Biomarkers of Thrombo-Inflammatory Responses in Pulmonary Embolism Patients With Pre-Existing Versus New-Onset Atrial Fibrillation.

Pulmonary embolism (PE) patients have an increased prevalence and incidence of atrial fibrillation (AF). Because comorbid AF increases risk of morbidity and mortality, we sought to investigate the role of thrombo-inflammatory biomarkers in risk stratifying patients who experience an acute PE episode. Study participants were enrolled from a Pulmonary Embolism Response Team (PERT) registry between March 2016 and March 2019 at Loyola University Medical Center and Gottlieb Memorial Hospital. This cohort was divided into 3 groups: PE patients with a prior diagnosis of AF (n = 8), PE patients with a subsequent diagnosis of AF (n = 11), and PE patients who do not develop AF (n = 71). D-dimer, CRP, PAI-1, TAFIa, FXIIIa, A2A, MP, and TFPI were profiled using the ELISA method. All biomarkers were significantly different between controls and PE patients (P < 0.05). Furthermore, TFPI was significantly elevated in PE patients who subsequently developed AF compared to PE patients who did not develop AF (157.7 ± 19.0 ng/mL vs. 129.0 ± 9.3 ng/mL, P = 0.0386). This study suggests that thrombo-inflammatory biomarkers may be helpful in indicating an acute PE episode. Also, elevated TFPI levels may be associated with an increased risk of developing AF after a PE.

Relationship Between 25-Hydroxyvitamin D, Renin, and Collagen Remodeling Biomarkers in Atrial Fibrillation.

The interplay between vitamin D, the renin-angiotensin system (RAS), and collagen remodeling has been implicated in the pathogenesis of various cardiovascular diseases. This study sought to explore this relationship in atrial fibrillation (AF) by profiling plasma levels of 25-hydroxyvitamin D, RAS biomarkers, and collagen remodeling biomarkers using the enzyme-linked immunosorbent assay method. We hypothesized that 25-hydroxyvitamin D levels would inversely correlate with RAS biomarkers and that levels of RAS and collagen remodeling biomarkers would positively correlate with each other. Although our AF cohort (n = 37) did not exhibit decreased 25-hydroxyvitamin D levels compared to normal controls (n = 26), these levels inversely correlated with renin (Spearman r = -0.57, P = 0.005). Renin levels were elevated in patients with AF compared to normal controls (1233 ± 238 ng/mL vs 401 ± 27 ng/mL, P = 0.0002) and positively correlated with levels of matrix metalloproteinase 1 (MMP-1; Spearman r = 0.89, P = 0.01) and MMP-2 (Spearman r = 0.82, P = 0.03). These data suggest that 25-hydroxyvitamin D may influence RAS activation, and renin may help mediate the collagen remodeling process in AF. Understanding mediators of RAS dysregulation in AF may elucidate targets for therapeutic intervention to prevent collagen remodeling.

Osteopontin Levels in Patients With Chronic Kidney Disease Stage 5 on Hemodialysis Directly Correlate With Intact Parathyroid Hormone and Alkaline Phosphatase.

Chronic kidney disease stage 5 (CKD5) marks the fifth stage of renal failure, frequently causing dysregulation of bone and mineral metabolism. Challenges exist in evaluating and managing chronic kidney disease-mineral bone disorder (CKD-MBD) with the standard panel of biomarkers. Our objective was to profile osteopontin (OPN) in patients with CKD5 on maintenance hemodialysis (CKD5-HD) and elucidate its relationship to phosphorus (P), calcium (Ca2+), alkaline phosphatase (AP), and intact parathyroid hormone (iPTH) to improve understanding of the present model of CKD-MBD. Elevation of plasma OPN was seen in the CKD5-HD cohort (n = 92; median: 240.25 ng/mL, interquartile range [IQR]: 169.85 ng/mL) compared to a normal group (n = 49; median: 63.30 ng/mL, IQR: 19.20 ng/mL; p < .0001). Spearman correlation tests revealed significant positive correlations of OPN with iPTH (p < .0001; r = 0.561, 95% confidence interval = 0.397-0.690) and OPN with AP (p < .0001; r = 0.444, 95% confidence interval = 0.245-0.590) in CKD5-HD patients. Ultimately, OPN may play an integral role in the MBD axis, suggesting that it may be important to actively monitor OPN when managing CKD5-HD.

ß1-Adrenoceptor blocker aggravated ventricular arrhythmia.

OBJECTIVES: To assess the impact of ß1 -adrenoceptor blockers (ß1 -blocker) and isoprenaline on the incidence of idiopathic repetitive ventricular arrhythmia that apparently decreases with preprocedural anxiety. METHODS: From January 2010 to July 2012, six patients were identified who had idiopathic ventricular arrhythmias that apparently decreased (by greater than 90%) with preprocedural anxiety. The number of ectopic ventricular beats per hour (VPH) was calculated from Holter or telemetry monitoring to assess the ectopic burden. The mean VPH of 24 hours from Holter before admission (VPH-m) was used as baseline (100%) for normalization. ß1 -Blockers, isoprenaline, and/or aminophylline were administrated successively on the ward and catheter lab to evaluate their effects on the ventricular arrhythmias. RESULTS: Among 97 consecutive patients with idiopathic ventricular arrhythmias, six had reduction in normalized VPHs in the hour before the scheduled procedure time from (104.6 ± 4.6%) to (2.8 ± 1.6%) possibly due to preprocedural anxiety (P < 0.05), then increased to (97.9 ± 9.7%) during ß1 -blocker administration (P < 0.05), then quickly reduced to (1.6 ± 1.0%) during subsequent isoprenaline infusion. Repeated ß1 -blocker quickly counteracted the inhibitory effect of isoprenaline, and VPHs increased to (120.9 ± 2.4%) from (1.6 ± 1.0%; P < 0.05). Isoprenaline and ß1 -blocker showed similar effects on the arrhythmias in catheter lab. CONCLUSIONS: In some patients with structurally normal heart and ventricular arrhythmias there is a marked reduction of arrhythmias associated with preprocedural anxiety. These patients exhibit a reproducible sequence of ß1 -blocker aggravation and catecholamine inhibition of ventricular arrhythmias, including both repetitive ventricular premature beats and monomorphic ventricular tachycardia.

A systematic review of depression and anxiety in patients with atrial fibrillation: the mind-heart link.

Atrial fibrillation (AF) is the most commonly seen arrhythmia in clinical practice. At present, few studies have been conducted centering on depression and anxiety in AF patients. Our aim in this systematic review is to use the relevant literature to (1) describe the prevalence of depression and anxiety in AF patients, (2) assess the impact that depression and anxiety have on illness perception in patients with AF, (3) provide evidence to support a hypothetical connection between the pathophysiology of AF and depression and anxiety, (4) evaluate the benefit of treatment of AF on depression and anxiety, and (5) give insight on medically managing a patient with AF and concomitant depression and anxiety.

Gastroesophageal reflux and atrial fibrillation: is there any correlation?

Atrial fibrillation (AF), gastroesophageal reflux disease (GERD) and hiatal hernias are commonly seen in clinical practice. GERD and hiatal hernias have been proposed to be a possible cause of AF. In this paper, we will briefly review GERD, AF and hiatal hernias, consider the available literature covering the association between these diseases and provide further insight into the topic in general.

Stroke prevention in atrial fibrillation: latest clinical trials and guidelines.

Atrial Fibrillation (AF) is the most common sustained arrhythmia and 1/6 strokes is attributed to AF. The cornerstone of treatment remains maintaining sinus rhythm or appropriate ventricular rate control in addition to prevention of stroke. Oral anticoagulation therapy (OAC) with vitamin K antagonists (VKAs) has been the gold standard for almost 50 years and a significant reduction in the risk of stroke in patients with AF has been demonstrated. Nonetheless, only 50% of patients with guideline recommendations for OAC treatment actually receive VKAs and half of these will discontinue therapy within 3 to 5 years with only another half achieving therapeutic ranges more than 50% of the time. The aforementioned limitations in addition with frequent blood monitoring have prompted the development of a series of new OAC therapies. The present review focuses on the current pharmacological management for stroke prevention in patients with AF based on current and emerging evidence.

Atrial fibrillation catheter ablation in females: same hardware, different findings.

Atrial fibrillation catheter ablation has gained a significant role in the management of the frequent arrhythmia and has been shown to be safe and effective. As with many other interventional therapies, gender bias is present and females are referred for catheter ablation less frequently than their male counterparts. Women referred for catheter ablation tend to be older, more symptomatic, have failed more antiarrhythmic agents and may have poorer procedure success and increased vascular complication rates. Efforts to close this referral gap are clearly needed and it is likely that early referral will reduce gender differences in atrial fibrillation catheter ablation success rates.

The Role of Atrial Fibrillation Catheter Ablation in Patients with Congestive Heart Failure: "Burning"for a Cure.

Atrial Fibrillation (AF) and congestive heart failure (CHF) often co-exist. Catheter ablation is increasingly used to cure AF related to CHF.Clinical evidence supports the feasibil- ity of catheter ablation as a treatment option in drug refractory AF patients with CHF.Investiga- tors have reported an improvement in ejection fraction, quality of life, and functional capacity.

Safety and efficacy of pulmonary vein antral isolation in patients with obstructive sleep apnea: the impact of continuous positive airway pressure.

BACKGROUND: Obstructive sleep apnea (OSA) may be associated with pulmonary vein antrum isolation (PVAI) failure. The aim of the present study was to investigate if treatment with continuous positive airway pressure (CPAP) improved PVAI success rates. METHODS AND RESULTS: From January 2004 to December 2007, 3000 consecutive patients underwent PVAI. Patients were screened for OSA and CPAP use. Six hundred forty (21.3%) patients had OSA. Patients with OSA had more procedural failures (P=0.024) and hematomas (P<0.001). Eight percent of the non-OSA paroxysmal atrial fibrillation patients had nonpulmonary vein antrum triggers (non-PV triggers) and posterior wall firing versus 20% of the OSA group (P<0.001). Nineteen percent of the non-OSA nonparoxysmal atrial fibrillation population had non-PV triggers versus 31% in the OSA group (P=0.001). At the end of the follow-up period (32±14 months), 79% of the non-CPAP and 68% of the CPAP group were free of atrial fibrillation (P=0.003). Not using CPAP in addition to having non-PV triggers strongly predicted procedural failure (hazard ratio, 8.81; P<0.001). CONCLUSIONS: OSA was an independent predictor for PVAI failure. Treatment with CPAP improved PVAI success rates. Patients not treated with CPAP in addition to having higher prevalence of non-PV triggers were 8 times more likely to fail the procedure.

Periprocedural stroke and management of major bleeding complications in patients undergoing catheter ablation of atrial fibrillation: the impact of periprocedural therapeutic international normalized ratio.

BACKGROUND: Catheter ablation of atrial fibrillation is associated with the potential risk of periprocedural stroke, which can range between 1% and 5%. We developed a prospective database to evaluate the prevalence of stroke over time and to assess whether the periprocedural anticoagulation strategy and use of open irrigation ablation catheter have resulted in a reduction of this complication. METHODS AND RESULTS: We collected data from 9 centers performing the same ablation procedure with the same anticoagulation protocol. We divided the patients into 3 groups: ablation with an 8-mm catheter off warfarin (group 1), ablation with an open irrigated catheter off warfarin (group 2), and ablation with an open irrigated catheter on warfarin (group 3). Outcome data on stroke/transient ischemic attack and bleeding complications during and early after the procedures were collected. Of 6454 consecutive patients in the study, 2488 were in group 1, 1348 were in group 2, and 2618 were in group 3. Periprocedural stroke/transient ischemic attack occurred in 27 patients (1.1%) in group 1 and 12 patients (0.9%) in group 2. Despite a higher prevalence of nonparoxysmal atrial fibrillation and more patients with CHADS2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score >2, no stroke/transient ischemic attack was reported in group 3. Complications among groups 1, 2, and 3, including major bleeding (10 [0.4%], 11 [0.8%], and 10 [0.4%], respectively; P>0.05) and pericardial effusion (11 [0.4%], 11 [0.8%], and 12 [0.5%]; P>0.05), were equally distributed. CONCLUSIONS: The combination of an open irrigation ablation catheter and periprocedural therapeutic anticoagulation with warfarin may reduce the risk of periprocedural stroke without increasing the risk of pericardial effusion or other bleeding complications.

Endocardial and epicardial mapping and catheter ablation of post myocardial infarction ventricular tachycardia: A substrate modification approach.

Ventricular tachycardia associated with prior myocardial infarction account for significant morbidity, mortality, and health care costs despite the favorable outcomes shown by ICD clinical trials. Catheter ablation has been increasingly used as an adjunctive therapy in the management of scar-related ventricular tachycardia. Novel technologies have facilitated the outcomes of current ablation strategies. Three-dimensional mapping systems have allowed identification of the scar substrate, its critical sites in the tachycardia circuit, and selection of ablation sites based on fairly precise electroanatomic substrate.

The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation.

OBJECTIVES: The aim of this multicenter study was to evaluate the safety of discontinuing oral anticoagulation therapy (OAT) after apparently successful pulmonary vein isolation. BACKGROUND: Atrial fibrillation (AF) is associated with an increased risk of thromboembolic events (TE) and often requires OAT. Pulmonary vein isolation is considered an effective treatment for AF. METHODS: We studied 3,355 patients, of whom 2,692 (79% male, mean age 57 +/- 11 years) discontinued OAT 3 to 6 months after ablation (Off-OAT group) and 663 (70% male, mean age 59 +/- 11 years) remained on OAT after this period (On-OAT group). CHADS(2) (congestive heart failure, hypertension, age [75 years and older], diabetes mellitus, and a history of stroke or transient ischemic attack) risk scores of 1 and > or =2 were recorded in 723 (27%) and 347 (13%) Off-OAT group patients and in 261 (39%) and 247 (37%) On-OAT group patients, respectively. RESULTS: During follow-up (mean 28 +/- 13 months vs. 24 +/- 15 months), 2 (0.07%) Off-OAT group patients and 3 (0.45%) On-OAT group patients had an ischemic stroke (p = 0.06). No other thromboembolic events occurred. No Off-OAT group patient with a CHADS(2) risk score of > or =2 had an ischemic stroke. A major hemorrhage was observed in 1 (0.04%) Off-OAT group patient and 13 (2%) On-OAT group patients (p < 0.0001). CONCLUSIONS: In this nonrandomized study, the risk-benefit ratio favored the suspension of OAT after successful AF ablation even in patients at moderate-high risk of TE. This conclusion needs to be confirmed by future large randomized trials.

The impact of statins and renin-angiotensin-aldosterone system blockers on pulmonary vein antrum isolation outcomes in post-menopausal females.

AIMS: To assess whether treatment with statins or renin-angiotensin-aldosterone system (RAAS) inhibitors as potential procedural 'augmenting agents' improved atrial fibrillation (AF) catheter ablation recurrence rates in post-menopausal females (PMFS). METHODS AND RESULTS: Five hundred and eighteen consecutive female patients had undergone AF catheter ablation from January 2005 to May 2008. Post-menopausal females were selected and procedure outcomes were compared between cohorts of PMFS treated with statins or RAAS inhibitors to untreated PMFS. Out of 408 PMFS, 36 (8.8%) were treated with a combination of RAAS inhibitors and statins, thus were excluded leaving a total of 372 (91.2%) patients in the study. Out of 372 patients, 111 (29.8%) were on statins (Group 1), 59 (15.9%) on RAAS inhibitors (Group 2), and 202 (54.3%) without RAAS inhibitors or statins [(Group 3) control population]. Over a mean follow-up time of 24 +/- 8.3 (median 25) months, 78 (70.6%) in Group 1, 38 (65.4%) in Group 2, and 139 (68.8%) in Group 3 had procedural success. Statin or RAAS inhibitor use did not predict lower recurrence rates [hazard ratio (HR): 1.26, P = 0.282 and HR: 1.14, P = 0.728, respectively]. When compared with controls, no difference in the cumulative incidence of recurrence was found with statin or RAAS inhibitors use (P = 0.385 and P = 0.761, respectively). CONCLUSION: Treatment with statins or RAAS inhibitors did not improve catheter ablation success rates among PMFS. Thereby, from a clinical standpoint, PMFS should not be started on these treatments as a procedural 'augmenting agent' at this time.

Outcomes and complications of catheter ablation for atrial fibrillation in females.

BACKGROUND: Most atrial fibrillation (AF) ablation studies have consisted predominantly of males; accordingly, there is a paucity of information on the safety and efficacy of catheter ablation in a large cohort of female AF patients. OBJECTIVE: The purpose of this study was to evaluate catheter ablation for AF in female patients. METHODS: From January 2005 to May 2008, 3265 females underwent pulmonary vein antrum isolation. Success rates, patient profiles, and complications were collected. RESULTS: Approximately 16% of our population was female (P <.001). Females were older (59 +/- 13 vs. 56 +/- 19 years; P <.01) and had a lower prevalence of paroxysmal atrial fibrillation (PAF; 46% vs. 55%; P <.001). Females failed more antiarrhythmics (4 +/- 1 vs. 2 +/- 3; P = .04) and were referred later for catheter ablation (6.51 +/- 7 vs. 4.85 +/- 6.5 years; P = .02) than males. More females failed ablation (31.5% vs. 22.5%; P = .001) and had nonantral sites of firing than males (P <.001). Female patients had 11 (2.1%) hematomas versus 27 (0.9%) in males. CONCLUSIONS: Five times as many males underwent catheter ablation than females. Females failed more ablations possibly because of a higher prevalence of nonantral firing, non-PAF, and longer history of AF. Females had more bleeding complications than males.

Long-term functional and neurocognitive recovery in patients who had an acute cerebrovascular event secondary to catheter ablation for atrial fibrillation.

INTRODUCTION: Cerebral thromboembolic event (CTE) is a possible complication of pulmonary vein antrum isolation (PVAI). The objective of this study was to report long-term functional and neurocognitive recovery in patients who had a CTE during or within 48 hours of catheter ablation. METHODS AND RESULTS: We screened 3,060 patients who underwent PVAI between January 2000 and June 2007. Out the 3,060 patients, 26 patients (0.8%) (61 +/- 8 years, 88% males) had a CTE during or within 48 hours of the procedure. We followed these 26 patients (study group) over time and assessed their functional and neurocognitive recovery status. No preferential vascular territory for the site of obstruction was found; right anterior circulation-5 patients (26%), left anterior circulation-5 patients (26%), posterior circulation-3 patients (16%), and 2 or more territories-6 patients (32%), (P-value = 0.8). The average international normalized ratio at the time of CTE was 1.33 +/- 0.4. Two patients died during the study period. At the end of 38.4 +/- 24 months follow-up, most surviving patients had complete neurocognitive and functional recovery irrespective of the severity of periprocedural stroke. CONCLUSIONS: Periprocedural stroke in the setting of catheter ablation for atrial fibrillation is relatively rare. When it occurs, complete functional and neurocognitive recovery over time is the likely outcome for most patients.

Omega-3 polyunsaturated Fatty Acid supplementation reduced atrial fibrillation recurrence after pulmonary vein antrum isolation.

OBJECTIVE: To assess if patients treated with omega-3(n-3) polyunsaturated fatty acids (PUFAS) had lower procedural failure rates compared to an untreated population. METHODS AND RESULTS: From January 2004 to 2007, 1500 PVAI patients underwent catheter ablation. Two hundred and eighty five (19%) patients were treated with PUFAs. These patients were matched in a nested case controlled analysis. After matching, there were 129 patients in the PUFA group and 129 in the control group. Thirty-five (27.1%) patients in the study group had early recurrence vs. 57 (44.1%) in the control group p-value< 0.0001. Twenty-nine (23.2%) patients in the PUFA group vs. 41 (31.7%) in the non-PUFA group had procedural failure (p-value < 0.003). There were no significant differences in complications in the PUFA and non-PUFA groups. CONCLUSION: Patients treated with PUFAs had lower incidences of early recurrence and procedural failure compared to an untreated population.

Esophageal capsule endoscopy after radiofrequency catheter ablation for atrial fibrillation: documented higher risk of luminal esophageal damage with general anesthesia as compared with conscious sedation.

BACKGROUND: Left atrioesophageal fistula is a rare but devastating complication that may occur after catheter ablation of atrial fibrillation. We used capsule endoscopy to assess esophageal injury after catheter ablation for atrial fibrillation in a population randomized to undergo general anesthesia or conscious sedation. METHODS AND RESULTS: Fifty patients undergoing atrial fibrillation ablation for paroxysmal symptomatic atrial fibrillation refractory to antiarrhythmic drugs were enrolled and randomized, including those undergoing the procedure under general anesthesia (25 patients, group 1) and those receiving conscious sedation with fentanyl or midazolam (25 patients, group 2). All patients underwent esophageal temperature monitoring during the procedure. The day after ablation, all patients had capsule endoscopy to assess the presence of endoluminal tissue damage of the esophagus. We observed esophageal tissue damage in 12 (48%) patients of group 1 and 1 esophageal tissue damage in a single patient (4%) of group 2 (P<0.001). The maximal esophageal temperature was significantly higher in patients undergoing general anesthesia (group 1) versus patients undergoing conscious sedation (group 2) (40.6+/-1 degrees C versus 39.6+/-0.8 degrees C; P< 0.003). The time to peak temperature was 9+/-7 seconds in group 1 and 21+/-9 seconds in group 2, and this difference was statistically significant (P<0.001). No complication occurred during or after the administration of the pill cam or during the procedures. All esophageal lesions normalized at the 2-month repeat endoscopic examination. CONCLUSIONS: The use of general anesthesia increases the risk of esophageal damage detected by capsule endoscopy.

Atrial fibrillation ablation strategies for paroxysmal patients: randomized comparison between different techniques.

BACKGROUND: Whether different ablation strategies affect paroxysmal atrial fibrillation (AF) long-term freedom from AF/atrial tachyarrhythmia is unclear. We sought to compare the effect of 3 different ablation approaches on the long-term success in patients with paroxysmal AF. METHODS AND RESULTS: One hundred three consecutive patients with paroxysmal AF scheduled for ablation and presenting in the electrophysiology laboratory in AF were selected for this study. Patients were randomized to pulmonary vein antrum isolation (PVAI; n=35) versus biatrial ablation of the complex fractionated atrial electrograms (CFAEs; n=34) versus PVAI followed by CFAEs (n=34). Patients were given event recorders and followed up at 3, 6, 9, 12, and 15 months postablation. There was no statistical significant difference between the groups in term of sex, age, AF duration, left atrial size, and ejection fraction. At 1 year follow-up, freedom from AF/atrial tachyarrhythmia was documented in 89% of patients in the PVAI group, 91% in the PVAI plus CFAEs group, and 23% in the CFAEs group (P<0.001) after a single procedure and with antiarrhythmic drugs. CONCLUSIONS: No difference in terms of success rate was seen between PVAI alone and PVAI associated with defragmentation. CFAEs ablation alone had the smallest impact on AF recurrences at 1-year follow-up. These results suggest that antral isolation is sufficient to treat most patients with paroxysmal AF.