2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation.

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Atrial fibrillation and the risk of early-onset dementia and cognitive decline: An updated review.

The relationship between atrial fibrillation (AF) and dementia has been well described; however, recent data suggest that AF confers a greater risk for the development of early-onset dementia irrespective of clinical stroke. Numerous mechanisms have been hypothesized to explain cognitive decline in the setting of AF, including silent cerebral ischemia, cerebral hypoperfusion, and cerebral microvascular disease. Despite the emergence of data supporting the increased risk of early-onset dementia in patients with AF, the underlying mechanism remains unclear. Furthermore, the mechanism may be influenced by survival bias, genetic susceptibility, or early dysfunction of brain adaptation. Investigation into why this relationship exists could change how prevention and treatment are evaluated.

Shorter distance between the esophagus and the left atrium is associated with higher rates of esophageal thermal injury after radiofrequency ablation.

BACKGROUND: Esophageal thermal injury (ETI) is a known and potentially serious complication of catheter ablation for atrial fibrillation. We intended to evaluate the distance between the esophagus and the left atrium posterior wall (LAPW) and its association with esophageal thermal injury. METHODS: A retrospective analysis of 73 patients who underwent esophagogastroduodenoscopy (EGD) after LA radiofrequency catheter ablation for symptomatic atrial fibrillation and pre-ablation magnetic resonance imaging (MRI) was used to identify the minimum distance between the inner lumen of the esophagus and the ablated atrial endocardium (pre-ablation atrial esophageal distance; pre-AED) and occurrence of ETI. Parameters of ablation index (AI, Visitag Surpoint) were collected in 30 patients from the CARTO3 system and compared with assess if ablation strategies and AI further impacted risk of ETI. RESULTS: Pre-AED was significantly larger in patients without ETI than those with ETI (5.23 ± 0.96 mm vs. 4.31 ± 0.75 mm, p < .001). Pre-AED showed high accuracy for predicting ETI with the best cutoff value of 4.37 mm. AI was statistically comparable between Visitag lesion markers with and without associated esophageal late gadolinium enhancement (LGE) detected by postablation MRI in the low-power long-duration ablation group (LPLD, 25-40 W for 10-30 s, 393.16 [308.62-408.86] vs. 406.58 [364.38-451.22], p = .16) and high-power short-duration group (HPSD, 50 W for 5-10 s, 336.14 [299.66-380.11] vs. 330.54 [286.21-384.71], p = .53), respectively. CONCLUSION: Measuring the distance between the LA and the esophagus in pre-ablation LGE-MRI could be helpful in predicting ETI after LAPW ablation.

Circulating Levels of Biomarkers of Cerebral Injury in Patients with Atrial Fibrillation.

Atrial fibrillation (AF) is a source of altered brain perfusion and ischemia, potentially leading to cerebral injury and blood brain barrier (BBB) disruption, which may result in the permeation of neurospecific molecules into the bloodstream. We retrospectively analyzed circulating levels of biomarkers of cerebral injury: Astrocyte-specific glial acidic fibrillary protein (GFAP), calcium-binding protein B (S100 b), stress response marker growth differential factor 15 (GDF15), and microtubule associated Tau protein, in patients with AF and non-AF controls. A total of 196 AF cases and 47 non-AF controls were enrolled in this study all without previous clinical stroke or cerebral injury. Plasma samples were obtained from the Intermountain INSPIRE biobank registry. AF status was determined at the time of the sample draw using clinical diagnosis. Assessment of circulating biomarkers was conducted with EIA. Multivariate linear modeling, using natural log, and square root transformation of the biomarkers, was done adjusting for (1) CHA2DS2-VASc and anticoagulation, and (2) age, gender, coronary artery disease and anticoagulation. Circulating Tau, GDF15, and GFAP were elevated in AF cases. After multivariate adjustment, GFAP and Tau remained significantly elevated in the AF, whereas the signal for GDF15 was confounded by age. In conclusion, circulating biomarkers of neuronal and glial injury Tau and GFAP are elevated in patients with AF that are consistent with subclinical cerebral injury and disruption of the BBB, which can predispose these patients to the development of cognitive dysfunction and/or dementia later in life.

The role of microRNAs in the development, regulation, and treatment of atrial fibrillation.

BACKGROUND: MicroRNAs (miRNA)s regulate expression of genes involved in various processes including cardiac automaticity, conduction, excitability, and fibrosis and therefore may provide a diagnostic utility to identify high-risk patients for atrial fibrillation (AF). In this study, we tested the hypothesis that specific profiles of circulating miRNAs can identify patients with AF and can also help to identify patients at high risk of AF recurrence after ablation. METHODS: Two patient populations were studied: 140 AF cases (93 paroxysmal and 47 persistent) and 50 healthy controls, and 141 AF ablation cases with (n = 86) and without (n = 55) 1-year recurrence. Assessment of several previously identified AF-associated plasma miRNAs (21, 29a, 133a, 133b, 150, 328) was performed with TaqMan assays, using synthetic miRNAs as standards. RESULTS: The AF cases compared to the healthy controls were older and were more often male and hypertensive. After multivariate adjustment, higher miRNA-21 levels significantly decreased the risk of AF (OR = 0.93 per fmol/µl (95% CI = 0.89-0.98, p = 0.007)). There were no significant differences in circulating miRNAs between the AF subtypes of persistent and paroxysmal. Among the AF ablation cases, miRNA-150 was lower for those with AF recurrences at 1 year (adjusted OR = 0.98 per 500,000 fmol/µl; 95% CI = 0.965, 0.998; p = 0.039). CONCLUSIONS: Decreased circulating miRNA-21 is associated with AF, but not with AF subtypes, suggestive that molecular mechanisms responsible for the onset and progression of the AF may be different. Circulating miRNA-150 was significantly associated with a reduction in 1-year AF recurrence post ablation suggestive of adverse structural and electrical remodeling as recurrence mechanisms.

Persistent left superior vena cava as an arrhythmogenic source in atrial fibrillation: results from a multicenter experience.

BACKGROUND: Persistent left superior vena cava (PLSVC) is one of the most frequently reported congenital anomalies and may be an important source of trigger of atrial fibrillation (AF). METHODS: This was a multicenter retrospective experience including 28 patients with PLSVC who were referred for catheter ablation for drug-refractory symptomatic AF. Pulmonary vein and PLSVC isolation were performed (3.5-mm open irrigated tip ablation catheter at maximum power of 20 W, maximum temperature 43 °C with flow rate of 17 ml/min). Clinical outcomes such as complications and long-term freedom from AF were measured. RESULTS: The mean age of the population was 61 ± 8 years, 21% were females, and AF duration was 60 ± 33 months. Sixty-one percent paroxysmal AF (17/28), 25% (7/28) persistent AF, and 14% (4/28) had long-standing persistent AF. There were no major complications that required any intervention. PLSVC isolation was achieved in 96% (27/28). Freedom from AF at 1 year without antiarrhythmic drugs was seen in 75% (21/28) of patients. CONCLUSIONS: In PLSVC patients with AF, segmental isolation of PLSVC appears to be feasible and safe and can translate into favorable clinical outcomes.

Atrial fibrillation incrementally increases dementia risk across all CHADS2 and CHA2DS2VASc strata in patients receiving long-term warfarin.

BACKGROUND: Patients with atrial fibrillation (AF) are at higher risk for developing dementia. Warfarin is a common therapy for the prevention of thromboembolism in AF, valve replacement, and thrombosis patients. The extent to which AF itself increases dementia risk remains unknown. METHODS: A total 6030 patients with no history of dementia and chronically anticoagulated with warfarin were studied. Warfarin management was provided through a Clinical Pharmacy Anticoagulation Service. Patients were stratified by warfarin indication of AF (n=3015) and non-AF (n=3015) and matched by propensity score (±0.01). Patients were stratified by the congestive heart failure, hypertension, age >75 years, diabetes, stroke (CHADS2) score calculated at the time of warfarin initiation and followed for incident dementia. RESULTS: The average age of the AF cohort was 69.3±11.2 years, and 52.7% were male; average age of non-AF cohort was 69.3±10.9 years, and 51.5% were male. Increasing CHADS2 score was associated with increased dementia incidence, P trend=.004. When stratified by warfarin indication, AF patients had an increased risk of dementia incidence. After multivariable adjustment, AF patients continued to display a significantly increased risk of dementia when compared with non-AF patients across all CHADS2 scores strata. CONCLUSIONS: In patients receiving long-term warfarin therapy, dementia risk increased with increasing CHADS2 scores. However, the presence of AF was associated with higher rates of dementia across all CHADS2 score strata. These data suggest that AF contributes to the risk of dementia and that this risk is not solely attributable to anticoagulant use. Dementia may be an end manifestation of a systemic disease state, and AF likely contributes to its progression.

Shortened telomere length is associated with paroxysmal atrial fibrillation among cardiovascular patients enrolled in the Intermountain Heart Collaborative Study.

BACKGROUND: Atrial fibrillation (AF) diminishes quality of life and accounts for approximately one-third of all strokes. Studies have associated mitochondrial dysfunction with both AF and telomere length (TL). OBJECTIVE: The purpose of this study was to test the hypothesis of a relationship between AF and TL. METHODS: Blood was collected from consenting participants in the Intermountain Heart Collaborative Study (n = 3576) and DNA extracted. TL was determined by multiplex quantitative polymerase chain reaction, normalized to a single copy gene, and reported as telomere/single gene ratio (t/s). Patient information was extracted from Intermountain Healthcare's electronic records database. Prevalent AF was determined by discharge ICD-9 code. AF subtype (paroxysmal [Px], persistent [Ps], long-standing persistent/permanent [Pm]) was determined by chart review. RESULTS: The t/s decreased with age (P <.00001). Subjects with a history of AF (n = 379 [10.6%] had shorter telomeres (mean t/s ± SD = 0.87 ± 0.29) compared to subjects without AF (mean t/s 0.95 ± 0.32, P <.0001). The association remained after adjustment for age (P = .017) and cardiovascular risk factors (P = .016). AF subtype was determined for 277 subjects; 110 (39.7%) had Px AF, 65 (23.5%) Ps, and 102 (36.8%) Pm AF. Mean t/s did not differ between Ps, Pm, and subjects without AF (0.94 ± 0.40, 0.94 ± 0.27, and 0.95 ± 0.32, respectively). However, the mean t/s for Px (0.81 ± 0.22) was significantly shorter than for Ps (P = .026), Pm (P = .004), or subjects without AF (P <.0001). CONCLUSION: The present study supports an association between Px AF and TL. Short TL may be a previously unrecognized risk factor for AF with potential applications in diagnosis and therapy.

Radiofrequency ablation of atrial fibrillation in patients with mitral or aortic mechanical prosthetic valves: a feasibility, safety, and efficacy study.

BACKGROUND: Patients with prosthetic valves have a high prevalence of atrial fibrillation (AF). We report a multicenter experience of performing pulmonary vein antral isolation (PVAI) in this challenging, high-risk cohort of patients. OBJECTIVE: The purpose of this study was to assess the feasibility, safety, and efficacy of radiofrequency (RF) ablation for sinus rhythm restoration in AF patients with mitral or aortic mechanical prosthetic valves. METHODS: A total of 50 patients with prosthetic valves (group I) who underwent RF ablation for AF between January 1, 2007, and April 30, 2009, were identified prospectively at four tertiary care centers. A matched group of 50 patients (group II) acted as controls. RESULTS: Total procedural time (199.4 ± 49 minutes vs 166.6 ± 27.5 minutes, P <.001) and fluoroscopy time (60 ± 17 minutes vs 53.8 ± 6.8 minutes, P <.01) were prolonged, with a higher incidence of atrial flutter at 3 months in group I (18% vs 6%, P = .1) compared to group II. At 12 months, 80% of patients in the valve group were in sinus rhythm after an average of 1.3 procedures, and 82% of controls were in sinus rhythm after an average 1.2 procedures (P = .9). There was a trend toward a higher nonfatal complication rate in the valve group than in the control group (8% vs 4%, P = .1). CONCLUSION: In patients with prosthetic valves, RF ablation for AF is feasible, safe, and efficacious, with a trend toward a higher nonfatal complication rate and an increased rate of postablation atrial flutter.

Pathophysiology of concomitant atrial fibrillation and heart failure: implications for management.

Atrial fibrillation (AF) and heart failure (HF) are two conditions regularly encountered in clinical practice. They share many common risk factors, and are often seen concurrently in an individual patient. Global aging of the population is likely to lead to an increase in the prevalence of both AF and HF alone, as well as in their combined state. The relationship between these two diseases is not simply coincidental; clinical and experimental data have defined multiple pathophysiological mechanisms to explain how either condition contributes to the de novo development of the other. The development of AF in the setting of HF, and vice versa, is associated with clinical deterioration and worsening prognosis, which indicates the need for an improved understanding of the clinical and pathological relationships between these conditions. Future research on pharmacologic therapies, such as antiarrhythmic medications, and nonpharmacologic strategies including atrioventricular nodal ablation and pulmonary vein isolation, will help to define the optimal therapeutic approach for concurrent AF and HF. This step is vital to improve both the outcomes of patients affected by these conditions and the cost-effectiveness of their care.

Pregnancy associated plasma protein-A and risk stratification of patients presenting with chest pain in the emergency department.

BACKGROUND: The aim of this study was to evaluate the clinical utility of serum pregnancy associated plasma protein-A (PAPP-A) levels in assisting triage of an intermediate to high-risk patient presenting with chest pain in the Emergency Department and no definite evidence of an acute coronary syndrome. METHODS: Serum levels of PAPP-A were measured in 59 patients presenting with chest pain to the Emergency Department. The patients were independently grouped according to the presence of acute coronary syndromes or the absence thereof. RESULTS: In a multivariate model that corrected for age, sex, type of chest pain, number of risk factors, history of coronary artery disease, troponin levels, and non-specific ECG changes, PAPP-A levels were still predictive of a final diagnosis of acute coronary syndrome in patients presenting with chest pain to the Emergency Department (Odds Ratio, 2.093; 95th confidence intervals, 1.037-4.224; p=0.039). CONCLUSIONS: Elevated serum PAPP-A levels were predictive of a diagnosis of acute coronary syndrome in intermediate- to high-risk patients presenting to the Emergency Department with chest pain and no definite evidence of an acute coronary syndrome. Thus, serum PAPP-A may be valuable as an adjunct, minimally invasive marker to improve risk stratification in chest pain patients.