional trans-venous approach is 4-8%. Surgical epicardial implantation is considered as an alternative, but this technique is not without morbidity. Evidence from case documentation and from small trial batches demonstrated the viability of endocardial LV lead implantation where surgical epicardial lead placement is not applicable.

MATERIAL AND METHODS

Four patients were implanted with endocardial LV lead using the transseptal atrial approach after unsuccessful transvenous implantation. Implantation of an endocardial active fixation LV leads was successful in all patients with stable electrical parameters immediately after implantation and over the follow-up period. All patients received anticoagulation therapy in order to target the international normalized ratio of 2.5-3.5 and have not experienced any thromboembolic, hemorrhagic events, or infection.

RESULTS

Follow-up echocardiography indicated significant improvement of LV systolic function (24 + 4.9 to 32 + 5.1 %, P = 0.023) with a notable improvement of the functional status.

CONCLUSIONS

Endocardial left ventricular lead implantation can be a valuable and safe alternative technique to enable LV stimulation in high surgical risk patients where standard coronary sinus implant is unsuccessful.

Role of signal-averaged electrocardiography and ventricular late potentials in patients with chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk for cardiac arrhythmias. Ventricular late potentials (VLP) on signal-averaged electrocardiography (SAECG) are associated with an increased risk for malignant ventricular arrhythmias. Our aim is to investigate the modifications of SAECG parameters and the presence of VLP as possible indicators of proarrhythmic substrate in patients with COPD. We prospectively enrolled 41 consecutive patients in the COPD group and 63 patients without any history of pulmonary disease, matched for age and hypertension history, in the control group. Pulmonary function tests, arterial blood gases, echocardiography, 24-hour Holter monitoring and SAECG were performed. We measured total filtered QRS duration (QRSf), duration of high frequency, low-amplitude signals < 40 V (HFLA40), and root mean square voltage in the last 40 ms (RMS40). VLP were considered if at least two of these parameters were abnormal. Results. We did not register any significant differences in QRSf, HFLA40 or RMS40 between the two groups. In the COPD group there was a non-significant higher percentage of patients with VLP in comparison with the control group. In the COPD patients we registered a significantly higher number of isolated premature ventricular beats and of combined complex ventricular arrhythmias, consisting of polymorphic PVC, couplets, triplets or nonsustained ventricular tachycardias. None of these arrhythmic parameters correlated with SAECG variables or with the presence of VLP. Conclusion. In COPD patients parameters measured on signal-averaged electrocardiography and ventricular late potentials analysis have little value in risk stratification for ventricular arrhythmias.

Extended Antiphospholipid Antibodies Screening in Systemic Lupus Erythematosus Patients

BACKGROUND

The antiphospholipid syndrome (APS) is one of the most encountered autoimmunity in systemic lupus erythematosus (SLE) patients and pathogenesis of these two seems to be intricate.

AIM

To investigate the association of antiphospholipid antibodies (APLAs) titer with the presence of secondary APS diagnosis in SLE patients.

METHODS

65 patients fulfilling the 2012 Systemic Lupus Collaborating International Clinics (SLICC) SLE's criteria were included. The APS diagnosis was sustained according to the 2006 Sydney APS's criteria. Three groups of patients were defined: SLE patients with secondary APS, SLE with history of positive "criteria" APLAs but without APS clinical features, respectively SLE patients without positive APLAs or clinical APS criteria. An extended APLAs panel was searched in all cases: both IgM and IgG of anticardiolipin antibodies (aCL), anti-P2 glycoprotein I antibodies (aβ2GPI), antiphosphatidylethanolamine antibodies (aPE), antiphosphatidylserine antibodies (aPS), respectively antiprothrombin antibodies (aPT). Results. Only the aβ2GPI, both IgM and IgG serotypes, had significantly higher titers in patients with SLE and secondary APS compared to no APS (with/ without positive APLAs): median (min; max) 7.0 (0.0-300.0) vs. 1.0 (0.0-28.0) vs. 1.0 (0.0-12.0), respectively 3.0 (0.0-79.0) vs. 1.0 (0.0-3.0) vs. 1.0 (0.0-12.0) (p<0.001, Kruskal-Wallis test)]. Also, in regression logistic models, only the aβ2 GPI (IgG and IgM ) were identified as risk factors for secondary APS diagnosis in the SLE patients: OR(95%CI) 5.9 (2.2-15.7), respectively 1.3 (1.1-1.5). In regard with the SLE markers, the IgG serotypes of the "non-criteria" APLAs analyzed (aPS, aPT, aPE) were correlated with the antiDNA titers while the IgM serotypes inversely associated with the complement C3 levels.

CONCLUSIONS

IgG aβ2 GPI are accompanied by almost 6-fold increase risk of secondary APS when screening SLE patients. On the contrary, the "non-criteria" APLAs do not seem associated with the APS diagnosis in SLE patients. Some correlates of the "non-criteria" APLAs with the antiDNA and complement C3 levels were also observed.

P Wave Signal-Averaged Electrocardiography in Patients with Chronic Obstructive Pulmonary Disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is associated with higher incidence of supraventricular arrhythmias. Atrial late potentials (ALP) detected by P-wave signal-averaged electrocardiography (SAECG) could be useful in detecting the patients at risk for supraventricular arrhythmias. Our objective was to assess the role of P-wave SAECG and ALP detection for arrhythmic risk evaluation of the patients with exacerbated COPD.

METHODS

We prospectively included 45 patients with exacerbation of COPD and 58 age- matched patients with no history of pulmonary disease in a control group. We performed pulmonary function tests, arterial blood gases, echocardiography, 24-hour Holter monitoring and P-wave SAECG. We measured filtered P-wave duration (FPD), the root mean square (RMS) voltages in the last 40, 30 and 20 ms of the filtered P-wave (RMS 40, RMS 30 and RMS 20), the root mean square voltage of the filtered P-wave potentials (RMS-p), and the integral of the potentials during the filtered P-wave (Integral-p). ALP was defined as FPD > 132 ms and RMS 20 < 2.3 μV.

RESULTS

Isolated atrial premature beats (APB) and supraventricular tachycardias (SVT) were more frequent in the COPD group. There were no significant differences between groups regarding the P wave SAECG parameters. In the COPD group none of the supraventricular arrhythmias was correlated with ALP or any P-wave SAECG parameters.

CONCLUSIONS

The patients with acute exacerbation of COPD but no apparent cardiac disease have a higher incidence of supraventricular arrhythmias. P-wave SAECG analysis and ALP detection have little value in the arrhythmic risk evaluation of these patients.

P751Low platelets in heart failure: small cells, important impact on all-cause long-term mortality

Introduction

Heart failure (HF) affects platelet activation, function, as well as the production of platelets from megakaryocytes. Low platelet counts have been described in HF patients, however without clear distinction whether this is a consequence of HF severity or an independent comorbidity contributing to worse outcomes.

Aim

Our purpose was to assess the prognostic role of thrombocytopenia in HF patients.

Methods

Patients with HF admitted to our Cardiology Department were included in this study, after excluding acute coronary syndromes, pulmonary embolisms, infections, malignancy and hepatic cirrhosis.

Thrombocytopenia was defined as a platelet number below 15ehz747.0353/uL and classified as severe below 5ehz747.0353/uL and moderate between 5ehz747.0353–1ehz747.03530/uL. Patients with a left ventricular ejection fraction (LVEF) <40% were classified as HF with reduced EF (HFrEF), those with a LVEF between 40 and 49% as HF with mid-range EF (HFmrEF) and the rest as HF with preserved EF (HFpEF).

All-cause mortality was assessed after a mean follow-up of 5.5 years.

Results

We included 1142 patients, with a mean age of 72.45±10.53 and 51.6% female. 121 (10.6%) patients had thrombocytopenia, of which 3 had severe thrombocytopenia and 21 had moderate thrombocytopenia. All-cause long-term mortality was 43.8%.

Patients with acute decompensated heart failure had similar prevalence of thrombocytopenia as those with stable heart failure (12.3% vs 9.5%, p=0.22).

Patients with thrombocytopenia had a higher risk ratio for all-cause mortality compared to patients with normal platelet counts (RR 1.35, 95% CI 1.14–1.60, p=0.002). Patients with severe thrombocytopenia had a risk ratio of 2.29 (95% CI 2.14–2.45, p=0.049), those with moderate thrombocytopenia had a risk ratio of 1.80 (95% CI 1.39–2.33, p=0.006) and those with mild thrombocytopenia had a risk ratio of 1.23 (95% CI 1.01–1.51, p=0.06) of all-cause long-term mortality, compared to patients with normal platelet counts.

Patients with thrombocytopenia and HFpEF (RR 1.66, 95% CI 1.16–2.37, p=0.021) or HFrEF (RR 1.35, 95% CI 1.09–1.68, p=0.03) had higher risk of all-cause long-term mortality, but not those with HFmrEF and thrombocytopenia (RR 1.09, 95% CI 0.67–1.76, p=0.73), possibly due to the predominance of mild thrombocytopenia (80.9%).

In multiple regression analysis, after adjusting for age and sex, alongside NT-proBNP levels and left ventricular ejection fraction, moderate thrombocytopenia (p=0.031) was an independent predictor of all-cause long-term mortality, but not mild thrombocytopenia (p=0.415). Due to the very low number of patients, no multiple regression analysis could be computed with severe thrombocytopenia.

Conclusions

Thrombocytopenia is an independent predictor of mortality in HF patients, especially platelet counts below 1ehz747.03530/uL. In both patients with HFrEF and HFpEF this biomarker should be assessed for prognosis.

P1376 The utility of platelets indices in predicting the presence of left atrial appendage thrombus in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is the most frequent arrhythmia with a high risk for thromboembolic events. The presence of left atrial appendage (LAA) thrombus is associated with a greater risk for stroke, yet few papers investgated predictor factors for LAA thrombus. Platelets indices-Mean platelet volume (MPV) and plateletcrit (PTC)-have been correlated with platelet reactivity, thrombogenicity and a high cardiovascular risk.

Purpose

The aim of this study is to determine if MPV-to-PCT and MPV-to-platelet (PLT) ratios could predict the presence of LAA thrombus in nonvalvular AF patients.

Methods

This retrospective study includes 112 patients screened with trans-esophageal echography (TEE) for LAA thrombus from January 2018 to Aprilie 2019. We excluded patients with manifest, deep vein thrombosis, pulmonary trombembolism and malignancies. The platelets indices were measured on admission.

ROC curve analysis and the Youden index associated criterion was used to determine the cut-off values and Chi –square test to estimate associated risks.

Results

The focus group consisted of 112 AF patients, with a mean age of 67 ± 10.02 and 52.3% males. 71% patients had persistent AF, 19.64% (22) patients had LAA thrombi.

Higher MPV-to-PCT, respectively MPV-to-PLT ratios were associated with LAA thrombus. In ROC curve analysis MPV-to-PLT ratio (AUC 0.618 95% CI 0.521 to 0.708, p = 0.0729) and MPV-to-PCT ratio (AUC 0.627, 95% CI 0.530 to 0.716, p = 0.05) predicted LAA thrombi, with a cut-off value of &gt;38 for MPV-to-PCT and &gt;0.049 for MPV-to-PLT ratio.

Patients with an MPV-to-PCT ratio &gt; 38 had a risk ratio of 1.21 (95% CI 1.03 - 1.44, p = 0.039) and those with an MPV-to-PLT ratio&gt; 0.049 a risk ratio of 1.27 (95%CI 1.03 - 1.58, p = 0.01 ) of having a LAA thrombus.

Conclusion

Platelets indices are cost efficient, readily available thrombogenesis biomarkers that could be auxilliary parameters useful for the associtation of LAA thrombi in non-valvular AF patients undergoing TEE before cardioversion. We suggest the cut-off values of MPV-to-PCT&gt; 38 and MPV-to-PLT &gt; 0.049 to be considered as risk indicator.

P5656Heart failure clinical phenotypes and outcomes in patients with atrial fibrillation: an analysis from the eurobservational research programme in atrial fibrillation long-term general registry

Introduction

Heart failure (HF) is a well-known risk factor for atrial fibrillation (AF). Moreover, HF is associated with worse clinical outcomes in patients with known AF. Recently, phenotypes of HF have been redefined according to the level of ejection fraction (EF). New data are needed to understand if a differential risk for outcomes exists according to the new phenotypes' definitions.

Purpose

To evaluate the risk of major adverse outcomes in patients with AF and HF according to HF clinical phenotypes.

Methods

We performed a subgroup analysis of AF patients enrolled in the EORP-AF Long-Term General Registry with a history of HF at baseline, available EF and follow-up data. Patients were categorized as follows: i) EF<40%, i.e. HF reduced EF [HFrEF]; ii) EF 40–49%, i.e. HF mid-range EF [HFmrEF]; iii) EF ≥50%, i.e. HF preserved EF [HFpEF]. Any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death, CV death and all-cause death were recorded.

Results

A total of 3409 patients were included in this analysis: of these, 907 (26.6%) had HFrEF, 779 (22.9%) had HFmrEF and 1723 (50.5%) had HFpEF. An increasing proportion with CHA2DS2-VASc ≥2 was found across the three groups: 90.4% in HFrEF, 94.6% in HFmrEF and 97.3% in HFpEF (p<0.001), while lower proportions of HAS-BLED ≥3 were seen (28.0% in HFrEF, 26.3% in HFmrEF and 23.6% in HFpEF, p=0.035). At discharge patients with HFpEF were less likely treated with antiplatelet drugs (22.0%) compared to other classes and were less prescribed with vitamin K antagonists (VKA) (57.0%) and with any oral anticoagulant (OAC) (85.7%). No differences were found in terms of non-vitamin K antagonist oral anticoagulant use. At 1-year follow-up, a progressively lower rate for all study outcomes (all p<0.001), with an increasing cumulative survival, was found across the three groups, with patients with HFpEF having better survival (all p<0.0001 for Kaplan-Meier curves). After full adjustment, Cox regression analysis showed that compared to HFrEF, HFmrEF and HFpEF were associated with risk of all study outcomes (Table).

Cox Regression Analysis HR (95% CI) Any TE/ACS/CV Death CV Death All-Cause Death HFmrEF 0.65 (0.49–0.86) 0.53 (0.38–0.74) 0.55 (0.41–0.74) HFpEF 0.50 (0.39–0.64) 0.42 (0.31–0.56) 0.45 (0.35–0.59) ACS = Acute Coronary Syndrome; CI = Confidence Interval; CV = Cardiovascular; EF = Ejection Fraction; HF = Heart Failure; HR = Hazard Ratio.

Conclusions

In this cohort of AF patients with HF, HFpEF was the most common phenotype, being associated with a profile related to an increased thromboembolic risk. Compared to HFrEF, both HFmrEF and HFpEF were associated with a lower risk of all major adverse outcomes in AF patients.

Anaemia and adverse outcomes in European patients with atrial fibrillation: a report from the ESC-EHRA EORP atrial fibrillation general long-term registry

Background

Anaemia is an independent predictor of atrial fibrillation (AF) and a common comorbidity. Real world data on the impact of anaemia on clinical outcomes, and on the benefits and risks of oral anticoagulation (OAC) are limited.

Purpose

To investigate the association of different degrees of anaemia with adverse outcomes in a cohort of European patients with AF.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry with baseline hemoglobin (Hb) values. Patients were stratified according to World Health Organization (WHO) definition of anaemia: (i) No anaemia (Hb≥12.0g/dl for women and Hb≥13.0g/dl for men), Mild anaemia (Hb 11.0–11.9g/dl for women and Hb 11.0–12.9g/dl for men), and moderate-severe anaemia (Hb ≤10.9 g/dl for both sexes). Primary outcomes were all-cause death, major adverse cardiac events (MACE, as the composite of any thromboembolism (TE)/acute coronary syndrome/cardiovascular death) and major bleeding.

Results

From the original 11,096 AF patients enrolled in the Registry, 7767 (69.9%) were included in the present analysis (median age 70 years, interquartile range [IQR] 62–77, males 58.3%, CHA2DS2VASc score median 3 [2–4], HAS-BLED median 2 [1–2]). A total of 5973 (76.9%) patients did not have anaemia, 1156 (14.9%) had mild anaemia, and 638 (8.2%) had moderate/severe anaemia. Patients with anaemia were more likely to have more comorbidities, frailty, permanent AF and polypharmacy (≥5 drugs). Overall, 318 (18.4%) patients with anaemia and an indication for anticoagulation [i.e. CHA2DS2-VASc≥1 (males), or ≥2 (females)] did not receive any OAC. After a median (IQR) follow-up of 730 (692–749) days, all-cause death was 10.5% and there were 841 (11.6%) MACE and 186 (2.5%) major bleeds. Kaplan–Meier analysis showed a higher cumulative risk for patients with moderate-severe anaemia for all the outcomes considered (Figure) (Log Rank tests, all p&lt;0.001). Adjusted Cox regression analyses revealed that patients with mild and moderate-severe anaemia had a higher risk for all-cause death (adjusted hazard ratio [aHR] 2.02, 95% confidence interval [CI] 1.71–2.40 and aHR 2.39, 95% CI 1.97–2.91, respectively), MACE (aHR 1.44, 95% CI 1.17–1.76 and aHR 1.64, 95% CI 1.30–2.07 respectively), and major bleeding (aHR 1.52, 05% CI 1.02–2.25 and aHR 3.73, 95% CI 2.59–5.37, respectively). Among patients with moderate-severe anaemia, use of OAC was associated with lower risk of all-cause mortality (HR 0.64, 95% CI 0.46–0.89) and MACE (HR 0.55, 95% CI 0.36–0.84), without a significant increased risk of major bleeding (HR 0.81, 95% CI 0.43–1.52).

Conclusions

In a large contemporary cohort of European AF patients, almost 25% have concomitant anaemia which is associated with an increased risk for all-cause mortality, MACE and major bleeding. Use of OAC was associated with a lower risk of all-cause mortality in patients with moderate-severe anaemia, without significant increased risk of major bleeding.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022)

Syncope in elderly patients--is there a place for endomyocardial biopsy?

Syncope in the aging population has two characteristics--it always has a multifactorial origin and age by itself is a predictor of a worse outcome even in syncope with an apparent benign mechanism. Therefore, it is worthwhile investigating extensively the cardiac substrate in selected cases when the initial evaluation demonstrates its presence. In the cases where the usual workup fails to unveil the cause for the decompensating heart substrate, morphological examination with endomyocardial biopsy should be taken into account, after matching every particular case with one of the clinical scenarios listed in the Scientific Statement on the role of endomyocardial biopsy in the management of cardiovascular disease.

ABC adherence and impact of optimal medical therapy in heart failure patients with atrial fibrillation

Background

Heart failure (HF) has close association with atrial fibrillation (AF). The ESC guideline recommended Atrial fibrillation Better care (ABC) pathway aims to reduce major cardiovascular adverse outcomes with an integrated care approach. Optimal medical treatment (OMT) represents the cornerstone in HF management.

Purpose

To investigate the variables affecting OMT treatment and its impact, in conjunction with ABC pathway adherence (vs non-adherence, ie.no ABC), in a large contemporary cohort of European AF patients with HF enrolled in the ESC-EHRA EORP-AF General Long-Term Registry.

Methods

OMT was defined as treatment with Angiotensin-converting-enzyme inhibitors (ACE-i)/ Angiotensin receptor blockers (ARBs) with Beta-Blockers and/or Mineralocorticoid receptor antagonists (MRAs), and compared to non-OMT adherence (“no OMT”). A logistic regression analysis explored factors associated with OMT adherence. We identified three patient groups: (i) HF with no OMT/no ABC; (ii) HF with OMT/no ABC; (iii) HF with OMT/ABC. Primary outcome was a composite outcome of all-cause death and major adverse cardiac events (MACE).

Results

Among the original 11096 patients enrolled, 9857 (88.8%) were included in this analysis. Among these, 3819 (38.7%) had HF. Compared to non HF patients, those with HF were older, more likely female, had more comorbidities and higher thromboembolic risk. OMT prevalence was 2228/3819 (58.3%), while ABC adherence was 23.3%.

On logistic multivariable regression, increasing age, higher BMI and higher frailty index were associated with OMT adherence, while male sex, anemia, renal disease and EHRA II–IV were inversely associated with OMT adherence. According to three HF groups, the rates of composite outcome progressively decreased (HF with no OMT/no ABC 26.4%; HF with OMT/no ABC 24%, HF with OMT/ABC 19%; p&lt;0.001). Kaplan Meier curve showed progressively lower cumulative risk for the composite outcome across the three groups with the lowest risk among HF patients with OMT/ABC (Log-rank: p=0.002) [Figure 1]. Adjusted Cox regression analysis showed that when compared to HF with no OMT/no ABC group, there was a progressively lower risk with OMT and/or ABC adherence (HF with OMT/no ABC: HR 0.81 [95% CI, 0.64–1.02]; HF with OMT/ABC: HR 0.68 [95% CI, 0.5–0.92]).

Conclusions

After two years of follow-up, in a large contemporary cohort of European AF patients with HF, OMT adherence was suboptimal, being influenced by several clinical factors, determining a low adherence to the ABC pathway. OMT alone showed a non-significant reduction in composite outcome events. Conversely HF patients managed with OMT in the context of ABC pathway adherence showed the best reduction in risk of adverse outcomes.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022). - I agree that this information can be anonymised and then used for statistical purposes only

Features of clinical complexity in european patients with atrial fibrillation: a report from the ESC-EHRA EORP atrial fibrillation general long-term registry

Introduction

There is increasing concern regarding the burden of clinical complexity, beyond thromboembolic risk, in patients with atrial fibrillation (AF). Also, clinical complexity is heterogenous and entails differential impact on the patients' clinical course.

Purpose

To explore different complexity features in AF patients in determining differences in clinical management and outcomes.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Features of complexity were analysed in the context of the following high-risk groups: i) only CHA2DS2-VASc ≥2; ii) history of stroke/bleeding; iii) chronic kidney disease (creatinine clearance &lt;60 mL/min, CKD); iv) frail (frailty index ≥0.25); v) ≥2 criteria. All these groups were compared to a low-risk group (CHA2DS2-VASc 0–1). We examined use of oral anticoagulant (OAC) and the risks of a composite outcome of all-cause death and major adverse cardiovascular events.

Results

A total of 10285 patients (mean [SD] age 68.8 [11.5] years, 4107 [39.9%] females) were included in the analysis. Of these, 3944 (38.3%) had only CHA2DS2-VASc ≥2; 412 (4.0%); history of stroke/bleeding; 1480 (14.4%) CKD; 1007 (9.8%) were frail; 1315 (12.8%) had ≥2 criteria; and 2127 (20.7%) were low-risk. After adjustment for age, sex, type of AF and EHRA score, compared to low-risk patients, all the other groups were associated with OAC prescription but with progressively lower odds ratio, while those ≥2 criteria which were least likely prescribed with OAC (Table 1).

After a mean (SD) 634.5 (223.0) days of follow-up, a total of 1432 events were recorded. After adjustment for confounders, Cox regression analysis found that all the complexity groups were associated with a higher risk of the composite outcome across the groups (Figure 1). In patients with available data about ABC (Atrial fibrillation Better Care) pathway adherence, the latter adherence was associated a significant incidence rate reduction (IRR) compared to non-ABC adherence in those with ≥2 criteria of clinical complexity (IRR 0.46, 95% CI 0.30–0.71), and in the CKD complexity group (IRR 0.57, 95% CI 0.41–0.81).

Conclusions

In a large contemporary cohort of European AF patients, features of clinical complexity affect differently prescriptions of OAC. All the subgroups of clinical complexity were associated with a higher risk of adverse outcomes, which were reduced by adherence to ABC pathway.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and PfizerAlliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022).

Impact on outcomes in Europe: a cluster analysis from the ESC-EHRA EORP AF general long-term registry

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

ESC-EHRA EORP AF General Long-Term Registry Investigators

Introduction

Data derived from recent observational studies in atrial fibrillation (AF) show how the complexity of the clinical phenotype, beyond baseline thromboembolic risk, can increase risk of major adverse outcomes. Importantly, risk factors tend to occur in clusters, rather than occur individually in isolation.

Aims

To describe AF patients’ clinical phenotypes among a large contemporary European AF cohort and to analyse the differential impact of these clinical phenotypes on the occurrence of major adverse outcomes.

Methods

We performed a hierarchical cluster analysis based on Ward’s Method and using Squared Euclidean Distance using 22 clinical covariates. All variables were considered as binary. Examining the distances between cluster coefficients and by visual inspection of the dendrogram produced we identified the optimal number of clusters. Patients with data available for all 22 variables were included. We considered occurrence of cardiovascular events and all-cause death.

Results

Among the original 11096 patients included, 9363 (84.4%) were available for this analysis. The cluster analysis identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients with prevalent noncardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients mainly admitted for first detected and paroxysmal AF with low prevalence of concomitant conditions; Cluster 3 (n = 2955; 31.6%) included patients with high prevalence of permanent AF, cardiac risk factors and comorbidities. Thromboembolic and bleeding risks were higher in Cluster 3 and progressively lower in Cluster 1 and Cluster 2 (both p &lt; 0.001). Use of oral anticoagulant was significantly lower for Cluster 2 (83.2% vs. 86.5% and 86.7% in Cluster 1 and Cluster 3, respectively; p &lt; 0.001). Over a mean follow-up of 22.5 (SD5.5) months, Cluster 3 had the highest rate of both cardiovascular events (10.0%) and all-cause death (13.2%), compared with Cluster 1 (6.6% and 9.4%, respectively) and Cluster 2 (3.7% and 3.8%, respectively) (both p &lt; 0.001). Kaplan-Meier curves (Figure) show that Cluster 2 (green line) had the lowest cumulative risk of outcomes; risk was progressively higher in Cluster 1 (orange line) and Cluster 3 (yellow line). A Cox multivariable regression analysis, adjusted for type of AF, symptomatic status, CHA2DS2-VASc score and use of oral anticoagulants, showed that both Cluster 3 and Cluster 1 were associated with a significantly increased risk of cardiovascular events (HR: 1.80, 95%CI: 1.39-2.33 and HR: 1.40, 95%CI: 1.09-1.80, respectively) and all-cause death (HR: 1.80, 95%CI: 1.40-2.30 and HR: 1.66, 95%CI: 1.30-2.11) compared to Cluster 2.

Conclusions

In European AF patients, three main clinical clusters were identified, those with non-cardiac comorbidities, low risk and cardiac comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of cardiovascular events and all-cause death. Abstract Figure. Kaplan-Meier Curves for Outcomes

P1087Prevalence and significance of mitral regurgitation in atrial fibrillation coexisting with HFpEF and HFmEF

Background

Recent data has acknowledged atrial induced functional mitral valve regurgitation (MR) in the setting of atrial fibrillation (AF) and/or heart failure with preserved ejection fraction (HFpEF)  as a distinct type of secondary MR, holding prognostic significance. However, evidence on its prevalence is still scarce, especially in the phenotype of mid-range ejection fraction heart failure (HFmEF).

Purpose

The aim of this study is to evaluate the occurrence of left atrial (LA) enlargement and MR in AF patients with or without heart failure with preserved or mid-range ejection fraction.

Methods

This retrospective study included 750 consecutive patients with AF admitted to a tertiary hospital from January 2018 to June 2019. We excluded patients with primary valvular disease and HF with reduced EF. MR presence and severity were assessed by evaluating the valve morphology, colour flow imaging and, when feasible, vena contracta and PISA methods. We measured LA anteroposterior diameter and used LA dilatation as a surrogate marker for mitral annulus dilatation.

Results

We evaluated 584 AF patients: mean age 72.22 ± 10.10 years; 58,73% females; 79.75% had HF: 73.13% of them had HFpEF and 26.87% had HFmEF.

Compared to those without HF, patients with HF had a relative risk (RR) of associating LA enlargement of 5.37 (95%CI = 3.05-9.48, p &lt; 0.001) and a RR of associating MR of 1.47 (95%CI 1.08-2.00, p = 0.01). Mean LA diameter was higher in the HF group, compared to non-HF (47.06 ± 7.26 mm vs 40.91 ± 7.10 mm, p &lt; 0.001). MR severity was more likely associated with HF (RR = 1.68, 95%CI = 1.46-1.94, p &lt; 0.001).

When comparing results between the two HF subgroups, patients with HFmEF had a higher mean LA diameter than those with HFpEF (48.52 ± 5.68 mm vs 46.36 ± 7.57 mm, p = 0.011), without associating a significant difference in the MR prevalence (72.97% vs 73.98%, p = 0.94).

The presence of a dilated LA was directly correlated with MR in the HF group (RR = 1.94, 95%CI = 1.18-3.20, p = 0.023), but not in those without HF (RR = 1.04, 95%CI = 0.57-1.90, p = 0.89).

In HF patients, permanent AF associated the highest prevalence of LA dilatation (96.67%) and MR (81.73%) in contrast to paroxysmal AF (81.10%, p &lt; 0.01, respectively 63.43%, p = 0.0002).

Conclusions

LA dilatation, the presence and severity of MR correlated with AF and HF, especially in permanent AF patients. In patients without HF, LA dilatation did not correlate with the presence of MR.

MR prevalence was similar in patients with HFmEF and HFpEF, irrespective of a higher degree of LA dilatation in HFmEF.

Our results suggest that the pathophysiological mechanisms involved in LA enlargement and MR are different for different phenotypes of AF in patients with or without HF.

Impact of the atrial fibrillation better care pathway in clinically complex patients with atrial fibrillation: a report from the ESC-EHRA EORP-AF General Long-Term Registry

Background

Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The “Atrial fibrillation Better Care” (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We analyzed the impact of the ABC pathway in a contemporary cohort of clinically complex AF patients.

Methods

From the ESC-EHRA EORP-AF General Long-Term Registry, we analyzed clinically complex AF patients, defined as the presence of frailty (according to a 40-items Frailty Index), multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on the risk of all-cause death, major adverse cardiovascular events (MACEs) and the composite outcome of all-cause death and MACE was analyzed through Cox-regression analyses, and delay of event (DoE) analyses; number needed to treat (NNT) was also estimated at 1 year of follow-up.

Results

Among 9,966 AF patients, 8,289 (92.3%) were clinically complex. Risk of all outcomes was higher among clinically complex patient. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.71, 95% CI 0.57–0.89), major adverse cardiovascular events (MACEs, aHR: 0.68, 95% CI 0.53–0.87) and composite outcome (aHR: 0.69, 95% CI: 0.57–0.84). Using cluster analysis, we identified a high clinical complexity group of AF patients. Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.73, 95% CI 0.55–0.96) and composite outcome (aHR: 0.69, 95% CI 0.57–0.84) in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all-cause death (Figure 1), MACEs, and composite outcome in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the NNTs for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome.

Conclusions

An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes amongst clinically complex AF patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Since the start of EORP, several companies have supported the programme with unrestricted grants.

Impact of malignancy on outcomes in European patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in Atrial Fibrillation General Long-Term Registry

Background

Management of patients with atrial fibrillation (AF) and malignancy is a clinical challenge given the paucity of evidence supporting the appropriate clinical management.

Purpose

To evaluate the outcomes of patients with active or prior malignancy in a large contemporary cohort of European AF patients.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. We stratified the population into three categories (i) No Malignancy (NoM) (ii) Prior Malignancy (PriorM) and (iii) Active Malignancy (ActM). The primary outcome for this analysis was all-cause death among the three groups. The association between anticoagulant treatment, all-cause death and haemorrhagic events was also evaluated.

Results

Among the original 11 096 AF patients enrolled, 10 383 were included in this analysis (median age 71 years (interquartile range [IQR] 63–77, males 59.7%). Of these, 9 597 (92.4%) were NoM patients, 577 (5.6%) PriorM and 209 (2%) ActM. Patients with malignancy (prior or active) had a higher median age, median CHA2DS2-VASc and HAS-BLED scores, compared to patients without malignancy (p&lt;0.001). Lack of anticoagulation (AC) prescription occurred more commonly in ActM (21.5%) as compared with the other groups (PriorM 10.1% vs NoM 12.8%, p&lt;0.001). In case of AC treatment, patients with ActM were treated more frequently with heparins (ActM 8.1% vs PriorM 2.4% vs NoM 2%, p&lt;0.001).

After a median follow-up of 730 days [IQR 692–749], 982 (9.5%) patients died. Among all deaths, the proportion of cardiovascular death was different according to the three groups (40.0% in NoM, 26.0% in PrioM and 22.2% in ActM, p=0.002). For all cause-death, Kaplan-Meier analysis showed a progressively higher cumulative risk in the PriorM and ActM groups compared to NoM patients (Figure 1).

On multivariable Cox regression analysis, adjusted for CHA2DS2-VASc score, use of AC, type of AF and chronic kidney disease, ActM group was independently associated with a higher risk for all cause death (hazard ratio [HR] 2.90, 95% confidence interval [CI] 2.23–3.76) while PriorM group was not.

Among PriorM and NoM patients, multivariable adjusted Cox regression analysis found that the use of any AC was independently associated with a lower risk for all-cause death (HR 0.36, 95% CI 0.19–0.66; HR 0.66, 95% CI 0.54–0.81). No significant association between AC and all-cause death was found for ActM patients.

Conclusions

In a large contemporary cohort of European AF patients, active malignancy was found to be independently associated with all-cause death. Use of any AC was associated with a lower risk for all-cause death in patients with no malignancies and with prior malignancies, but with no significant association amongst patients with active malignancies.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022). Figure 1. Kaplan-Meier for all-cause death

Factors associated with progression of atrial fibrillation and impact on all-cause mortality: an ancillary analysis from the ESC-EHRA EURObservational Research Programme in Atrial Fibrillation General

Background

Paroxysmal atrial fibrillation (AF) often shows a natural progression towards more sustained forms of the arrhythmia. Real-world data on clinical factors associated to AF progression and its impact on long-term outcome are limited.

Purpose

To investigate the factors associated with progression of AF and its impact on all-cause mortality in a contemporary cohort of European AF patients

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Patients with paroxysmal AF at baseline or first detected AF who underwent successful cardioversion were included. Patients with known rhythm status at 1-year were then stratified into two groups: (i) No AF progression and (ii) AF progression (as defined by transition to persistent or permanent AF). All-cause mortality at 2-year of follow-up was the primary outcome of the analysis.

Results

A total of 2688 patients were included (median age 67 years, interquartile range [IQR] 60–75, females 44.7%, CHA2DS2VASc score median 3 [1–4], HASBLED median 1 [1–2]). After 1-year of follow-up 2094 (77.9%) patients showed no AF progression while 594 (22.1%) developed AF progression. On multivariable logistic regression analysis, no physical activity (odds ratio [OR] 1.35, 95% confidence interval [CI] 1.02–1.78), valvular heart disease (OR 1.63, 95% CI 1.23–2.15), left atrium diameter (OR 1.03, 95% CI 1.01–1.05) and left ventricular ejection fraction (OR 0.98, 95% CI 0.97–1.00) were independently associated with AF progression at 1-year. At the end of 2-year of follow-up, death occurred in 80/2621 (3.1%) patients. Kaplan-Meier analysis showed a lower cumulative survival from all-cause mortality in patients with AF progression compared to non-progression AF patients (Log Rank p=0.01, Figure 1). On multivariable Cox regression analysis, adjusted for age, sex, heart failure, coronary artery disease, hypertensions, diabetes mellitus, previous thromboembolic events, peripheral artery disease, chronic kidney disease and use of oral anticoagulants, patients with AF progression had an independently higher risk for all-cause mortality (adjusted hazard ratio [aHR] 1.77, 95% CI 1.09–2.89).

Conclusions

In a contemporary cohort of European AF patients, a substantial number of patients progressed to sustained AF within 1 year. Clinical factors related to atrial structural remodeling were independently associated with arrhythmia progression. AF progression was associated with an increased risk of all-cause mortality.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022).

Heart failure and cardiovascular outcomes in european patients with atrial fibrillation

Background

Heart failure (HF) has an intimate bidirectional association with atrial fibrillation (AF). Few data are available about the impact of HF phenotypes (HF with preserved ejection fraction, HFpEF; HF with mildly reduced ejection fraction, HFmrEF; HF with reduced ejection fraction, HFrEF) as predictors for adverse outcomes in AF patients.

Purpose

To investigate the association of HFpEF, HFmrEF and HFrEF with adverse outcomes in a large contemporary cohort of European AF patients and evaluate the effect of EF throughout its entire spectrum.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. HF patients were categorized according the three phenotypes and compared to those without HF (“non HF”). Main outcome was a composite outcome of all-cause death and major adverse cardiac events (MACE).

Results

Among the original 11,096 AF patients enrolled, 9857 (88.8%) were included in this analysis (median age 71 years, interquartile range [IQR 63–77], 40.1% females) with median EF 55% [IQR 45–61%] and CHA2DS2-VASc 3 [2–4]). In this cohort, 5935 (60.2%) were non HF patients, and 3240 (32.9%) had HF patients (with HF status and EF values data available). Accordingly, 1662 (51.2%) were categorized as HFpEF; 523 (14.1%) were HFmrEF; and 1235 (35.1%) were HFrEF.

After a median follow-up of 731 days [IQR 690–748], the composite outcome was significantly higher throughout HF categories (HFpEF 19.0%, HFmrEF 21.8% and HFrEF 29.6%, compared to non HF 10.7%; p&lt;0.001). In a fully adjusted multivariate Cox regression, HF phenotypes were associated with a progressively higher risk for the composite outcome (HFpEF HR 1.45 [95% CI, 1.23–1.70]; HFmrEF HR 1.82 [95% CI, 1.45–2.3]; HFrEF HR 2.51 [95% CI, 2.14–2.95], when compared to non HF patients). Considering EF in its continuous spectrum, an adjusted regression curve analysis found that progressively lower EF was associated with a progressively higher risk for the composite outcome, both in HF and overall AF patients (Figure 1, left and right panel, respectively).

Conclusions

Over a two-years follow-up, in a large contemporary cohort of European AF patients, HF phenotypes were associated with a progressively higher risk for adverse outcomes. Lower EF values increased the risk of adverse outcomes both in HF patients and overall AF patients, irrespective of HF phenotype status.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022).

Myocardial involvement in systemic lupus erythematosus and systemic sclerosis--pulsed Doppler echocardiographic evaluation of left ventricular diastolic function

Myocardial involvement (MI) in connective tissue diseases is commonly found at autopsy but seldom recognized clinically. To assess the subclinical MI, the left ventricular (LV) diastolic function was studied in 16 patients with systemic lupus erythematosus (SLE) and 15 patients with systemic sclerosis (SSc) by means of pulsed Doppler echocardiography. Patients with abnormal LV systolic function were not included. A control group (C) included 16 sex and age-matched healthy subjects. The parameters analyzed were: peak early diastolic flow velocity (E), peak late diastolic flow velocity (A), E/A ratio, isovolumic relaxation time (IRT). LV diastolic function was found impaired in SLE and SSc patients even when systolic function was normal as could be demonstrated by pulsed Doppler echocardiography.

Syncope due to autonomic insufficiency syndromes associated with orthostatic intolerance

Recurrent syncope may be either a sign or a symptom and may occur due to a wide variety of very different causes. Extensive investigations into the nature of this disorder soon uncovered that it represents only one aspect of a broad, heterogenous group of disturbances of the autonomic nervous system (ANS) that can result in hypotension, orthostatic intolerance, and often syncope. Disorders of orthostatic regulation may be subgrouped into both primary and secondary forms. In primary autonomic failure syndromes, as opposed to the intermittent periods of hypotension seen in the reflex syncopes, patients could develop orthostatic intolerance due to a failure of the ANS to function under normal circumstances. Chronic autonomic insufficiency has two entities: Pure Autonomic Failure (PAF) and Multiple System Atrophy (MSA). Over the last several years, it has become apparent that a milder form of autonomic insufficiency occurs that is now referred to as the Postural Orthostatic Tachycardia Syndrome (POTS). The secondary forms of autonomic failure occur in association with a particular disease process. One of the most important things to remember are the vast number of pharmacologic agents that may either cause or worsen orthostatic hypotension. The principal feature that all of these conditions share is that normal cardiovascular regulation is disturbed resulting in postural hypotension. The comerstone of evaluation is a detailed history and physical examination. One of the physician's most important tasks is to identify whether hypotensive syncope is primary or secondary in nature, and to determine if there are any potentially reversible causes (i.e., drugs, anemia, volume depletion). It is equally important to educate the patient. Nonpharmacologic therapies are useful. Pharmacotherapy should be used cautiously in selected cases.

Transcatheter radiofrequency ablation of atrioventricular by-pass tracts--a definitive cure of Wolff-Parkinson White syndrome

Patients with an accessory atrioventricular pathway (AAVP) may have to face either life-threatening arrhythmias or life-long antiarrhythmic drug treatment with the associated expense and morbidity, to which some may be refractory. The actual refinement of radiofrequency (RF) ablation technique has dramatically changed the management of these patients. The aim of this study is to describe the results of transcatheter RF ablation of AAVP in 29 consecutive patients with recurrent and/or drug refractory tachyarrhythmias mediated by AAVP. After an approximate localization of the AAVP according to Arruda et al. ECG algorithm, the precise identification of the site of AAVP was attempted. This was accomplished by mapping the mitral and tricuspid annuli. The tricuspid annulus was mapped directly using deflectable multielectrode catheters and the mitral annulus was mapped by means of a multielectrode catheter inserted in the coronary sinus. For finer localization we looked for AAVP activation potentials recorded from the ablation catheter. Mapping evaluation was made by means of BARD LAB SYSTEM 24 EP laboratory: 14 patients had left free-wall AAVP, 11 patients had posteroseptal AAVP and 4-midseptal AAVP. RF energy was delivered (30-40 W for 30 sec) by an Osypka HAT 200 S generator. The procedure lasted a mean 150 min and the maximum number of applications in successful sessions was 9. Twenty patients out of 29 (68.97%) were successfully ablated: 10 in the left free-wall group (71.43%), 7 in the posteroseptal group (63.64%) and 3 in the mid-septal group (75%). These lower figures are explained by the inclusion of the "learning curve" patients. For the patients of the last period the success percentage was of 90. The single complication was an arterial embolization during an arterial approach for ablation. After a mean 206-day follow-up no return of accessory pathway conduction was noticed.

CONCLUSION

Transcatheter RF ablation of AAVP is a safe and effective therapeutic modality in selected patients.