The Diagnostic Value of the 12-Lead ECG in Arrhythmogenic Left Ventricular Cardiomyopathy: Novel ECG Signs.

BACKGROUND: Electrocardiographic (ECG) findings in arrhythmogenic left ventricular cardiomyopathy (ALVC) are limited to small case series. OBJECTIVES: This study aimed to analyze the ECG characteristics of ALVC patients and to correlate ECG with cardiac magnetic resonance and genotype data. METHODS: We reviewed data of 54 consecutive ALVC patients (32 men, age 39 ± 15 years) and compared them with 84 healthy controls with normal cardiac magnetic resonance. RESULTS: T-wave inversion was often noted (57.4%), particularly in the inferior and lateral leads. Low QRS voltages in limb leads were observed in 22.2% of patients. The following novel ECG findings were identified: left posterior fascicular block (LPFB) (20.4%), pathological Q waves (33.3%), and a prominent R-wave in V1 with a R/S ratio ≥0.5 (24.1%). The QRS voltages were lower in ALVC compared with controls, particularly in lead I and II. At receiver-operating characteristic analysis, the sum of the R-wave in I to II ≤8 mm (AUC: 0.909; P < 0.0001) and S-wave in V1 plus R-wave in V6 ≤12 mm (AUC: 0.784; P < 0.0001) effectively discriminated ALVC patients from controls. It is noteworthy that 4 of the 8 patients with an apparently normal ECG were recognized by these new signs. Transmural late gadolinium enhancement was associated to LPFB, a R/S ratio ≥0.5 in V1, and inferolateral T-wave inversion, and a ringlike pattern correlated to fragmented QRS, SV1+RV6 ≤12 mm, low QRS voltage, and desmoplakin alterations. CONCLUSIONS: Pathological Q waves, LPFB, and a prominent R-wave in V1 were common ECG signs in ALVC. An R-wave sum in I to II ≤8 mm and SV1+RV6 ≤12 mm were specific findings for ALVC phenotypes compared with controls.

Risk of cardioembolic ischemic events and relation to atrial fibrillation/flutter in patients with arrhythmogenic cardiomyopathy during a long-term follow-up.

BACKGROUND: Arrhythmogenic cardiomyopathy (ACM) is an inherited heart disease characterized by fibro-fatty replacement of myocardium. Limited data is available concerning cardioembolic stroke. This study sought to determine the occurrence of cardioembolic ischemic events (CIEs) in ACM patients and to identify clinical and imaging predictors of CIEs. METHODS: Every consecutive ACM patient was enrolled. ECG, Holter monitoring or implantable cardiac devices were used to detect atrial arrhythmias (AAs). CIEs were defined according to TOAST classification. RESULTS: In our cohort of 111 patients, CIEs were observed in eleven (10%) over a 12.9-year median follow-up, with an incidence of 7.9 event/1000 patient-year (HR 4.12 compared to general population). Mean age at the event was 42 ± 9 years. Female sex (p = 0.03), T-wave inversion (p = 0.03), RVOT dilatation (p = 0.006) and lower LVEF (p = 0.006) were associated with CIEs. Among patients with AAs (23/111, 20.7%), 5 (21.7%) experienced CIEs. CHA2DS2-VASc did not prove useful to define patients at higher risk of CIEs (p = 0.098). 60% of stroke suffering patients had a pre-event score between 0 and 1 (if female). CONCLUSIONS: In ACM patients, CIEs are much more common than in general population and present a high burden at younger age. AAs relate to less than half of these events. In AAs patients, CHA2DS2-VASc is not useful to stratify those requiring oral anticoagulation. As a hypothesis-generating study, our research proposes the role of atrial myopathy, irrespective of AAs, as a pivotal factor in thrombogenesis risk, pointing out a definite unmet need in ACM therapeutic algorithm.

Sport activity in patients with cardiomyopathies: a review.

Exercise has undisputable benefits and is an important therapy component for most cardiovascular diseases, with a proven role in reducing mortality. On the contrary, exercise may paradoxically trigger sudden cardiac arrest in patients with cardiomyopathies requiring refrain from competitive sports participation. The 2020 European guidelines for patients with cardiovascular disease provided indication for sports participation for patients with cardiac conditions, including cardiomyopathies. Although in some cases, the knowledge of the natural history of the disease and the risk of death during intensive exercise is more robust, in others, the evidence is scarce. Therefore, recommendations are not available for all possible scenarios with several uncertainties. In addition, many patients aspire to continue competitive sports or practise recreational activities after a diagnosis of cardiomyopathy. These aspects generate concern for the physician, who should make complex decisions, and confronts the request to design specific exercise programmes without specific indications. This article will review the available evidence on the sports-related risk of sudden cardiac death or cardiovascular events and the progression of the disease in cardiomyopathies.

Prevalence and predictors of left atrial thrombosis in atrial fibrillation patients treated with non-vitamin K antagonist oral anticoagulants.

BACKGROUND: Few data are available regarding the prevalence of left atrium (LA) thrombi in atrial fibrillation (AF) patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods: We evaluated the prevalence and predictors of LA/LA appendage (LAA) thrombi in non-valvular AF patients treated with NOACs referring to a single centre for a scheduled electrical cardioversion (ECV) or catheter ablation (CA). Transesophageal echocardiography (TEE) was performed within 12 h prior to the index procedure. RESULTS: A total of 352 consecutive patients with non-valvular AF treated with NOACs were included in this analysis (ECV group n = 176 and CA group n = 176) between 2013 and 2018. 85 patients (24.2%) were on dabigatran, 150 (42.7%) on rivaroxaban, 104 (29.6%) on apixaban and 13 (3.7%) on edoxaban. A LA/LAA thrombus was detected by TEE in 27 (7.7%) patients, 18 in the ECV group and nine in the ablation group; 18 (5.1%) patients presented dense LA/LAA spontaneous echo contrast (SEC). Predictors of LA/LAA thrombi were a CHA2DS2-VASc score > 3 (OR 4.54, 95% CI 1.50 - 13.70, p value = .007) and obesity (OR 6.01, 95% CI 1.95 - 18.50, p value = .001). CONCLUSIONS: Among real-world patients with non-valvular AF treated with NOACs, we found a high incidence of LA/LAA thrombi compared to previous reports. The main predictors of LA/LAA thrombosis were a CHA2DS2-VASc score > 3 and obesity.

Incidence and Clinical Relevance of COVID-19 in a Population of Young Competitive and Elite Football Players: A Retrospective Observational Study.

BACKGROUND: The COVID-19 pandemic dramatically changed lifestyle worldwide, including sport. A comprehensive evaluation of the prevalence of cardiac involvement in COVID-19 is essential to finalize a safe protocol for resuming elite sport. The aim of this study is to evaluate incidence of cardiac involvement and COVID-19 impact on athletic performance. MATERIALS AND METHODS: This retrospective observational study analysed the data collected from consecutive competitive athletes who performed medical-sports examinations at the J Medical Center from March 2020 to March 2021. All athletes periodically performed a molecular test using a nasopharyngeal swab to detect COVID-19 infection. Positive athletes performed laboratory (cardiac troponin T-cTnT) and instrumental (echocardiography, stress test, Holter ECG) investigations following recovery to identify any cardiac involvement. Cardiac magnetic resonance imaging (MRI) was performed in case of abnormal findings at first-level evaluation. RESULTS: Among 238 athletes (median age 20 years), 77 contracted COVID-19, mainly males (79%) with a median age of 16 years. Fifty-one athletes (66%) presented mild symptoms, and none required hospitalization. Evaluation for resuming sport was performed after a median of 30 days from the first positive test. Abnormal findings were obtained in 13 cases (5 athletes [6%] with elevated cTnT values; 13 athletes [17%] with arrhythmias on Holter ECG and/or during stress test; 2 athletes [3%] anomalies at echocardiography). Cardiac MRI discovered abnormalities in 9 cases, but none of these was clearly related to COVID-19 and none fulfilled acute myocarditis criteria. No negative impact on athletic performance was observed, and none of the athletes developed persistent COVID-related symptoms. CONCLUSIONS: Our registry confirms the predominantly self-limiting illness in young athlete population. The incidence of clear COVID-19-related structural myocardial injury was very low, but transient exertional ventricular arrhythmias or pericardial effusion was observed without significant impact on athletic performance. Implemented screening for return to activity is likely reasonable only in moderate-to-severe symptomatic athletes.

Long-term efficacy and impact on quality of life of atrial fibrillation catheter ablation in competitive athletes.

BACKGROUND: Limited data are available on the efficacy of catheter ablation (CA) for sport-associated atrial fibrillation (AF), in particular at long term follow-up. Moreover, the impact of AF CA on Quality of Life (QoL) in this population remains unknown. We aimed to determine AF CA efficacy in athletes, to assess the impact on athletes' QoL (with SF36 score) and on training capabilities in a long-term follow-up (FU). METHODS: A total of 1215 AF patients' candidates to CA between January 2007 and December 2012, were retrospectively screened. Athletes were defined as patients performing ≥5 h/week of vigorous sports, achieving a total of ≥1500 h lifetime sport activity, for at least one year before AF first symptomatic episode. RESULTS: Out of 1215 AF patients, 133 were considered competitive athletes and underwent CA. Overall, 43% of our cohort showed typical or atypical atrial flutter, which required a more extensive ablation procedure. Before AF, athletes used to practice for a mean of 8.5±2.7 h/week, while after the first AF episode the mean practice duration decreased to 2.8±2.5 h/week. At 10-year follow-up, 83% of athletes did not present any recurrent event, and training capabilities increased up to 5.6±3.6 h/week after the procedure. Moreover, intense physical activity before AF CA was related to long-term AF recurrence rates (P=0.05). QoL scores significantly improved in each single domain (P<0.05). CONCLUSIONS: AF CA represents an effective procedure to maintain sinus rhythm in athletes, with a significant improvement in QoL.

Atrial fibrillation and coronary artery disease: a review on the optimal use of oral anticoagulants.

Atrial fibrillation (AF) represents the most prevalent supraventricular arrhythmia in adults population and up to 15% of AF patients undergo percutaneous coronary intervention (PCI) for coronary artery disease (CAD) during their life. While oral anticoagulants (OACs) exert a protective effect in the setting of stroke prevention and systemic embolization in AF patients, patients undergoing PCI are recommended to receive dual antiplatelet therapy (DAPT) to reduce the risk of cardiovascular death, recurrent myocardial infarction and stent thrombosis. When these two scenarios coexist, as all antithrombotic regimens are burdened by an increase in bleeding risk, antithrombotic regimen and therapy duration must be cautiously tailored on individual patients' characteristics after attentive assessment of ischemic and bleeding risks. Non-vitamin K oral anticoagulants (NOACs), directly inhibiting either thrombin or factor Xa of the coagulation cascade, have progressively replaced warfarin as first choice OACs in several scenarios; recently, randomized controlled trials have compared antithrombotic regimens including NOAC molecules vs vitamin K antagonists in AF patients undergoing PCI to explore the efficacy and safety of NOACs in this setting. These studies have provided a deeper understanding of antithrombotic therapy after PCI in AF patients and have been promptly implemented by the most recent guidelines on AF and CAD management. The aim of the present review was to summarize the current available literature on the perils and benefits of individual OAC molecules in AF patients with acute and/or chronic coronary syndromes in order to provide guidance on the optimal use of OACs in these complex scenarios.

Risk Factors for Intracerebral Hemorrhage in Patients With Atrial Fibrillation on Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention.

[Figure: see text].

Clinical Discussions in Antithrombotic Therapy Management in Patients With Atrial Fibrillation: A Delphi Consensus Panel.

BACKGROUND: In recent years, direct-acting oral anticoagulants (DOACs) have entered clinical practice for stroke prevention in non-valvular atrial fibrillation or prevention and treatment of venous thromboembolism. However, remaining uncertainty regarding DOAC use in some clinical scenarios commonly encountered in the real world has not been fully explored in clinical trials. METHODS: We report on use of a Delphi consensus process on DOAC use in non-valvular atrial fibrillation patients. The consensus process dealt with 9 main topics: (i) DOACs vs vitamin K antagonists in atrial fibrillation (AF) patients; (ii) therapeutic options for patients with stable total time in range treated with vitamin K antagonists; (iii) therapeutic options for patients aged > 85 years; (iv) therapeutic management of hyperfiltering patients; (v) pharmacologic interactions; (vi) therapeutic options in the long-term treatment (prevention) of patients with AF and acute coronary syndrome after the triple therapy; (vii) low doses of DOACs in AF patients; (viii) ischemic stroke in patients inappropriately treated with low doses of DOACs; (ix) management of patients taking DOACs with left atrial appendage thrombosis. RESULTS: A total of 101 physicians (cardiologists, internists, geriatricians, and hematologists) from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = somewhat agree; 4 = agree; 5 = strongly agree). Votes 1-2 were considered to be disagreement; votes 3-5 were considered to be agreement. Agreement among the respondents of ≥ 66% for each statement was considered consensus. A brief discussion of the results for each topic is also reported. CONCLUSIONS: In clinical practice, there is still uncertainty on DOAC use, especially in elderly, fragile, comorbid, and hyperfiltering patients.

CONTEXTE: Depuis quelques années, les cliniciens prescrivent des anticoagulants oraux directs (AOD) pour prévenir les accidents vasculaires cérébraux (AVC) chez les patients présentant une fibrillation auriculaire (FA) non valvulaire ou pour prévenir et traiter les thromboembolies veineuses. Cependant, les doutes que suscite encore l'emploi des AOD dans certains contextes courants de la pratique clinique n'ont pas encore été bien explorés dans le cadre des études cliniques. MÉTHODOLOGIE: Nous avons utilisé la méthode de Delphes, une démarche visant à dégager un consensus, afin d'évaluer le recours aux AOD chez des patients présentant une FA non valvulaire. L'étude comprenait 9 thèmes principaux : i) utilisation des AOD et des antagonistes de la vitamine K chez les patients présentant une FA; ii) options thérapeutiques pour les patients traités par un antagoniste de la vitamine K dont l'état se maintient depuis un certain temps dans une plage de valeurs normales; iii) options thérapeutiques pour les patients âgés de plus de 85 ans; iv) prise en charge thérapeutique des patients souffrant d'hyperfiltration; v) interactions pharmacologiques; vi) options thérapeutiques pour le traitement prolongé (préventif) des patients présentant une FA et un syndrome coronarien aigu après une trithérapie; vii) utilisation des AOD à faible dose chez les patients présentant une FA; viii) AVC ischémique chez les patients traités de façon inappropriée par un AOD à faible dose; ix) prise en charge des patients prenant un AOD qui présentent une thrombose de l'appendice auriculaire gauche. RÉSULTATS: Au total, 101 médecins (cardiologues, internistes, gériatres et hématologues) italiens ont exprimé leur degré d'accord avec chacun des énoncés proposés sur une échelle de Likert à 5 points (1 = tout à fait en désaccord; 2 = en désaccord; 3 = moyennement d'accord; 4 = d'accord; 5 = tout à fait d'accord). Une note de 1 ou 2 a été considérée comme un désaccord et une note de 3, 4 ou 5, comme un accord. On considérait qu'il y avait un consensus si 66 % ou plus des répondants étaient d'accord avec l'énoncé. Nous présentons également brièvement les résultats obtenus pour chacun des thèmes. CONCLUSIONS: Dans la pratique clinique, l'emploi des AOD soulève encore des doutes, en particulier chez les patients âgés, fragiles ou présentant des affections concomitantes ou une hyperfiltration.

Causes and Risk Factors of Cerebral Ischemic Events in Patients With Atrial Fibrillation Treated With Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention.

Background and Purpose- Despite treatment with oral anticoagulants, patients with nonvalvular atrial fibrillation (AF) may experience ischemic cerebrovascular events. The aims of this case-control study in patients with AF were to identify the pathogenesis of and the risk factors for cerebrovascular ischemic events occurring during non-vitamin K antagonist oral anticoagulants (NOACs) therapy for stroke prevention. Methods- Cases were consecutive patients with AF who had acute cerebrovascular ischemic events during NOAC treatment. Controls were consecutive patients with AF who did not have cerebrovascular events during NOACs treatment. Results- Overall, 713 cases (641 ischemic strokes and 72 transient ischemic attacks; median age, 80.0 years; interquartile range, 12; median National Institutes of Health Stroke Scale on admission, 6.0; interquartile range, 10) and 700 controls (median age, 72.0 years; interquartile range, 8) were included in the study. Recurrent stroke was classified as cardioembolic in 455 cases (63.9%) according to the A-S-C-O-D (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; D, dissection) classification. On multivariable analysis, off-label low dose of NOACs (odds ratio [OR], 3.18; 95% CI, 1.95-5.85), atrial enlargement (OR, 6.64; 95% CI, 4.63-9.52), hyperlipidemia (OR, 2.40; 95% CI, 1.83-3.16), and CHA2DS2-VASc score (OR, 1.72 for each point increase; 95% CI, 1.58-1.88) were associated with ischemic events. Among the CHA2DS2-VASc components, age was older and presence of diabetes mellitus, congestive heart failure, and history of stroke or transient ischemic attack more common in patients who had acute cerebrovascular ischemic events. Paroxysmal AF was inversely associated with ischemic events (OR, 0.45; 95% CI, 0.33-0.61). Conclusions- In patients with AF treated with NOACs who had a cerebrovascular event, mostly but not exclusively of cardioembolic pathogenesis, off-label low dose, atrial enlargement, hyperlipidemia, and high CHA2DS2-VASc score were associated with increased risk of cerebrovascular events.

Incidence of thromboembolic events following atrial fibrillation catheter ablation and rate control strategies according to the kind of oral anticoagulation: A systematic review and meta-analysis.

INTRODUCTION: Anticoagulantion therapy (OAT) represents the cornerstone to reduce thromboembolic events for atrial fibrillation (AF). Recent studies suggest that AF catheter ablation on top of OAT may be useful to further reduce the thromboembolic risk in AF patients. The aim of the present study is to compare the long-term risk of thromboembolic events and treatment-related complications in patients with AF treated by OAT strategies and catheter ablation. METHODS: Pubmed, Cochrane and Google Scholar were searched for studies including >500 patients evaluating AF patients treated with OAT (VKA: vitamin K antagonist or DOAC: Direct oral anticoagulants) and/or AF ablation. Pooled incidence of stroke/year was the primary end point, while that of stroke, of all cause bleeding and of major bleeding the secondary ones. All the analyses were stratified according to the CHADS2 score of included patients. RESULTS: Overall, 27 studies were selected, including 50,973 patients in the AF catheter ablation group; 281,595 patients in the VKA group; 54,811 patients in the DOAC group. After a mean follow-up of 2.4 (1.5-3.8) years, the overall incidence of stroke and thromboembolic events was 0.63 per 100 patients/year in AF ablation group, 2.09 per 100 patients/year in VKA group and 1.24 per 100 patients/year in DOAC group (p < 0.001). After stratification in 4 groups according to CHADS2 score, the incidence of thromboembolic events remained lower in patients included in the AF ablation, followed by DOAC and VKA respectively (p < 0.001), for each CHADS2 cluster. Both the incidence of all cause bleedings and major bleedings resulted lower in AF ablation group (p < 0.001). The incidence of all-cause mortality in the AF ablation group was significant lower than in the group of OAT (p < 0.0001). CONCLUSION: AF catheter ablation significantly reduces the incidence of long-term thromboembolic events compared to both VKA and DOAC. This reduction is maintained in all CHADS2 score clusters and is strengthened by the concomitant reduction in hemorrhagic complications provided by AF ablation.

NOACs and atrial fibrillation: Incidence and predictors of left atrial thrombus in the real world.

AIMS: Despite optimal oral anticoagulation with vitamin K antagonist, left atrial (LA) thrombus could be detected in the left appendage (LAA) in >2% of patients with atrial fibrillation (AF) and CHA2DS2-VASc score≥1 but few data are available for patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). We evaluated the occurrence and predictors of LA thrombi by means of transesophageal echocardiography (TOE) in consecutive patients with non-valvular AF who received for at least 3weeks Apixaban, Dabigatran, or Rivaroxaban. METHODS: This study included 414 consecutive patients (male 252, 60.6%, mean age 67.3years) referred to our Centers for catheter ablation of AF (n=220, 53.1%) or scheduled electrical cardioversion (n=194, 46.9%). Patients were on Dabigatran (n=160), Rivaroxaban (n=150) or Apixaban (n=104). TOE was performed in all cases within 12h prior to ablation or cardioversion. RESULTS: Preprocedural TOE revealed LA thrombus in 15/414 patients (3.6%), all located in the LAA (Apixaban 3/104 2.9%, Dabigatran 5/160 3.1%, and Rivaroxaban 7/150 4.7%, p=0.69). Of these, 14 patients had persistent AF. Patients with LAA thrombus had a mean CHA2DS2-VASc score of 3 (3-4). Higher CHA2DS2-VASc score (p=0.02), but not the type of NOAC, significantly predicted the presence of LA thrombus. CONCLUSION: The incidence of LAA thrombus in a cohort of patients anticoagulated with NOACs is low but not negligible, in any case similar among the 3 drugs. Preprocedural TOE should be considered in patients with a CHA2DS2-VASc score>3.

Does antiarrhythmic drugs premedication improve electrical cardioversion success in persistent atrial fibrillation?

AIMS: Aim of this study is to evaluate the impact of antiarrhythmic drugs (AADs) administration for at least one month before ECV on the acute and long term success rate of the procedure. METHODS: 1313 consecutive persistent AF patients were enrolled in 3 different centers (Turin, Asti and Avellino): 692 patients received AADs before and after ECV (group A), 621 patients were treated only after the procedure, at discharge (group B). Primary end point was the restoration and maintenance of sinus rhythm acutely and at a long-term follow up. RESULTS: Acute ECV success was higher in group A compared with group B (99% vs. 88%, p=0.0001) and a fewer number of shock attempts were administered (1.15±0.42 vs. 1.27±0.53 p<0.0001). Moreover group A maintained SR more often than group B at one month (99% vs. 89%, log-rank p<0.0001), at one year (55% vs. 48% log-rank p=0.01) and at the end of follow up (mean 2.7±2.1years, 45% vs. 29%, log-rank p<0.0001). At multivariate analysis AADs premedication was the strongest independent predictor of acute and long-term ECV success (respectively p<0.0001 OR 10.71 CI 5.10-22.50 and p=0.004, OR 1.50 CI 1.14-1.97). At sensitivity analysis no differences were found between ADDs in terms of acute success improvement (p=0.605), number of shock attempts (p=0.853) and long term SR maintenance (log-rank p=0.480). CONCLUSIONS: AADs administration for at least 4weeks before the ECV in persistent AF increases significantly the acute success rate and this result was maintained over a long-term follow-up.

Long-term events following atrial fibrillation rate control or transcatheter ablation: a multicenter observational study.

BACKGROUND: Atrial fibrillation increases thromboembolic risk. Oral anticoagulation with antivitamin K (AVK) reduces thromboembolic event rate, but increases hemorrhagic risk. OBJECTIVE: The aim of the present study was to describe long-term cerebral thromboembolic/hemorrhagic event rates in atrial fibrillation patients managed by rhythm control, pursued by atrial fibrillation transcatheter ablation (AFTCA), and rate control strategy. METHODS AND RESULTS: One thousand and five hundred consecutive patients referring to three medical care centers for atrial fibrillation were retrospectively divided into three groups: AFTCA maintaining AVK (group A); AFTCA discontinuing AVK (group B); and rate control strategy and AVK (group C). Thromboembolic and hemorrhagic events were recorded in 60 ±â€Š28 months of follow-up. Thromboembolic events did not differ between the groups (5/500, 1% group A; 7/500, 1.4% group B; 11/500, 2.2% group C; P = 0.45), and hemorrhagic events were greater in group A (9/500, 1.8%) and C (12/500, 2.4%) than in group B (no events; P = 0.003). Among patients with CHA2DS2 VASc score 2 or less, thromboembolic events did not differ in the group discontinuing AVK (group B, 4/388, 1%) or not (group A, 1/319, 0.3%; P = 0.38), whereas hemorrhagic events were more common in patients on AVK (5/319, 1.5% group A and 3/175, 1.7% group C; P = 0.02) compared with those discontinuing AVK (0/388, group B). Following AFTCA (groups A and B), 299/1000 experienced atrial fibrillation relapses; all thromboembolic events (12/299, 4%) occurred within these patients (P < 0.001). CONCLUSION: Considering this multicenter design study, AVK continuation following AFTCA, especially within patients with low-to-intermediate thromboembolic risk, confers a hemorrhagic risk greater to the thromboembolic protective effect. All thromboembolic events following AFTCA occur within patients experiencing atrial fibrillation relapses; therefore, in patients with high thromboembolic risk routine rhythm monitoring is essential after AVK discontinuation.

Does periprocedural anticoagulation management of atrial fibrillation affect the prevalence of silent thromboembolic lesion detected by diffusion cerebral magnetic resonance imaging in patients undergoing radiofrequency atrial fibrillation ablation with open irrigated catheters? Results from a prospective multicenter study.

BACKGROUND: Silent cerebral ischemia (SCI) has been reported in 14% of cases after catheter ablation of atrial fibrillation (AF) with radiofrequency (RF) energy and discontinuation of warfarin before AF ablation procedures. OBJECTIVE: The purpose of this study was to determine whether periprocedural anticoagulation management affects the incidence of SCI after RF ablation using an open irrigated catheter. METHODS: Consecutive patients undergoing RF ablation for AF without warfarin discontinuation and receiving heparin bolus before transseptal catheterization (group I, n = 146) were compared with a group of patients who had protocol deviation in terms of maintaining the therapeutic preprocedural international normalized ratio (patients with subtherapeutic INR) and/or failure to receive pretransseptal heparin bolus infusion and/or ≥2 consecutive ACT measurements <300 seconds (noncompliant population, group II, n = 134) and with a group of patients undergoing RF ablation with warfarin discontinuation bridged with low molecular weight heparin (group III, n = 148). All patients underwent preablation and postablation (within 48 hours) diffusion magnetic resonance imaging. RESULTS: SCI was detected in 2% of patients (3/146) in group I, 7% (10/134) in group II, and 14% (21/148) in group III (P <.001). "Therapeutic INR" was strongly associated with a lower prevalence of postprocedural silent cerebral ischemia (SCI). Multivariable analysis demonstrated nonparoxysmal AF (odds ratio 3.8, 95% confidence interval 1.5-9.7, P = .005) and noncompliance to protocol (odds ratio 2.8, 95% confidence interval 1.5-5.1, P <.001] to be significant predictors of ischemic events. CONCLUSION: Strict adherence to an anticoagulation protocol significantly reduces the prevalence of SCI after catheter ablation of AF with RF energy.

Long-term progression from paroxysmal to permanent atrial fibrillation following transcatheter ablation in a large single-center experience.

BACKGROUND: The natural history of atrial fibrillation (AF) is characterized by gradual increase in duration and frequency of relapses until a definitive shift to permanent AF. Heart disease and comorbidities modulate AF progression. However, to date the influence of catheter ablation on AF evolution has rarely been investigated. OBJECTIVE: The purpose of this study was to identify long-term predictors of AF progression in a large cohort of patients undergoing AF transcatheter ablation (AFTCA). METHODS: A total of 889 patients (mean age 57 ± 11 years; 53.3% paroxysmal AF, 40.5% persistent AF, 6.2% long-standing AF) underwent AFTCA. All patients underwent pulmonary vein isolation, with linear lesions and complex fractionated atrial electrogram ablation reserved for patients with persistent/long-standing AF and/or confirmed structural heart disease. RESULTS: After median follow-up of 64 months (range 41-84 years), AF progression despite AFTCA occurred in 57 cases (6.4%). However, AF progression was much more pronounced in patients with persistent (10%) or long-standing persistent AF (14.6%) than in those with paroxysmal AF (2.7%, P <.001). Furthermore, AF progression was more frequently reported in patients who presented with underlying comorbidities/cardiomyopathies (9.1%) than in those who presented with lone AF (29.9%, P <.001). At multivariate analysis, comorbidities/cardiomyopathies and baseline persistent/long-standing AF proved to be independent predictors of progression (odds ratio 11.3, 95% confidence interval 2.6-48.0, P <.001, and odds ratio 1.6, 95% confidence interval 1.2-2.1, P <.001, respectively). CONCLUSION: The presence of comorbidities/cardiomyopathies and persistent/long-standing AF seem to predict AF progression in patients undergoing AFTCA. Performing AFTCA in the paroxysmal phase of the arrhythmia may reduce progression of AF to its permanent form.

Incidence of cerebral thromboembolic events during long-term follow-up in patients treated with transcatheter ablation for atrial fibrillation.

AIMS: Net clinical benefit of long-term oral anticoagulation therapy (OAT) continuation after successful atrial fibrillation (AF) ablation is still controversial. To evaluate long-term thromboembolic (TE) and haemorrhagic events incidence according to OAT strategy used after AF transcatheter ablation. METHODS AND RESULTS: Three months after AF ablation, OAT was discontinued in patients with CHADS2 ≤ 1 if no recurrences were documented, while OAT was maintained in patients with CHADS2 ≥ 2 regardless of AF recurrences. CHA2DS2VASc and HAS-BLED scores have been retrospectively evaluated. Seven hundred and sixty-six patients were followed for a median of 60.5 months. Six (6/267 = 2.2%) and five (5/499 = 1%) TE events occurred in the ON and the OFF-OAT patients, respectively (P = 0.145), all in concomitance with the AF recurrence. CHADS2 and CHA2DS2VASc ≥ 2 were associated with high TE incidence (P = 0.047 and P = 0.020). Among patients with a CHADS2 score of 0 or 1, a CHA2DS2VASc score ≥ 2 was predictive of TE events (P = 0.014). Overall, the incidence of the TE events in patients with CHA2DS2VASc ≥ 2 was 0.6 per 100 patient-years whereas seven haemorrhagic events occurred, all of them in the ON-OAT patients (7/267 = 2.6%). CONCLUSION: Patients with AF undergoing transcatheter ablation have a lower incidence of TE events as compared with the general AF population, regardless of OAT maintenance. The unpredictable risk of AF recurrence, mandate the routine use of the CHADS2, CHA2DS2VASc, and HAS-BLED scores to guide clinical decision regarding OAT management in this peculiar setting of patients. The potential protective role of rhythm control strategy in the TE events needs to be confirmed by future large randomized trials.

Prevalence of silent cerebral ischemia in paroxysmal and persistent atrial fibrillation and correlation with cognitive function.

OBJECTIVES: The aim of this study was to compare the prevalence of silent cerebral ischemia (SCI) and cognitive performance in patients with paroxysmal and persistent atrial fibrillation (AF) and controls in sinus rhythm. BACKGROUND: Large registries have reported a similar risk for symptomatic stroke in both paroxysmal and persistent AF. The relationship among paroxysmal and persistent AF, SCI, and cognitive impairment has remained uncharted. METHODS: Two hundred seventy subjects were enrolled: 180 patients with AF (50% paroxysmal and 50% persistent) and 90 controls. All subjects underwent clinical assessment, neurological examination, cerebral magnetic resonance, and the Repeatable Battery for the Assessment of Neuropsychological Status. RESULTS: At least 1 area of SCI was present in 80 patients (89%) with paroxysmal AF, 83 (92%) with persistent AF (paroxysmal vs. persistent, p = 0.59), and 41 (46%) controls (paroxysmal vs. controls and persistent vs. controls, p < 0.01). The number of areas of SCI per subject was higher in patients with persistent AF than in those with paroxysmal AF (41.1 ± 28.0 vs. 33.2 ± 22.8, p = 0.04), with controls reporting lower figures (12.0 ± 26.7, p < 0.01 for both). Cognitive performance was significantly worse in patients with persistent and paroxysmal AF than in controls (Repeatable Battery for the Assessment of Neuropsychological Status scores 82.9 ± 11.5, 86.2 ± 13.8, and 92.4 ± 15.4 points, respectively, p < 0.01). CONCLUSIONS: Patients with paroxysmal and persistent AF had a higher prevalence and number of areas of SCI per patient than controls and worse cognitive performance than subjects in sinus rhythm.

Berberine behind the thriller of marked symptomatic bradycardia.

Patients with chronic aortic dissections are at high risk of catheter-induced complications. We report a Berberine is used in traditional Chinese medicine for the treatment of congestive heart failure, hypertension, diabetes, and dyslipidaemia and has a good safety profile. We report a case of a 53-year-old sportsman referred to our hospital for the onset of fatigue and dyspnoea upon exertion after he started berberine to treat hypercholesterolaemia. An electrocardiogram showed sinus bradycardia (45 bpm), first-degree atrioventricular block, and competitive junctional rhythm. An ergometric stress test showed slightly reduced chronotropic competence and the presence of runs of competitive junctional rhythm, atrial tachycardia, and sinus pauses in the recovery. After 10 d of wash-out from berberine, the patient experienced a complete resolution of symptoms, and an ergometric stress test showed good chronotropic competence. An electrocardiogram Holter showed a latent hypervagotonic state. This is the first case report that shows that berberine could present certain side effects in hypervagotonic people, even in the absence of a situation that could cause drug accumulation. Therefore, berberine's use should be carefully weighed in hypervagotonic people due to the drug's bradycardic and antiarrhythmic properties, which could became proarrhythmic, exposing patients to potential health risks.