Impact of Atrial Fibrillation Ablation on Left Ventricular Filling Pressure and Left Atrial Remodeling / Impacto da Ablação da Fibrilação Atrial na Pressão de Enchimento Ventricular Esquerdo e Remodelamento Atrial Esquerdo

Background: Left ventricular (LV) diastolic dysfunction is associated with new-onset atrial fibrillation (AF), and the estimation of elevated LV filling pressures by E/e' ratio is related to worse outcomes in patients with AF. However, it is unknown if restoring sinus rhythm reverses this process. Objective: To evaluate the impact of AF ablation on estimated LV filling pressure. Methods: A total of 141 patients underwent radiofrequency (RF) ablation to treat drug-refractory AF. Transthoracic echocardiography was performed 30 days before and 12 months after ablation. LV functional parameters, left atrial volume index (LAVind), and transmitral pulsed and mitral annulus tissue Doppler (e' and E/e') were assessed. Paroxysmal AF was present in 18 patients, persistent AF was present in 102 patients, and long-standing persistent AF in 21 patients. Follow-up included electrocardiographic examination and 24-h Holter monitoring at 3, 6, and 12 months after ablation. Results: One hundred seventeen patients (82.9%) were free of AF during the follow-up (average, 18 ± 5 months). LAVind reduced in the successful group (30.2 mL/m2 ± 10.6 mL/m2 to 22.6 mL/m2 ± 1.1 mL/m2, p < 0.001) compared to the non-successful group (37.7 mL/m2 ± 14.3 mL/m2 to 37.5 mL/m2 ± 14.5 mL/m2, p = ns). Improvement of LV filling pressure assessed by a reduction in the E/e' ratio was observed only after successful ablation (11.5 ± 4.5 vs. 7.1 ± 3.7, p < 0.001) but not in patients with recurrent AF (12.7 ± 4.4 vs. 12 ± 3.3, p = ns). The success rate was lower in the long-standing persistent AF patient group (57% vs. 87%, p = 0.001). Conclusion: Successful AF ablation is associated with LA reverse remodeling and an improvement in LV filling pressure. .

Fundamento: A disfunção diastólica do ventrículo esquerdo (VE) está associada a novos episódios de fibrilação atrial (FA), e a estimativa das pressões de enchimento do VE através da razão E/e' está relacionada a um pior prognóstico em pacientes com FA. Entretanto, não se sabe se a restauração do ritmo sinusal pode reverter este processo. Objetivo: Avaliar o impacto da ablação da FA na estimativa da pressão de enchimento do VE. Métodos: Um total de 141 pacientes foi submetido à ablação por radiofrequência (RF) para o tratamento da FA refratária a drogas. Foi realizado ecocardiograma transtorácico 30 dias antes e 12 meses após a ablação. Foram avaliados os parâmetros funcionais do VE, volume do átrio esquerdo indexado (VAEi) e Doppler transmitral pulsado e Doppler tecidual do anel mitral (e' e E/e'). Dezoito pacientes apresentavam FA paroxística, 102 persistente e 21 pacientes FA persistente de longa duração. O acompanhamento incluiu ECG e monitoramento pelo sistema Holter 24h, 3, 6 e 12 meses após a ablação. Resultados: Cento e dezessete pacientes (82,9%) não apresentaram FA durante o acompanhamento (média de 18 meses ± 5 meses). O VAEi apresentou redução significativa no grupo com sucesso (30,2 mL/m2 ± 10,6 mL/m2 para 22,6 mL/m2 ± 1,1 mL/m2, p < 0,001) em comparação ao grupo sem sucesso (37,7 mL/m2 ± 14,3 mL/m2 para 37,5 mL/m2 ± 14,5 mL/m2, p = ns). A melhora da estimativa da pressão de enchimento do VE, avaliada através da redução na razão E/e', foi observada apenas após ablação com sucesso (11,5 ± 4,5 vs. 7,1 ± 3,7, p < 0,001), não sendo observada em pacientes com FA recorrente (12,7 ± 4,4 vs. 12 ± 3,3, p = ns). A taxa de ...

Impact of atrial fibrillation ablation on left ventricular filling pressure and left atrial remodeling.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is associated with new-onset atrial fibrillation (AF), and the estimation of elevated LV filling pressures by E/e' ratio is related to worse outcomes in patients with AF. However, it is unknown if restoring sinus rhythm reverses this process. OBJECTIVE: To evaluate the impact of AF ablation on estimated LV filling pressure. METHODS: A total of 141 patients underwent radiofrequency (RF) ablation to treat drug-refractory AF. Transthoracic echocardiography was performed 30 days before and 12 months after ablation. LV functional parameters, left atrial volume index (LAVind), and transmitral pulsed and mitral annulus tissue Doppler (e' and E/e') were assessed. Paroxysmal AF was present in 18 patients, persistent AF was present in 102 patients, and long-standing persistent AF in 21 patients. Follow-up included electrocardiographic examination and 24-h Holter monitoring at 3, 6, and 12 months after ablation. RESULTS: One hundred seventeen patients (82.9%) were free of AF during the follow-up (average, 18 ± 5 months). LAVind reduced in the successful group (30.2 mL/m(2) ± 10.6 mL/m(2) to 22.6 mL/m(2) ± 1.1 mL/m(2), p < 0.001) compared to the non-successful group (37.7 mL/m(2) ± 14.3 mL/m(2) to 37.5 mL/m(2) ± 14.5 mL/m(2), p = ns). Improvement of LV filling pressure assessed by a reduction in the E/e' ratio was observed only after successful ablation (11.5 ± 4.5 vs. 7.1 ± 3.7, p < 0.001) but not in patients with recurrent AF (12.7 ± 4.4 vs. 12 ± 3.3, p = ns). The success rate was lower in the long-standing persistent AF patient group (57% vs. 87%, p = 0.001). CONCLUSION: Successful AF ablation is associated with LA reverse remodeling and an improvement in LV filling pressure.

Baixa concordância entre diâmetro e volume do átrio esquerdo em pacientres com maior risco de fibrilação atrial / Low agreement between left atrial diameter and volume in patients with increased risk of atrial fibrillation

Introdução: O aumento do átrio esquerdo (AE) está diretamente relacionado a disfunção diastólica do VE(VD) e ambos estão associados a ocorrência de fibrilação atrial (FA). Embora o diâmetro (DAE) seja mundialmente usado como medida do AE, muitas evidencias mostram que o volume indexado para a superficie corporea (indVAE) é mais acurado. Objetivo: Avaliar a correlação entre DAE e IndVAE em pacientes (pt) com DD. Material e Métodos: Dentre 892 pacientes encaminhados ao ecocardiograma, (ECO) de uma clínica terciaria no DF, entre janeiro de 2008 a junho de 2009, foram selecionados 540 com addos clínicos e ecocardiograficos, dos quais foram excluidos 21, devido a idade < 18 anos e 18 pacientes com lesão valvar mitral > discreta. A função diastólica foi considerada, significativamente, anormal se E/e'>-15 (elevação das pressões de encihmento ventricular esquerdo). A concordância entre as medidas de DAE e IndVAE foi avaliada da seguinte forma concordante (IndVAE<- 40mm ou IndVAE > 40); e discordante (indVAE<- 32 e DAE > 40 ou IndVAE > 32 e DAE <- 40.). Resultados: Dos 501 pacientes estudados, 33 (6,6%) tinham E/e' >- 15 e 468 (93,4%) E/e' < 15. Houve boa correlação entre DAE e IndVAE tanto para pacientes com E/e' >- 15 (r=0,57), quando para pacientes com E/e' < 15 (r=0,62). A discordância entre DAF e IndVAE foi maior nos pacientes...

Background: Increased left atrial (LA) is directly related to LV diastolic dysfunction (DD), and both are associated with atrial fibrillation (AF). Although the diameter (LAD) is used as a measure of LA, many evidences show that LA volume index (iLAV) is more accurate. Objective: To evaluate the correlation between LAD and iLAV in patients (pt) with DD. Material and Methods: Among 892 pt referred to the echocardiography laboratory of a tertiary clinic, from Jan/08 to June/09, 540 pt with clinical and echocardiographic data were selected and 21 were excluded for being <18yo and 18 pt presenting more than mild mitral valve lesion. Diastolic function was considered abnormal when E/e¡¯ ratio ¡Ý 15 (elevated left ventricular filling pressures). Agreement between measures of LAD and iLAV was evaluated: agreement if iLAV ¡Ü 32ml/m2 and LAD ¡Ü 40mm or iLAV > 32 and LAD > 40; and disagreement if iLAV ¡Ü 32 and LAD > 40 or iLAV > 32 and LAD ¡Ü 40. Results: Of 501 pt, 33 (6.6%) presented E/e¡¯ ratio ¡Ý 15 and 468 (93.4%) < 15. There was a good correlation between LAD and iLAV in both patients with E/e¡¯ ¡Ý 15 (r = 0.57), and E/e¡¯ < 15 (r = 0.62). The disagreement between LAD and iLAV was higher in p with E/e¡¯ ¡Ý 15 (21.2% vs 9% - p <0.0001). Clinical and echocardiographic data were, respectively, for E/e¡¯ ¡Ý15 and E/e¡¯ < 15: male 54.5% vs 45.5% (p = ns), age 73.2 ¡À 12.4 vs 50.1 ¡À 16.5 (p <0.0001), LAD (cm) 38.8 ¡À 6.3 vs 35.2 ¡À 5.2 (p <0.0001); iLAV (ml/m2) 35 ¡À 16.2 x 21.9 ¡À 7 (p <0.0001), EF (%) 60.7 ¡À 16.2 vs 70.7 ¡À 6.9 (p <0.0001), E/e¡¯ 21 , 1 ¡À 8.1 vs 16.5 ¡À 2.4 (p <0.0001), HBP 81.8% vs. 50.2% (p <0.0001), DM 21.2% vs. 9.4% (p = 0.04); CHF 24.2% vs. 3.2% (p <0.0001), CAD 33.3% versus 9% (p <0.0001). Conclusion: Patients with elevated left ventricular filling pressures are older, have larger LA diameter and volume, worse EF and higher incidence of HBP, diabetes, CHF and CAD. There is less agreement between LAD and iLAV in these patients.

Luminal esophageal temperature monitoring with a deflectable esophageal temperature probe and intracardiac echocardiography may reduce esophageal injury during atrial fibrillation ablation procedures: results of a pilot study.

BACKGROUND: Luminal esophageal temperature (LET) monitoring is one strategy to minimize esophageal injury during atrial fibrillation ablation procedures. However, esophageal ulceration and fistulas have been reported despite adequate LET monitoring. The objective of this study was to assess a novel approach to LET monitoring with a deflectable LET probe on the rate of esophageal injury in patients undergoing atrial fibrillation ablation. METHODS AND RESULTS: Forty-five consecutive patients undergoing an atrial fibrillation ablation procedure followed by esophageal endoscopy were included in this prospective observational pilot study. LET monitoring was performed with a 7F deflectable ablation catheter that was positioned as close as possible to the site of left atrial ablation using the deflectable component of the catheter guided by visualization of its position on intracardiac echocardiography. Ablation in the posterior left atrial was limited to 25 W and terminated when the LET increased 2°C from baseline. Endoscopy was performed 1 to 2 days after the procedure. All patients had at least 1 LET elevation >2°C necessitating cessation of ablation. Deflection of the LET probe was needed to accurately measure LET in 5% of patients when ablating near the left pulmonary veins, whereas deflection of the LET probe was necessary in 88% of patients when ablating near the right pulmonary veins. The average maximum increase in LET was 2.5±1.5°C. No patients had esophageal thermal injury on follow-up endoscopy. CONCLUSIONS: A strategy of optimal LET probe placement using a deflectable LET probe and intracardiac echocardiography guidance, combined with cessation of radiofrequency ablation with a 2°C rise in LET, may reduce esophageal thermal injury during left atrial ablation procedures.

[Oral anticoagulation in patients with atrial fibrillation: from guidelines to bedside]. / Anticoagulação oral em pacientes com fibrilação atrial: das diretrizes à prática clínica.

OBJECTIVE: Although oral anticoagulation has proved beneficial for patients with atrial fibrillation (AF) and embolic risk factors, it is still underused. The objective of this study was to evaluate the adequacy of anticoagulation therapy in patients with AF followed in a private clinic specialized in cardiology, in accordance with the American and European societies of cardiology guidelines/2006 and with the Brazilian Guidelines/2003. METHODS: Between November 2005 and August 2006, we evaluated 7,486 electrocardiograms and selected 53 patients with AF and complete chart records. Clinical characteristics, including embolic risk factor, echocardiographic data and medical treatment were reviewed. RESULTS: Among the 53 patients (68+/-16 years; 29 men), 25 (48%) had hypertension, 20 (38%) heart failure and 3 (6%) diabetes. Among the 15 patients with high embolic risk, 13 (86%) were on oral anticoagulation. In accordance with the American and European guidelines: 32 (60%) patients were Class I, 17 (32%) Class IIa, 1 (2%) Class IIb and 3 (6%) Class III. Treatment was adequate in 21 (66%) Class I patients and 13 (76%) Class IIa. In these, anticoagulation therapy was used in 7/19 (37%) patients > 75 years compared to 22/30 (73%) younger. Among the 3 patients within Class III, 1 was incorrectly on OAC. According to Brazilian guidelines, 33 (62%) were on correctly indicated antithrombotic therapy. There was no difference in the appropriate prescription of oral anticoagulants, comparing the international and Brazilian guidelines (55% vs. 55%). CONCLUSION: According to recent guidelines, anticoagulant therapy has been adequately prescribed for the majority of AF patients, although this is still far from ideal, especially in a cardiology clinic. It is even more critical in the group of older patients.

Anticoagulação oral em pacientes com fibrilação atrial: das diretrizes à prática clínica / Oral anticoagulation in patients with atrial fibrillation: from guidelines to bedside

OBJETIVO: Apesar da anticoagulação oral (ACO) ter benefício comprovado em pacientes com fibrilação atrial (FA) e fatores de risco embólico, ela vem sendo subutilizada. O objetivo desse estudo foi avaliar a adequação da terapêutica anticoagulante em pacientes com FA acompanhados em clínica especializada em cardiologia, privada, de acordo com as diretrizes das sociedades americana e europeia de cardiologia de 2006 e a diretriz da Sociedade Brasileira de Cardiologia (SBC) de 2003. MÉTODOS: No período de novembro/2005 a agosto/2006 foram avaliados 7.486 eletrocardiogramas e selecionados 53 pts com laudo de FA e informações claras relatadas em prontuário sobre fatores de risco embólico e terapêutica de ACO. RESULTADOS: Dentre os 53 pacientes incluídos (68±16 anos; 29 homens - 55 por cento), 25 (48 por cento) tinham HAS, 20 (38 por cento) insuficiência cardíaca e 3 (6 por cento) DM. Dentre os 15 pacientes com alto risco embólico, 13 (86 por cento) estavam em uso de ACO. De acordo com a recomendação das diretrizes americana e europeia: 32 (60 por cento) pacientes tinham indicação Classe I, 17 (32 por cento) Classe IIa, 1 (2 por cento) Classe IIb e 3 (6 por cento) Classe III. Estavam adequadamente tratados 21 (66 por cento) pacientes da Classe I e 13 (76 por cento) pacientes Classe IIa. Nesse subgrupo, 7/19 (37 por cento) pacientes com idade >75 anos estavam sendo anticoagulados, comparado a 22/30 (73 por cento) daqueles com idade inferior (p=0,016). Dentre os três pacientes com indicação Classe III, um estava incorretamente com prescrição de anticoagulante. Pela diretriz da SBC, 33 (62 por cento) recebiam terapêutica antitrombótica adequada. Não houve diferença na utilização correta de ACO, comparando-se a diretriz brasileira e diretrizes americana e europeia (55 por cento vs. 55 por cento). CONCLUSÃO: A terapêutica anticoagulante está sendo prescrita adequadamente na maioria dos pacientes com FA, embora esse índice ainda esteja muito aquém ...

OBJECTIVE: Although oral anticoagulation has proved beneficial for patients with atrial fibrillation (AF) and embolic risk factors, it is still underused. The objective of this study was to evaluate the adequacy of anticoagulation therapy in patients with AF followed in a private clinic specialized in cardiology, in accordance with the American and European societies of cardiology guidelines/2006 and with the Brazilian Guidelines/2003. METHODS: Between November 2005 and August 2006, we evaluated 7,486 electrocardiograms and selected 53 patients with AF and complete chart records. Clinical characteristics, including embolic risk factor, echocardiographic data and medical treatment were reviewed. RESULTS: Among the 53 patients (68±16 years; 29 men), 25 (48 percent) had hypertension, 20 (38 percent) heart failure and 3 (6 percent) diabetes. Among the 15 patients with high embolic risk, 13 (86 percent) were on oral anticoagulation. In accordance with the American and European guidelines: 32 (60 percent) patients were Class I, 17 (32 percent) Class IIa, 1 (2 percent) Class IIb and 3 (6 percent) Class III. Treatment was adequate in 21 (66 percent) Class I patients and 13 (76 percent) Class IIa. In these, anticoagulation therapy was used in 7/19 (37 percent) patients > 75 years compared to 22/30 (73 percent) younger. Among the 3 patients within Class III, 1 was incorrectly on OAC. According to Brazilian guidelines, 33 (62 percent) were on correctly indicated antithrombotic therapy. There was no difference in the appropriate prescription of oral anticoagulants, comparing the international and Brazilian guidelines (55 percent vs. 55 percent). CONCLUSION: According to recent guidelines, anticoagulant therapy has been adequately prescribed for the majority of AF patients, although this is still far from ideal, especially in a cardiology clinic. It is even more critical in the group of older patients.