Machine learned clusters explain heterogeneity in outcomes from map-guided ablation of Atrial Fibrillation results from the large PROspective STanford AF Registry (ProSTAR)

Background

Several mapping systems are being introduced to guide atrial fibrillation (AF) ablation to patient-specific regions of interest. However, results have been extremely heterogeneous between studies, ranging from very poor to very promising. It is unknown if this reflects specific patient characteristics or procedural factors because most prior series were middle sized (N∼30–100 patients).

Purpose

To study 1 year and 3 year very long-term outcomes from map guided AF-driver ablation in a large patient registry with multiple operators, to identify clinical and procedural features influencing outcomes. In real-world AF patients with diverse comorbidities, we applied a consistent patient-tailored AF mapping and ablation strategy, monitored outcomes carefully and applied statistical and unsupervised machine learning approaches to identify features of success and failure.

Method

We studied 632 consecutive patients (65±10 y, 178 F) undergoing ablation for drug-refractory AF. 59.7% had persistent AF, and 29.9% had prior unsuccessful ablation (median 1 procedure). All patients underwent pulmonary vein isolation (PVI), followed by ablation of AF regions of interest mapped from 64 pole baskets (RhythmView, Abbott, IL), by 11 operators. Patients were followed using ambulatory ECG monitors quarterly for one year, and at the time of symptoms for 3 years.

Results

Fig. 1A shows overall freedom from AF at 1-year of 77.5% (95% CI: 74.2%, 80.9%) and at 3 years of 55.5% (95% CI: 51.2%, 60.1%). Freedom from AF/AT at 1-year was 70.1% (95% CI: 66.5%, 73.8%), and at 3 years was 48.6% (95% CI: 44.3%, 53.3%). Success was higher in patients with procedural termination, first ablation versus prior unsuccessful procedures, for paroxysmal AF than non-paroxysmal AF (1 year: AT/AF freedom 74.9% versus 66.7%, p=0.006), and smaller left atrium. Three clusters (Fig 1B) were identified comprising CHA2DS2VASc score, enlarged LA, prior failed case, presenting rhythm and termination during the procedure (Table 2). At 1 year, freedom from AT/AF was 77.8% (95% CI: 72.2%, 82.1%) for cluster 3 and 56.2% (95% CI: 48.3%, 65.4%) for cluster 1 (Fig. 1B).

Conclusion

In our large registry of N=632 patients undergoing AF-map guided ablations, machine learned clusters identified cohorts with success of 56.2 to 77.8% at 1 year. Future studies should identify if lower success represents technical challenges, such as difficulties in mapping very large atria, or more difficult to treat mechanisms. These results may inform patient inclusion and ablation strategy in upcoming AF treatment trials.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National budget only - NIH, R01 HL149134, R01HL83359

Loss of cytomegalovirus-specific CD4+ T cell responses in human immunodeficiency virus type 1-infected patients with high CD4+ T cell counts and recurrent retinitis

Clinical histories are reported for 2 patients treated with highly active antiretroviral therapy (HAART) who experienced multiple relapses of cytomegalovirus (CMV) retinitis, despite suppression of human immunodeficiency virus type 1 (HIV-1) viremia and improvement in CD4+ T cell counts (to >400 cells/microL). CMV-specific CD4+ T cell immune reconstitution was measured directly, using cytokine flow cytometry, which revealed persistent deficits in CMV-specific CD4+ T cell responses in both patients. CMV-specific T cells constituted 0.14% and 0.05% of the total CD4+ T cell count in these patients, which is significantly lower than the percentages for 34 control subjects (0.6%-46%; CD4+ T cell count range, 7-1039 cells/microL; P=.019). Deficits in pathogen-specific immune responses may persist in some individuals, despite suppression of HIV-1 replication and substantial increases in circulating CD4+ T cells after HAART, and such deficits may be associated with significant morbidity from opportunistic infections.

Restoration of cytomegalovirus-specific CD4+ T-lymphocyte responses after ganciclovir and highly active antiretroviral therapy in individuals infected with HIV-1

Recent studies of subjects infected with human immunodeficiency virus (HIV-1) have produced conflicting results about the extent of reconstitution possible in the CD4+ lymphocyte repertoire after highly active antiretroviral therapy (HAART). The effect of HAART on the incidence of opportunistic infections will probably depend on reconstitution of antigen-specific CD4+ lymphocyte responses to important pathogens, including cytomegalovirus (CMV), the leading cause of blindness in AIDS. Several studies have demonstrated an important role for CD4+ lymphocytes in controlling CMV replication in vitro and in clinical studies. It is now possible to quantitate antigen-specific CD4+ lymphocyte responses by flow cytometry. Using this method, we studied CMV-specific CD4+ lymphocyte responses in individuals infected with HIV-1 with and without a history of active CMV-associated end organ disease (EOD), and in those with quiescent CMV EOD after ganciclovir therapy and HAART. The presence of active CMV-associated EOD strongly correlated with loss of CMV-specific lymphocyte responses (P = 0.0004). In contrast, patients with no history of CMV-associated EOD and most patients with quiescent EOD after HAART demonstrated strong CMV-specific CD4+ lymphocyte responses. These data indicate that the loss of CMV-specific CD4+ lymphocyte responses in individuals infected with HIV-1 who have active CMV EOD may be restored after ganciclovir therapy and HAART, which provides evidence for functional immune reconstitution to an important pathogen.

The PAL1 gene product is a peroxisomal ATP-binding cassette transporter in the yeast Saccharomyces cerevisiae

The PAL1 gene was isolated using PCR and degenerate oligonucleotide primers corresponding to highly conserved amino acid sequence motifs diagnostic of the ATP-binding cassette domain of the superfamily of membrane-bound transport proteins typified by mammalian multidrug resistance transporter 1 and Saccharomyces cerevisiae Ste6. The deduced PAL1 gene product is similar in length to, has the same predicted topology as, and shares the highest degree of amino acid sequence identity with two human proteins, adrenoleukodystrophy protein and peroxisomal membrane protein (70 kD), which are both presumptive ATP-binding cassette transporters thought to be constituents of the peroxisomal membrane. As judged by hybridization of a PAL1 probe to isolated RNA and by expression of a PAL1-lacZ fusion, a PAL1 transcript was only detectable when cells were grown on oleic acid, a carbon source which requires the biogenesis of functional peroxisomes for its metabolism. A pal1delta mutant grew normally on either glucose- or glycerol-containing media; however, unlike PAL1+ cells (or the pal1delta mutant carrying the PAL1 gene on a plasmid), pal1delta cells were unable to grow on either a solid medium or a liquid medium containing oleic acid as the sole carbon source. Antibodies raised against a chimeric protein in which the COOH-terminal domain of Pal1 was fused to glutathione S-transferase specifically recognized a protein in extracts from wild-type cells only when grown on oleic acid; this species represents the PAL1 gene product because it was missing in pal1delta cells and more abundant in pal1delta cells expressing PAL1 from a multicopy plasmid. The Pal1 polypeptide was highly enriched in the organellar pellet fraction prepared from wild-type cells by differential centrifugation and comigrated upon velocity sedimentation in a Nycodenz gradient with a known component of the peroxisomal matrix, e-oxoacyl-CoA thiolase. As judged by both subcellular fractionation and indirect immunofluorescence, localization of 3-oxoacyl-CoA thiolase to peroxisomes was unchanged whether Pal1 was present, absent, or overexpressed. These findings demonstrate that Pal1 is a peroxisome-specific protein, that it is required for peroxisome function, but that it is not necessary for the biogenesis of peroxisomes or for the import of 3-oxoacyl-CoA thiolase (and at least two other peroxisomal matrix proteins).

The Rainfall/Water-Table Level Relationship of an Unconfined Aquifer

The soil parameters that determine the infiltration rates of a shallow unconfined coastal aquifer due to rainfall were obtained using the recursive least squares method. The parameters were predicted by minimizing the mean square error between the estimated and measured water-table levels in a bore hole. The parameters λ_t , a drainage factor, β_t , a parameter which accounts for external disturbances, and α_t , a set of parameters which determine the infiltration rates due to rainfall, were all treated as time-dependent variables. Their variation is traced by introducing a "forgetting factor" in the algorithm used to determine the parameters. The parameters were determined using rainfall and water-table levels for the year 1979 at a bore hole. The parameters β_t and α_t varied considerably over the period of time and λ_t remained constant. From the parameters obtained, it appears that most of the recharge due to rainfall takes place within the first two days of the event. After two days there is very little variation in the water-table level due to rainfall although there is a slight drop on the third, fourth and fifth day, presumably due to the escape of entrapped air beneath the water-table level.