Clinical Outcomes of Early Rhythm or Rate Control for New Onset Atrial Fibrillation Following Transcatheter Aortic Valve Replacement.

BACKGROUND: New onset atrial fibrillation (NOAF) is a common occurrence after transcatheter aortic valve replacement (TAVR) and portends a poorer prognosis. The optimal strategy for managing NOAF in this population is uncertain. METHODS: This retrospective cohort study utilized deidentified patient data from the TriNetX Research Network. Patients with TAVR and NOAF were stratified into a rhythm control cohort if they were treated with antiarrhythmics, received AF ablation, or underwent cardioversion within 1 year of AF diagnosis. A rate control cohort was similarly defined by the absence of rhythm control strategies and treatment with a beta blocker, calcium channel blocker, or digoxin. After 1:1 propensity score matching, the Kaplan-Meier survival analysis and Cox proportional hazard ratios (HRs) were used to compare outcomes at 7 years of follow-up. RESULTS: We identified 569 patients in each cohort following propensity matching. At 7 years, the primary composite outcome of all-cause death, myocardial infarction, cerebrovascular accident, and heart failure hospitalization was not significantly different between the rhythm and rate control cohorts (HR 0.99, 95% CI 0.83-1.18). The individual components of the primary outcome in addition to all-cause hospitalization were also similar between the groups. CONCLUSIONS: Similar outcomes were seen among patients receiving an early rhythm or rate control strategy to manage NOAF after TAVR. The attenuated benefits of an early rhythm control strategy observed in this setting may be due to the overall high burden of comorbidities and advanced age of these patients.

Hybrid ablation for persistent/long-standing persistent atrial fibrillation: a meta-analysis and trial sequential analysis of randomized controlled trials.

The efficacy and safety of hybrid ablation (HA) for patients with non-paroxysmal atrial fibrillation (AF) remain unclear. PubMed, Embase, Cochrane, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing HA (endo-epicardial ablation) versus endocardial ablation (EA) for patients with persistent/long-standing persistent AF. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled. Our meta-analysis included 3 RCTs comprising 358 patients, of whom 233 (65.1%) were randomized to HA. Compared with EA, HA reduced the recurrence of atrial tachyarrhythmias (RR 0.53; 95% CI 0.41-0.69; p < 0.01) but had no subgroup interaction according to AF type (p = 0.90). There was no significant difference in major adverse events (RR 1.22; 95% CI 0.46-3.25; p = 0.68). Trial sequential analysis indicates that the observed effects can be deemed conclusive. In conclusion, in patients with persistent/long-standing persistent AF, HA substantially reduced the recurrence of atrial tachyarrhythmias. Notably, patients with long-standing persistent AF may benefit more from this ablation strategy.

Catheter ablation for atrial fibrillation in heart failure with reduced ejection fraction patients: A meta-analysis.

BACKGROUND: The optimal treatment of atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (HFrEF) remains unsettled. OBJECTIVE: The purpose of this study was to assess the efficacy of catheter ablation (CA) and medical therapy compared to medical therapy alone in patients with AF and HFrEF. METHODS: We performed a systematic review of randomized controlled trials (RCTs) comparing CA with guideline-directed medical therapy for AF in patients with HFrEF (left ventricular ejection fraction [LVEF] ≤ 40%). We systematically searched PubMed, Embase, and Cochrane for eligible trials. A random effects model was used to calculate the risk ratios (RRs) and mean differences (MDs), with 95% confidence intervals (CIs). RESULTS: Six RCTs comprising 1055 patients were included, of whom 530 (50.2%) were randomized to CA. Compared with medical therapy, CA was associated with a significant reduction in heart failure (HF) hospitalization (RR 0.57; 95% CI 0.45-0.72; P < .01), cardiovascular mortality (RR 0.46; 95% CI 0.31-0.70; P < .01), all-cause mortality (RR 0.53; 95% CI 0.36-0.78; P < .01), and AF burden (MD -29.8%; 95% CI -43.73% to -15.90%; P < .01). Also, there was a significant improvement in LVEF (MD 3.8%; 95% CI 1.6%-6.0%; P < .01) and quality of life (Minnesota Living with Heart Failure Questionnaire; MD -4.92 points; 95% CI -8.61 to -1.22 points; P < .01) in the ablation group. CONCLUSION: In this meta-analysis of RCTs of patients with AF and HFrEF, CA was associated with a reduction in HF hospitalization, cardiovascular mortality, and all-cause mortality as well as a significant improvement in LVEF and quality of life.

Adjunctive low-voltage area ablation for patients with atrial fibrillation: An updated meta-analysis of randomized controlled trials.

BACKGROUND: The efficacy and safety of adjunctive low-voltage area (LVA) ablation on outcomes of catheter ablation (CA) for atrial fibrillation (AF) remains uncertain. METHODS: PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing CA with versus without LVA ablation for patients with AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. Our primary endpoint was recurrence of atrial tachyarrhythmia (ATA), including AF, atrial flutter, or atrial tachycardia. We used R version 4.3.1 for all statistical analyses. RESULTS: Our meta-analysis included 10 RCTs encompassing 1780 patients, of whom 890 (50%) were randomized to LVA ablation. Adjunctive LVA ablation significantly reduced recurrence of ATA (RR 0.76; 95% CI 0.67-0.88; p < .01) and reduced the number of redo ablation procedures (RR 0.54; 95% CI 0.35-0.85; p < .01), as compared with conventional ablation. Among 691 (43%) patients with documented LVAs on baseline substrate mapping, adjunctive LVA ablation substantially reduced ATA recurrences (RR 0.57; 95% CI 0.38-0.86; p < .01). There was no significant difference between groups in terms of periprocedural adverse events (RR 0.78; 95% CI 0.39-1.56; p = .49). CONCLUSIONS: Adjunctive LVA ablation is an effective and safe strategy for reducing recurrences of ATA among patients who undergo CA for AF.

Left Bundle Branch Pacing of His-Purkinje Conduction System: Initial Experience. / Estimulação do Ramo Esquerdo do Sistema His-Purkinje: Experiência Inicial.

BACKGROUND: Conventional right ventricular pacing increases the risk of atrial fibrillation and heart failure in pacemaker patients. Stimulation of the left bundle branch (LBB) of the His-Purkinje system can prevent the unwanted outcomes of right ventricular pacing. OBJECTIVE: To retrospectively analyze the intraoperative outcomes, electrocardiographic and clinical data from the initial follow-up of patients submitted to stimulation of the LBB. METHODS: The electronic parameters of the implant and of possible early complications of 52 consecutive patients submitted to stimulation of the conduction system were evaluated. The adopted significance level was 0.05. RESULTS: Fifty-two patients underwent left bundle branch stimulation, with 50 successful procedures; 69.2% of the patients were male, and the median and interquartile range of age at the time of implantation was 73.5 (65.0-80.0) years. The pre-implant QRS duration was 146 (104-175) ms and 120 (112-130) ms after the procedure. The left ventricle activation time was 78 (70-84) ms. The R-wave amplitude was 12.00 (7.95-15.30) mV, with a stimulation threshold of 0.5 (0.4-0.7) V x 0.4 ms and impedance of 676 (534-780) ohms. The procedure duration was 116 (90-130) min, and the fluoroscopy time was 14.2 (10.0-21.6) min. CONCLUSION: Cardiac stimulation of the His-Purkinje conduction system through the stimulation of the left bundle branch is a safe and feasible technique. In this study, it showed a high success rate, with low procedure and fluoroscopy periods, achieving adequate electronic measurements.

FUNDAMENTO: A estimulação ventricular direita convencional aumenta o risco de fibrilação atrial e insuficiência cardíaca em portadores de marca-passo. A estimulação do ramo esquerdo (RE) do sistema His-Purkinje pode evitar os desfechos indesejados da estimulação ventricular direita. OBJETIVO: Analisar retrospectivamente os desfechos intraoperatórios, eletrocardiográficos e os dados clínicos do seguimento inicial de pacientes submetidos à estimulação do RE. MÉTODOS: Foram avaliados os parâmetros eletrônicos do implante e eventuais complicações precoces de 52 pacientes consecutivos submetidos à estimulação do sistema de condução. O nível de significância alfa adotado foi igual a 0,05. RESULTADOS: 52 pacientes foram submetidos a estimulação do RE do sistema His-Purkinje, obtendo sucesso em 50 procedimentos. 69,2% dos pacientes eram do sexo masculino e a mediana e intervalo interquatil da idade no momento do implante foi de 73,5 (65,0-80,0) anos. A duração do QRS pré-implante foi de 146 (104-175) ms e de 120 (112-130) ms após o procedimento. O tempo de ativação do ventrículo esquerdo foi de 78 (70-84) ms. A amplitude da onda R foi de 12,00 (7,95-15,30) mV, com limiar de estimulação de 0,5 (0,4-0,7) V × 0,4 ms e impedância de 676 (534-780) ohms. O tempo de procedimento foi de 116 (90-130) min e o tempo de fluoroscopia foi de 14,2 (10,0-21,6) min. CONCLUSÃO: A estimulação cardíaca do sistema de condução His-Purkinje por meio da estimulação do ramo esquerdo é uma técnica segura e factível. Nesta casuística, apresentou alta taxa de sucesso, foi realizada com tempo de procedimento e fluoroscopia baixos e obteve medidas eletrônicas adequadas.

Non-Vitamin K Antagonists Versus Warfarin in Patients with Atrial Fibrillation and Bioprosthetic Valves: A Systematic Review and Meta-Analysis.

BACKGROUND: Patients with atrial fibrillation and bioprosthetic valves are at high risk for thromboembolic events. The pooled efficacy and safety of non-vitamin K oral anticoagulants (NOACs), as a class, relative to warfarin in this population is not well-known. We aimed to compare the efficacy and safety of NOACs relative to warfarin in patients with bioprosthetic valves or valve repair. METHODS: We systematically searched EMBASE, PubMed, and Cochrane databases for randomized controlled trials comparing NOACs to warfarin in patients with atrial fibrillation and bioprosthetic valves or valve repair. We pooled outcomes for stroke or systemic embolism, ischemic stroke, hemorrhagic stroke, and major bleeding. RESULTS: We included 4 trials with 1379 patients, of whom 723 (52.4%) received a NOAC. Mean follow-up ranged from 90 days to 2.8 years. In the pooled analysis, stroke or systemic embolism was significantly lower in patients treated with NOACs (1.9%) compared with warfarin (3.7%) (odds ratio [OR] 0.43; 95% confidence interval [CI] 0.22-0.85; P = .02). Ischemic stroke (OR 0.72; 95% CI 0.18-2.93), hemorrhagic stroke (OR 0.18; 95% CI 0.03-1.05), cardiovascular death (OR 0.78; 95% CI 0.38-1.62), and all-cause mortality (OR 0.94; 95% CI 0.55-1.62) were not significantly different among groups. Major bleeding was significantly lower in patients treated with NOAC (2.8%) compared with warfarin (4.7%) (OR 0.49; 95% CI 0.28-0.88; P = .02). CONCLUSIONS: In patients with atrial fibrillation and bioprosthetic valves or valve repair, NOACs are associated with a reduced incidence of thromboembolic events and major bleeding as compared with warfarin. Thus, NOACs may be considered a preferred option for this patient population.

Estimulação do Ramo Esquerdo do Sistema His-Purkinje: Experiência Inicial / Left Bundle Branch Pacing of His-Purkinje Conduction System: Initial Experience

Resumo Fundamento A estimulação ventricular direita convencional aumenta o risco de fibrilação atrial e insuficiência cardíaca em portadores de marca-passo. A estimulação do ramo esquerdo (RE) do sistema His-Purkinje pode evitar os desfechos indesejados da estimulação ventricular direita. Objetivo Analisar retrospectivamente os desfechos intraoperatórios, eletrocardiográficos e os dados clínicos do seguimento inicial de pacientes submetidos à estimulação do RE. Métodos Foram avaliados os parâmetros eletrônicos do implante e eventuais complicações precoces de 52 pacientes consecutivos submetidos à estimulação do sistema de condução. O nível de significância alfa adotado foi igual a 0,05. Resultados 52 pacientes foram submetidos a estimulação do RE do sistema His-Purkinje, obtendo sucesso em 50 procedimentos. 69,2% dos pacientes eram do sexo masculino e a mediana e intervalo interquatil da idade no momento do implante foi de 73,5 (65,0-80,0) anos. A duração do QRS pré-implante foi de 146 (104-175) ms e de 120 (112-130) ms após o procedimento. O tempo de ativação do ventrículo esquerdo foi de 78 (70-84) ms. A amplitude da onda R foi de 12,00 (7,95-15,30) mV, com limiar de estimulação de 0,5 (0,4-0,7) V × 0,4 ms e impedância de 676 (534-780) ohms. O tempo de procedimento foi de 116 (90-130) min e o tempo de fluoroscopia foi de 14,2 (10,0-21,6) min. Conclusão A estimulação cardíaca do sistema de condução His-Purkinje por meio da estimulação do ramo esquerdo é uma técnica segura e factível. Nesta casuística, apresentou alta taxa de sucesso, foi realizada com tempo de procedimento e fluoroscopia baixos e obteve medidas eletrônicas adequadas.

Abstract Background Conventional right ventricular pacing increases the risk of atrial fibrillation and heart failure in pacemaker patients. Stimulation of the left bundle branch (LBB) of the His-Purkinje system can prevent the unwanted outcomes of right ventricular pacing. Objective To retrospectively analyze the intraoperative outcomes, electrocardiographic and clinical data from the initial follow-up of patients submitted to stimulation of the LBB. Methods The electronic parameters of the implant and of possible early complications of 52 consecutive patients submitted to stimulation of the conduction system were evaluated. The adopted significance level was 0.05. Results Fifty-two patients underwent left bundle branch stimulation, with 50 successful procedures; 69.2% of the patients were male, and the median and interquartile range of age at the time of implantation was 73.5 (65.0-80.0) years. The pre-implant QRS duration was 146 (104-175) ms and 120 (112-130) ms after the procedure. The left ventricle activation time was 78 (70-84) ms. The R-wave amplitude was 12.00 (7.95-15.30) mV, with a stimulation threshold of 0.5 (0.4-0.7) V x 0.4 ms and impedance of 676 (534-780) ohms. The procedure duration was 116 (90-130) min, and the fluoroscopy time was 14.2 (10.0-21.6) min. Conclusion Cardiac stimulation of the His-Purkinje conduction system through the stimulation of the left bundle branch is a safe and feasible technique. In this study, it showed a high success rate, with low procedure and fluoroscopy periods, achieving adequate electronic measurements.

SGLT2 inhibitors decrease cardiovascular death and heart failure hospitalizations in patients with heart failure: A systematic review and meta-analysis.

BACKGROUND: Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the composite of heart failure (HF) hospitalizations or cardiovascular mortality among patients with HF. However, the efficacy of SGLT2 inhibitors in secondary endpoints of randomized trials and in subgroups of HF patients is not well known. METHODS: We performed a systematic review and meta-analysis of placebo-controlled, randomized trials of SGLT2 inhibitors in patients with HF. PubMed, Embase, and Cochrane databases were searched for trials published up to January 21, 2021. Data were extracted from published reports and quality assessment was performed per Cochrane recommendations. Hazard ratios (HRs) with 95% CI were pooled across trials. The primary endpoints of interest were all-cause and cardiovascular mortality. RESULTS: Out of 3969 database results, 15 randomized trials and 20,241 patients were included; 10,594 (52·3%) received SGLT2 inhibitors. All-cause mortality (HR 0·86; 95% CI 0·79-0·94; p = 0·0007; I2=0%) and cardiovascular mortality (HR 0·86; 95% CI 0·78-0·96; p = 0·006; I2=0%) were significantly lower in patients treated with SGLT2 inhibitors compared with placebo. The composite of cardiovascular mortality, HF hospitalizations, or urgent visits for HF was significantly reduced with SGLT2 inhibitors in all the following subgroups: male, female, age < 65, age ≥ 65, race - Black and White, estimated glomerular filtration rate (eGFR) <60, eGFR ≥60, New York Heart Association (NYHA) class II, NYHA ≥III, and HF with preserved ejection fraction. INTERPRETATION: In patients with HF, SGLT2 inhibitors significantly reduce all-cause and cardiovascular mortality compared with placebo. In addition, the composite of cardiovascular mortality or HF hospitalizations/urgent visits is reduced with SGLT2 inhibitors across subgroups of sex, age, race, eGFR, HF functional class, and ejection fraction.

Sacubitril/valsartan versus angiotensin inhibitors and arrhythmia endpoints in heart failure with reduced ejection fraction.

BACKGROUND: Angiotensin receptor-neprilysin inhibitor (ARNI) therapy has been associated with improved survival for patients with symptomatic heart failure and reduced ejection fraction (HFrEF). OBJECTIVES: We performed a meta-analysis of arrhythmia endpoints from studies comparing ARNI with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) for patients with HFrEF to assess for incremental benefit. METHODS: We searched PubMed, Embase, and ClinicalTrials.gov. Baseline study characteristics were collected and outcomes were sustained ventricular arrhythmias, atrial arrhythmias, appropriate implantable cardioverter-defibrillator (ICD) therapy, sudden cardiac death (SCD), and biventricular (BiV) pacing rate. RESULTS: We included 9 studies, 4 randomized trials, and 5 observational studies (5589 patients on ARNI vs 5615 on ACEIs/ARBs). Follow-up ranged from 2 to 51 months. The mean age was 65.4 ± 9.8 years, with 77.3% male patients and a mean ejection fraction of 29.0% ± 7.6%. Ischemic cardiomyopathy was present in 62% of patients. In the ARNI group, there were less SCD (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.96; P = .02), ventricular arrhythmias (OR 0.45, 95% CI 0.25-0.79; P = .005), and appropriate ICD therapy (OR 0.39, 95% CI 0.21-0.74; P = .004). Higher rates of BiV pacing were seen (mean difference 3.13, 95% CI 2.58-3.68; P < .00001) when compared with ACEIs/ARBs. No difference in atrial arrhythmias was seen. CONCLUSION: ARNI therapy provides incremental benefit with respect to ventricular tachyarrhythmias/SCD, which may, in part, explain improved outcomes in patients with HFrEF compared to ACEIs/ARBs. There was increased BiV pacing and decreased ICD therapy in the ARNI group.