Catheter Ablation as First-Line Therapy in Persistent Atrial Fibrillation: Patient Characteristics and Clinical Outcomes.

BACKGROUND: In patients with persistent atrial fibrillation (PerAF), antiarrhythmic drugs (AADs) are considered a first-line rhythm-control strategy, whereas catheter ablation is a reasonable alternative. OBJECTIVES: This study sought to examine the prevalence, patient characteristics, and clinical outcomes of patients with PerAF who underwent catheter ablation as a first or second-line strategy. METHODS: This multicenter observational study included consecutive patients with PerAF who underwent first-time ablation between January 2020 and September 2021 in 9 medical centers in the United States. Patients were divided into those who underwent ablation as first-line therapy and those who had ablation as second-line therapy. Patient characteristics and clinical outcomes were compared between the groups. RESULTS: A total of 2,083 patients underwent first-time ablation for PerAF. Of these, 1,086 (52%) underwent ablation as a first-line rhythm-control treatment. Compared with patients treated with AADs as first-line therapy, these patients were predominantly male (72.6% vs 68.1%; P = 0.03), with a lower frequency of hypertension (64.0% vs 73.4%; P < 0.001) and heart failure (19.1% vs 30.5%; P < 0.001). During a mean follow-up of 325.9 ± 81.6 days, arrhythmia-free survival was similar between the groups (HR: 1.13; 95% CI: 0.92-1.41); however, patients in the second-line ablation strategy were more likely to continue receiving AAD therapy (41.5% vs 15.9%; P < 0.001). CONCLUSIONS: A first-line ablation strategy for PerAF is prevalent in the United States, particularly in men with fewer comorbidities. More data are needed to identify patients with PerAF who derive benefit from an early intervention strategy.

EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA).

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

The impact of catheter ablation in patient's heart failure and atrial fibrillation: a meta-analysis of randomized clinical trials.

BACKGROUND: Recent trial data suggest a benefit to catheter ablation (CA) compared to medical therapy for atrial fibrillation (AF) in patients with heart failure (HF). Nevertheless, because of mixed trial evidence, contemporary guidelines give it a class 2 recommendation. Accordingly, we sought to assess the currently available evidence for CA in HF with AF. METHODS: Electronic databases were searched to identify randomized clinical trials (RCTs) comparing CA to medical therapy in patients with AF and HF. Study data was pooled using fixed and random effects, and the number needed to treat (NNT) was calculated to gauge absolute risk differences. Heterogeneity was quantified using I2. Our primary outcome was all-cause mortality. RESULTS: Nine trials (CA 1075 patients; medical therapy 1083 patients) were included. Ablation reduced the relative risk of all-cause mortality by 31.5% (95% CI 13.7 to 45.6%; NNT = 23), cardiovascular mortality by 39.3% (95% CI 10.9 to 58.7%; NNT = 31), cardiovascular hospitalization by 29.1% (95% CI 9.4 to 44.6%; NNT = 9), and heart failure hospitalization by 28.5% (95% CI 6.5 to 45.4%; NNT = 22). Improvements in quality of life were observed with CA using the Minnesota Living with Heart Failure Questionnaire (mean difference - 5.26; 95% CI - 2.73 to - 7.78) and the Atrial Fibrillation Effect on Quality of Life (mean difference 5.36; 95% CI 2.72 to 8.00). CONCLUSION: Compared to medical therapy, CA for AF in patients with HF reduces all-cause mortality, cardiovascular mortality, cardiovascular hospitalizations, and heart failure hospitalizations, and may improve quality of life.

Outcomes of uninterrupted vs interrupted Periprocedural direct oral Anticoagulants in atrial Fibrillation ablation: A meta-analysis.

BACKGROUND: Studies indicate that uninterrupted anticoagulation (UA) is superior to interrupted anticoagulation (IA) in the periprocedural period during catheter ablation of atrial fibrillation. Still IA is followed in many centers considering the bleeding risk. This meta-analysis compares interrupted and uninterrupted direct oral anticoagulation during catheter ablation of atrial fibrillation. METHODS: A systematic search into PubMed, EMBASE, and the Cochrane databases was performed and five studies were selected that directly compared IA vs UA before ablation and reported procedural outcomes, embolic, and bleeding events. The primary outcome of the study was major adverse cerebro-cardiovascular events. RESULTS: The meta-analysis included 840 patients with UA and 938 patients with IA. Median follow-up was 30 days. Activated clotting time (ACT) before first heparin bolus was significantly longer with UA (P = .006), whereas mean ACT was similar between the two groups (P = .19). Total heparin dose needed was significantly higher with IA (mean, ‒1.61; 95% CI, ‒2.67 to ‒0.55; P = .003). Mean procedure time did not vary between groups (P = .81). Overall complication rates were low, with similar major adverse cerebro-cardiovascular event (P = .40) and total bleeding (P = .55) rates between groups. Silent cerebral events (SCEs) were significantly more frequent with IA (log odds ratio, ‒0.90; 95% CI, ‒1.59 to ‒0.22; P < .01; I 2, 33%). Rates of major bleeding, minor bleeding, pericardial effusion, cardiac tamponade, and puncture complications were similar between groups. CONCLUSIONS: UA during atrial fibrillation ablation has similar bleeding event rates, procedural times, and mean ACTs as IA, with fewer SCEs.

Venous Vascular Closure System Versus Manual Compression Following Multiple Access Electrophysiology Procedures: The AMBULATE Trial.

OBJECTIVES: This study compared the efficacy and safety of the VASCADE MVP Venous Vascular Closure System (VVCS) device (Cardiva Medical, Santa Clara, California) to manual compression (MC) for closing multiple access sites after catheter-based electrophysiology procedures. BACKGROUND: The VASCADE MVP VVCS is designed to provide earlier ambulatory hemostasis than MC after catheter-based procedures. METHODS: The AMBULATE (A Randomized, Multi-center Trial to Compare Cardiva Mid-Bore [VASCADE MVP] VVCS to Manual Compression in Closure of Multiple Femoral Venous Access Sites in 6 - 12 Fr Sheath Sizes) trial was a multicenter, randomized trial of device closure versus MC in patients who underwent ablation. Outcomes included time to ambulation (TTA), total post-procedure time (TPPT), time to discharge eligibility (TTDe), time to hemostasis (TTH), 30-day major and minor complications, pain medication usage, and patient-reported outcomes. RESULTS: A total of 204 patients at 13 sites were randomized to the device arm (n = 100; 369 access sites) or the MC arm (n = 104; 382 access sites). Baseline characteristics were similar between groups. Mean TTA, TPPT, TTDe, and TTH were substantially lower in the device arm (respective decreases of 54%, 54%, 52%, and 55%; all p < 0.0001). Opioid use was reduced by 58% (p = 0.001). There were no major access site complications. Incidence of minor complications was 1.0% for the device arm and 2.4% for the MC arm (p = 0.45). Patient satisfaction scores with duration of and comfort during bedrest were 63% and 36% higher in device group (both p < 0.0001). Satisfaction with bedrest pain was 25% higher (p = 0.001) for the device overall, and 40% higher (p = 0.002) for patients with a previous ablation. CONCLUSIONS: Use of the closure device for multiple access ablation procedures resulted in significant reductions in TTA, TPPT, TTH, TTDe, and opioid use, with increased patient satisfaction and no increase in complications. (A Randomized, Multi-center Trial to Compare Cardiva Mid-Bore VVCS to Manual Compression in Closure of Multiple Femoral Venous Access Sites in 6 - 12 Fr Sheath Sizes [AMBULATE]; NCT03193021).

Complex Left Atrial Appendage Morphology Is an Independent Risk Factor for Cryptogenic Ischemic Stroke.

Importance: Ischemic strokes pose a significant health burden. However, the etiology of between 20 and 40% of these events remains unknown. Left atrial appendage morphology may influence the occurrence of thromboembolic events. Design: A retrospective cross-sectional study was conducted to investigate the role of LAA morphology in patients with atrial fibrillation (AF) and cardioembolic-associated stroke and patients with cryptogenic stroke without atrial fibrillation. LAA morphology is classified into two groups: (1) simple (chicken-wing) vs. (2) complex (non-chicken wing) based on transesophageal echocardiography (TEE) findings. In addition to the LAA morphology, left atrial parameters, including orifice diameter, depth, emptying velocity, and filling velocity, were collected for both groups. Mathematical, computational models were constructed to investigate flow velocities in chicken-wing and non-chicken wing morphological patterns to assess LAA function further. Findings: TEE values for volume, size, emptying, and filling velocities were similar between simple and complex LAA morphology groups. Patients with cryptogenic stroke without coexisting AF were noted to have significantly higher rates of complex LAA morphology. Chicken-wing LAA morphology was associated with four-fold higher flow rate (kg/s) in computational simulations. Conclusions: Complex LAA morphology may be an independent contributing factor for cryptogenic strokes. Further studies are warranted to investigate the mechanism involved in LAA morphology and thromboembolic events.

Ventricular Tachycardia Ablation in the Elderly: An International Ventricular Tachycardia Center Collaborative Group Analysis.

BACKGROUND: Successful ventricular tachycardia (VT) ablation is associated with improved survival in patients with heart failure. However, the safety and efficacy of VT ablation in the elderly, a population with higher competing nonsudden death risk and comorbidities, have not been well defined. METHODS AND RESULTS: The International Ventricular Tachycardia Center Collaborative Study Group registry of 2061 patients who underwent VT ablation at 12 international centers was analyzed. Kaplan-Meier analysis was used to estimate survival of patients ≥70 years with and without VT recurrence. Of the 2049 patients who met inclusion criteria, 681 (33%) patients were ≥70 years of age (mean age, 75±4 years). Among these, 92% were men, 71% had ischemic VT, and 42% had VT storm at presentation. Mean (±SD) left ventricular ejection fraction was 30±11%. Compared with patients <70 years, patients ≥70 years had higher in-hospital (4.4% versus 2.3%; P=0.01) and 1-year mortality (15% versus 11%; P=0.002) but a similar incidence of VT recurrence at 1 year (26% versus 25%; P=0.74) and time to VT recurrence (280 versus 289 days; P=0.20). Absence of VT recurrence during follow-up was strongly associated with improved survival in patients ≥70 years. CONCLUSION: VT ablation in the elderly is feasible and reasonably safe with a modestly higher in-hospital and 1-year mortality, with similar rates of VT recurrence at 1 year compared with younger patients. Successful VT ablation, that is, lack of VT recurrence, is strongly associated with improved survival even in this elderly subgroup.

Doppler derived coronary flow reserve during dobutamine stress echocardiography further improves detection of myocardial ischemia.

BACKGROUND: The coronary flow velocity (CFV) has been used to estimate coronary flow reserve (CFR) during dobutamine stress echocardiography (DSE). However, the relationship of the CFR to myocardial wall thickening (WT) has not been investigated. OBJECTIVES: The aims of this study were: (1) to assess the feasibility of obtaining systolic and diastolic CFV and thus CFR during DSE and (2) to assess the relation between CFR and stress induced WT. METHODS: Distal left anterior descending CFV was recorded by transthoracic Doppler echocardiography during DSE. Systolic and diastolic velocities were measured at rest, low and peak dobutamine doses, simultaneously, WT of distal anteroseptal segment was assessed by 2D-guided M-mode. The CFV and CFR of patients with normal WT defined as thickening of >50% (group 1) at peak stress were compared to that of patients with abnormal WT (group 2). RESULTS: A total of 67 patients, 34 females and 33 males (mean age of 66.5+/-14.5 years) were studied. The feasibility of assessing the CFR was 97% from peak diastolic velocity, 91% from diastolic time velocity integral, 91% from peak systolic velocity, and 90% from systolic time velocity integral. Contrast agent was used in 6 patients (7%) to obtain the CFV. Twenty-five of 67 patients demonstrated abnormal wall thickening. The percentage of WT was 30.9+/-15.7% in group 2 compared to 80.8+/-24.3% in group 1 (p<0.0001). The 25 patients in group 2, who developed abnormal WT, demonstrated significantly lower CFR at low dose, as well as at peak dobutamine dose compared to patients in group 1 (1.55+/-0.5 vs. 2.03+/-0.6, p<0.008). CONCLUSION: CFV and CFR assessments are feasible during DSE with second harmonic imaging in most patients without use of contrast agent. CFR assessment during DSE correlates well with wall thickening and was able to detect ischemia early before development of wall motion abnormality.