Pulmonary Thromboembolism After Catheter Ablation of Cardiac Arrhythmias.

No Abstract.

The impact of anticoagulation therapy on kidney function in patients with atrial fibrillation and chronic kidney disease.

INTRODUCTION: Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related. These diseases share common risk factors and are associated with increased risk of thromboembolic events. Choosing the appropriate oral anticoagulant therapy (OAC) in patients with AF and CKD is challenging. Deterioration of renal function is common in patients with AF treated with OACs, although not all OACs affect the kidneys equally. AREAS COVERED: In this review, we aim to summarize the current knowledge of the prevention of thromboembolic events in patients with AF and CKD, focusing on the impact of specific OAC agents on renal function. EXPERT OPINION: Consideration of OAC use is mandatory in patients with AF and CKD who are at increased risk of stroke or systemic embolism. Available evidence suggests that the use of non-vitamin K antagonist oral anticoagulants (NOACs) is associated with slower deterioration of renal function in comparison to Vitamin K antagonists (VKAs). Hence, a NOAC should be used in preference to VKAs in all NOAC-eligible patients with AF and CKD. Regarding patients with end-stage renal dysfunction and those on dialysis or renal replacement therapy, the use of NOAC should be considered in line with locally relevant formal recommendations.

Long-Term Renal Function after Catheter Ablation of Atrial Fibrillation.

Background: Atrial fibrillation (AF) is associated with the development and progression of chronic kidney disease (CKD). This study evaluated the impact of long-term rhythm outcome after catheter ablation (CA) of AF on renal function. Methods and results: The study group included 169 consecutive patients (the mean age was 59.6 ± 10.1 years, 61.5% were males) who underwent their first CA of AF. Renal function was assessed by eGFR (using the CKD-EPI and MDRD formulas), and by creatinine clearance (using the Cockcroft-Gault formula) in each patient before and 5 years after index CA procedure. During the 5-year follow-up after CA, the late recurrence of atrial arrhythmia (LRAA) was documented in 62 patients (36.7%). The mean eGFR, regardless of which formula was used, significantly decreased at 5 years following CA in patients with LRAA (all p < 0.05). In the arrhythmia-free patients, the mean eGFR at 5 years post-CA remained stable (for the CKD-EPI formula: 78.7 ± 17.3 vs. 79.4 ± 17.4, p = 0.555) or even significantly improved (for the MDRD formula: 74.1 ± 17.0 vs. 77.4 ± 19.6, p = 0.029) compared with the baseline. In the multivariable analysis, the independent risk factors for rapid CKD progression (decline in eGFR > 5 mL/min/1.73 m2 per year) were the post-ablation LRAA occurrence (hazard ratio 3.36 [95% CI: 1.25-9.06], p = 0.016), female sex (3.05 [1.13-8.20], p = 0.027), vitamin K antagonists (3.32 [1.28-8.58], p = 0.013), or mineralocorticoid receptor antagonists' use (3.28 [1.13-9.54], p = 0.029) after CA. Conclusions: LRAA after CA is associated with a significant decrease in eGFR, and it is an independent risk factor for rapid CKD progression. Conversely, eGFR in arrhythmia-free patients after CA remained stable or even improved significantly.

Sex-related differences in self-reported treatment burden in patients with atrial fibrillation.

Background: Treatment burden (TB) is defined as the patient's workload of healthcare and its impact on patient functioning and wellbeing. High TB can lead to non-adherence, a higher risk of adverse outcomes and lower quality of life (QoL). We have previously reported a higher TB in patients with atrial fibrillation (AF) vs. those with other chronic conditions. In this analysis, we explored sex-related differences in self-reported TB in AF patients. Materials and methods: A single-center, prospective study included consecutive patients with AF under drug treatment for at least 6 months before enrollment from April to June 2019. Patients were asked to voluntarily and anonymously answer the Treatment Burden Questionnaire (TBQ). All patients signed the written consent for participation. Results: Of 331 patients (mean age 65.4 ± 10.3 years, mean total AF history 6.41 ± 6.62 years), 127 (38.4%) were females. The mean TB was significantly higher in females compared to males (53.7 vs. 42.6 out of 170 points, p < 0.001), and females more frequently reported TB ≥ 59 points than males (37.8% vs. 20.6%, p = 0.001). In females, on multivariable analysis of the highest TB quartile (TB ≥ 59), non-vitamin K Antagonist Oral Anticoagulant (NOAC) use [Odds Ratio (OR) 0.319; 95% Confidence Interval (CI) 0.12-0.83, P = 0.019], while in males, catheter ablation and/or ECV of AF (OR 0.383; 95% CI 0.18-0.81, P = 0.012) were negatively associated with the highest TB quartile. Conclusion: Our study was the first to explore the sex-specific determinants of TB in AF patients. Females had significantly higher TB compared with males. Approximately 2 in 5 females and 1 in 5 males reported TB ≥ 59 points, previously shown to be an unacceptable burden of treatment for patients. Using a NOAC rather than vitamin K antagonist (VKA) in females and a rhythm control strategy in males could decrease TB to acceptable values.

Anxiety and Comorbidities Differences in Adults with Chronic Pulmonary Diseases: Serbian Single Center Experience.

Background and objectives: The purpose of this study is to investigate the differences in the degree of the anxiety and comorbidity levels in patients with different chronic pulmonary diseases such as chronic obstructive bronchitis (COPD) without emphysema phenotype, pulmonary emphysema, bronchial asthma and lung cancer. Materials and Methods: The prospective clinical study included 272 patients that were diagnosed and treated of pulmonary pathology. COPD (without emphysema phenotype) (Group-1), pulmonary emphysema (Group-2), bronchial asthma (Group-3) and lung cancer (Group-4) were assessed. For the evaluation of the anxiety degree, we used Hamilton Anxiety Rating Scale (HAM-A). Results: The degree of cardiovascular symptoms was significantly higher in Group-1 versus Group-2 (p < 0.001), Group-3 (p = 0.001) and Group-4 (p = 0.013), and significantly higher in Group-4 versus Group-2 (p = 0.046). The degree of respiratory symptoms was significantly higher in Group-1 versus Group-2 (p < 0.001), Group-3 (p < 0.001) and Group-4 (p = 0.002), and significantly higher in Group-4 versus Group-2 (p = 0.013) and versus Group-3 (p = 0.023). For gastrointestinal symptoms, the degree of one was significantly higher in Group-1 versus Group-2 (p < 0.001), Group-3 (p < 0.001) and Group-4 (p = 0.017). Somatic subscale values were significantly higher in Group-1 versus Group-2 (p < 0.001), Group-3 (p < 0.001) and Group-4 (p = 0.015), and significantly higher in Group-4 versus Group-2 (p = 0.024). Total HAM-A score was significantly higher in Group-1 versus Group-2 (p = 0.002) and Group-3 (p = 0.007). Conclusions: Patients with COPD (without emphysema phenotype) followed by the lung cancer are at elevated risk of being more mentally challenged in terms of increased anxiety. Furthermore, patients with exacerbation of evaluated pulmonary pathologies have various levels of comorbidities degrees.

Risk factors for late reconnections after circumferential pulmonary vein isolation guided by lesion size index - Data from repeat invasive electrophysiology procedure.

Background: Late reconnections (LR) of pulmonary veins (PVs) after wide antral circumferential ablation (WACA) using point-to-point radiofrequency (RF) ablation are common. Lesion size index (LSI) is a novel marker of lesion quality proposed by Ensite Precision mapping system, expected to improve PV isolation durability. This study aimed to assess the durability of LSI-guided PVI and the risk factors for LR of PVs. Methods: The prospective study included 33 patients with paroxysmal atrial fibrillation (PAF) who underwent (1) the index LSI-guided WACA procedure (with target LSI of 5.5-6.0 for anterior and 5.0-5.5 for posterior WACA segments) and (2) the 3-month protocol-mandated re-mapping procedure in all patients, irrespective of AF recurrence after the index procedure. Ablation parameters reported by Ensite mapping system were collected retrospectively. The inter-lesion distance (ILD) between all adjacent WACA lesions was calculated off-line. Association between index ablation parameters and the LRs of PVs at 3 months was analyzed. Results: The median patient age was 61 (IQR: 53-64) years and 55% of them were males. At index procedure, the first-pass WACA isolation rate was higher for the left PVs than the right PVs (64 vs. 33%, p = 0.014). In addition, a low acute reconnection rates were observed, as follows: in 12.1% of patients, in 6.1% of WACA circles, in 3.8% of WACA segments and in 4.5% of PVs. However, the 3-month remapping study revealed LR of PV in 63.6% of patients, 37.9% of WACA circles, 20.5% of WACA segments and 26.5% of PVs. The LRs were identified mostly along the left anterior WACA segment. Independent risk factors for the LR of WACA were left-sided WACA location (OR 3.216 [95%CI: 1.065-9.716], p = 0.038) and longer ILD (OR 1.256 [95%CI: 1.035-1.523] for each 1-mm increase, p = 0.021). The ILD of > 8.0 mm showed a predictive value for the LR of WACA, with the sensitivity of 84% and specificity of 46%. A single case of cardiac tamponade occurred following the re-mapping invasive procedure. No other complications were encountered. Conclusion: Although the LSI-guided PVI ensures a consistent PVI during the index procedure, LRs of PVs are still common. Besides the LSI, the PVI durability requires an optimal ILD between adjacent lesions, especially along the anterior lateral ridge.

Focal Myocarditis after Mild COVID-19 Infection in Athletes.

COVID-19 infection in athletes usually has a milder course, but in the case of complications, myocarditis and even sudden cardiac death may occur. We examined an athlete who felt symptoms upon returning to training after asymptomatic COVID-19 infection. Physical, laboratory, and echocardiography findings were normal. The cardiopulmonary exercise test was interrupted at submaximal effort due to severe dyspnea in the presence of reduced functional capacity in comparison to previous tests. Cardiac magnetic resonance (CMR) detected the focal myocarditis. After three months of recovery, CMR still revealed the presence of focal myocarditis and the persistence of decreased functional capacity. This case raises the question of screening athletes even after asymptomatic forms of COVID-19 infection.

Improvement of Maximal Exercise Performance After Catheter-Ablation of Atrial Fibrillation and Its Prognostic Significance for Long-Term Rhythm Outcome.

Background Rhythm control may improve functional capacity in patients with atrial fibrillation (AF). Long-term exercise tolerance improvement and its prognostic implications following catheter-ablation (CA) of paroxysmal and nonparoxysmal AF are underreported. Methods and Results Consecutive patients underwent cardiopulmonary exercise testing just before and 12 months after their index CA of AF. Follow-up 24-hour Holter recordings were obtained at 6-month intervals post-CA, and any atrial arrhythmia >30 seconds detected after 3 months postprocedure was considered AF recurrence. Of 110 patients (mean age 57.5±10.6 years, 77.2% males) with paroxysmal AF (n=66) or nonparoxysmal AF (n=44), the 12-month exercise tolerance improved significantly in those who maintained sinus rhythm during the first 12 months post-CA (n=96), but not in patients with AF recurrence (n=14). After CA, the 12-month respiratory exchange ratio at maximal workload significantly increased in patients with paroxysmal AF, whereas those with nonparoxysmal AF significantly reduced their heart rate during the 12-month cardiopulmonary exercise testing (all P≤0.001). During the follow-up of 42.8±7.8 months, a total of 29 patients (26.3%) experienced recurrent AF. On multivariate analysis including patients without recurrent AF at 12 months after CA, the extent of work time improvement at follow-up cardiopulmonary exercise testing was independently associated with the rhythm outcome beyond 12 months postprocedure (hazard ratio of 0.936 [95% CI, 0.894-0.979] for each 10 seconds increase in the work time following ablation, P=0.004). Conclusions CA of AF was associated with recovery of exercise intolerance in patients with paroxysmal AF or nonparoxysmal AF. Inability to improve exercise capacity at 12 months post-CA was an independent risk factor for later AF recurrence.

Self-reported treatment burden in patients with atrial fibrillation: quantification, major determinants, and implications for integrated holistic management of the arrhythmia.

AIMS: Treatment burden (TB) refers to self-perceived cumulative work patients do to manage their health. Using validated tools, TB has been documented in several chronic conditions, but not atrial fibrillation (AF). We measured TB and analysed its determinants and impact on quality of life (QoL) in an AF cohort. METHODS AND RESULTS: A single-centre study prospectively included consecutive adult AF patients and non-AF controls managed from 1 April to 21 June 2019, who voluntarily and anonymously answered the TB questionnaire (TBQ) and 5-item EQ-5D QoL questionnaire; TB was calculated as a sum of TBQ points (maximum 170) and expressed as proportion of the maximum value. Of 514 participants, 331 (64.4%) had AF. The mean self-reported TB was 27.6% among AF patients and 24.3% among controls, P = 0.011. The mean TB was significantly higher in patients taking vitamin K antagonists (VKAs) vs. those taking non-VKA antagonist oral anticoagulants (NOAC; 29.5% vs. 24.7%, P = 0.006). The highest item-specific TB was reported for healthcare system organization-related items (e.g. visit appointment), diet, and physical activity modifications. On multivariable analyses, female sex, younger age, and permanent AF were associated with a higher TB, whereas NOACs and electrical AF cardioversion exhibited an inverse association; TB was an independent predictor of decreased QoL (all P < 0.05). CONCLUSION: Our study provided clinically relevant insights into self-perceived TB among AF patients. Approximately one in four patients with AF have a high TB. Specific AF treatments and optimization of healthcare system-required patient activities may reduce the self-perceived TB in AF patients.

Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome and / or undergoing percutaneous coronary intervention.

The use of triple antithrombotic therapy (TAT) consisting of an oral anticoagulant (OAC), aspirin, and a P2Y12 inhibitor in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) and / or undergoing percutaneous coronary intervention (PCI) is associated with a high risk of bleeding. Recently, several randomized clinical trials tested the hypothesis as to whether dual antithrombotic therapy (DAT) regimens (consisting of an OAC and a single antiplatelet drug) may be safer in terms of bleeding events as compared with TAT. They also investigated the role of non-vitamin K antagonist oral anticoagulants (NOACs) as a part of DAT and TAT. The purpose of this review is to provide an overview of available evidence regarding the safety and efficacy of DAT compared with TAT regimens, international guidelines recommendations, knowledge gaps, and unmet needs in the management of patients with AF and ACS and / or undergoing PCI.

Risk factor modification for the primary and secondary prevention of atrial fibrillation. Part 1.

Modifiable risk factors, such as cardiometabolic and lifestyle risk factors, considerably contribute to (bi)atrial remodeling, finally resulting in clinical occurrence of atrial fibrillation (AF). Early identification and prompt intervention on these risk factors may delay further progression of atrial arrhythmia substrate and prevent the occurrence of new­onset AF. Moreover, in patients with previous history of recurrent AF, aggressive risk factor management may improve efficacy of other rhythm control strategies, including antiarrhythmic drugs and catheter ablation in sinus rhythm maintenance. Finally, modification of risk factors improves overall health and reduces cardiovascular mortality and morbidity. The first part of this review evaluates the association between AF and the following risk factors: hypertension, diabetes mellitus, physical activity, and cigarette smoking. We systematically discuss the impact of risk factor modification on primary and secondary prevention of AF.

Risk factor modification for the primary and secondary prevention of atrial fibrillation. Part 2.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased risk of death, stroke, and heart failure. Prevalence and incidence of AF are rising due to better overall medical treatment, longer survival, and increasing incidence of cardiometabolic and lifestyle risk factors. Treatment of AF and AF­related complications significantly increases healthcare costs. In addition, the use of conventional rhythm control strategies (including, antiarrhythmic drugs and catheter ablation) is associated with limited efficacy for sinus rhythm maintenance and serious adverse effects. Aggressive cardiometabolic risk factor management may prevent incident as well as recurrent AF, improve overall health, and reduce mortality. Therefore, modifiable risk factor management became one of the 3 treatment pillars in AF management along with anticoagulation as well as conventional rate and rhythm control strategies. The second part of this review systematically discusses the association between AF and potentially modifiable risk factors for AF, such as obesity, obstructive sleep apnea, alcohol consumption, and dyslipidemia. We also provide practical guidelines for the risk factor management with respect to primary and secondary prevention of AF.

A square root pattern of changes in heart rate variability during the first year after circumferential pulmonary vein isolation for paroxysmal atrial fibrillation and their relation with long­term arrhythmia recurrence.

BACKGROUND: An incidental lesion of the parasympathetic ganglia during circumferential pulmonary vein isolation (CPVI) may affect heart rate variability (HRV). AIMS: We studied the pattern of changes in HRV parameters and the relationship between the 1­year HRV change following CPVI and the recurrence of atrial fibrillation (AF). METHODS: A total of 100 consecutive patients undergoing CPVI for paroxysmal AF were enrolled (mean [SD] age, 56 [11.2] years; 61 men). We measured HRV on the day before and after CPVI, and then at 1 month as well as 3, 6, and 12 months after CPVI using 24­hour Holter monitoring. RESULTS: During the median follow­up of 33 months, 38 patients experienced the late recurrence of AF (LRAF). Compared with the pre­CPVI values, HRV was significantly attenuated on day 1 after CPVI in all patients. However, at 3 to 6 months after CPVI, all HRV parameters remained significantly decreased in LRAF­free patients but not in those with LRAF. The multivariate Cox analysis showed that early AF recurrence within the blanking period (hazard ratio [HR], 4.87; 95% CI, 2.44­9.69; P <0.001) and a change in the standard deviation of normal­to­normal intervals (SDNN) observed 3 months after ablation (HR, 0.99; 95% CI, 0.98­1; P = 0.01) were associated with LRAF. The cumulative LRAF freedom after CPVI was greater in patients with an SDNN reduction of more than 25 ms reported 3 months after ablation than in those with a reduction of 25 ms or lower (log­rank P = 0.004). CONCLUSIONS: Sustained parasympathetic denervation during 12 months after CPVI was a marker of successful CPVI, whereas a 3­month post­CPVI SDNN reduction of 25 ms or lower predicted LRAF.

The role of amiodarone in contemporary management of complex cardiac arrhythmias.

Amiodarone is an iodinated benzofuran derivative, a highly lipophilic drug with unpredictable pharmacokinetics. Although originally classified as a class III agent due to its ability to prolong refractoriness in cardiac regions and prevent/terminate re-entry, amiodarone shows antiarrhythmic properties of all four antiarrhythmic drug classes. Amiodarone is a potent coronary and peripheral vasodilator and can be safely used in patients with left ventricular dysfunction after myocardial infarction or those with congestive heart failure or hypertrophic cardiomyopathy. Its use is regularly accompanied with QT and QTc-interval prolongation but rarely with ventricular proarrhythmia. It is the most powerful pharmacological agent for long-term sinus rhythm maintenance in patients with atrial fibrillation. Amiodarone, particularly if co-administered with beta-blockers, reduces the rate of arrhythmic death due to ventricular tachyarrhythmias in patients with heart failure, but its benefit on cardiovascular and overall survival in these patients is uncertain. In addition, amiodarone is an important adjuvant drug for the reduction of shocks in patients with an implantable cardioverter-defibrillator. Over the past 40 years, amiodarone became the most prescribed antiarrhythmic. Nevertheless, the slow onset of its antiarrhythmic action requires a loading dose while the high risk of non-cardiac toxicity and common drug-drug interactions limit its long-term use. Furthermore patients treated with amiodarone require a close supervision by the treating physician. Therefore amiodarone is generally considered a secondary therapeutic option. Long-term treatment with amiodarone should be based on the use of minimal doses for satisfactory arrhythmia outcome and serial screening for thyroid, liver and pulmonary toxicity.

Revisiting the effects of omitting aspirin in combined antithrombotic therapies for atrial fibrillation and acute coronary syndromes or percutaneous coronary interventions: meta-analysis of pooled data from the PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS trials.

AIMS: Recently, three randomized trials reported that dual antithrombotic treatments (DATs) including non-vitamin K antagonist oral anticoagulants (NOACs) and a P2Y12 inhibitor without aspirin were associated with significantly less bleeding than vitamin K antagonist (VKA)-based triple antithrombotic therapy (TAT) in atrial fibrillation (AF) patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). We conducted an analysis of pooled data from these trials. METHODS AND RESULTS: A meta-analysis of the PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS trials considering major bleeding [International Society on Thrombosis and Haemostasis (ISTH) and Thrombolysis in Myocardial Infarction], clinically relevant non-major bleeding, all-cause/cardiovascular death, stroke, myocardial infarction (MI), and stent thrombosis. Treatment effect is reported as odds ratio (OR) and 95% confidence interval. Among 9463 patients (53% with ACS), DAT regimens were associated with significantly less bleeding than TAT (OR 0.598, 0.491 -0.727; P < 0.001 for ISTH major bleeding), as were NOAC-based vs. VKA-based regimens (OR 0.577, 0.477 -0.698; P < 0.001). Stroke and mortality rates were similar, but there was statistically non-significant trend towards greater risk of MI (OR 1.211, 0.955 -1.535; P = 0.115) and significantly higher risk for stent thrombosis (OR 1.672, 1.022 -2.733, P = 0.041) with DAT vs. TAT (but not NOAC- vs. VKA-based regimens). This was mainly driven by Dabigatran 110 mg; the trends were lower with full-dose NOAC or Rivaroxaban 15 mg-based DATs. CONCLUSION: Our findings support the use of full-dose NOAC (Apixaban 5 mg, Dabigatran 150 mg) or Rivaroxaban 15 mg-based treatments in most AF patients with ACS or undergoing PCI. Notwithstanding the better safety of DAT, an initial course of NOAC-based TAT may be desirable in most AF patients.

Clinical approach to the patient with Brugada Syndrome: risk stratification and optimal management.

The Brugada Syndrome (BrS) is an inherited cardiac ion channel disorder associated with increased risk of ventricular arrhythmias and mortality. Diagnosis is based on a characteristic electrocardiographic (ECG) pattern of coved type ST-segment elevation >2 mm followed by a negative T-wave in ≥1 of the right precordial leads V1 to V3. Since the first description of BrS, the definition of disease and underlying pathophysiological mechanisms have been significantly improved in recent years. Also, significant progress has been made in the field of genetic testing in these patients. Still, there are several open questions regarding the management and outcome of these patients. There is more information about patients who would need an implantable cardiac defibrillator for the primary prevention of sudden cardiac death (that is, those with spontaneous Type I Brugada ECG pattern and arrhythmia-related syncope), but currently published data concerning asymptomatic patients with Brugada ECG pattern and other less-well defined presentations are conflicting. Whereas the role of cardiac defibrillator in patients with Brugada Syndrome is clear, optimal use of catheter ablation and antiarrhythmic drug therapy needs to be further investigated. In this review, we summarize current evidence and contemporary management of patients with BrS.