AH jump duration is associated with elimination of slow pathway during ablation of atrioventricular nodal reentrant tachycardia.

INTRODUCTION: Ablating the slow pathway (SP) is the superior treatment for atrioventricular nodal reentrant tachycardia (AVNRT) with a low complication rate. However, the ablation of the SP could result in either complete elimination or modification of the SP. We aimed to investigate whether the duration of AH jump pre-ablation associated with the outcome of elimination of SP. METHODS: We included 56 patients with typical AVNRT (slow-fast), 20 males and 36 females, aged 44.2 ± 15.1 years. Slow pathway ablation was performed using classical approach. Univariate and multivariate analysis was performed for potential predictors of SP elimination. RESULTS: Typical AVNRT was inducible in all patients. Post-ablation, non-inducibility of AVNRT was obtained in all 56 (100%) patients, with SP elimination in 33 (61%) patients and SP modification in 23 (39%) patients. Patients with SP elimination had significantly longer AH jump than patients with SP modification. Cox regression analysis showed that AH jump duration was the independent predictor of SP elimination, in which every 20 ms increase in AH jump duration was associated with 1.30 higher rate of SP elimination. Furthermore, ROC curve analysis indicated that the AH jump duration of ≥100 ms had 6.14 times higher probability for complete elimination of the SP with a sensitivity of 79%, specificity of 70%, PPV of 79% and NPV of 70%. CONCLUSIONS: AH jump duration pre-ablation is associated with complete elimination of slow pathway during AVNRT ablation.

Identification of Pacemaker Lead Position Using Fluoroscopy to Avoid Significant Tricuspid Regurgitation.

Permanent pacemaker implantation improves survival but can cause tricuspid valve dysfunction in the form of tricuspid regurgitation (TR). The dominant mechanism of pacemaker-mediated TR is lead impingement. This study evaluated the association between the location of the pacemaker leads crossing the tricuspid valve and the incidence of worsening TR and lead impingement using fluoroscopy. Lead positions were evaluated using perpendicular right anterior oblique (RAO) and parallel left anterior oblique (LAO) fluoroscopic angulation views of the tricuspid annulus. A two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate the maximum TR jet area-to-right atrium ratio and define regurgitation severity. A three-dimensional TTE was performed to evaluate lead impingement. A worsening of TR was observed in 23 of 82 subjects. Most leads had an inferior position in the RAO view and a septal position in the LAO view. The mid position in the RAO view and septal position in the LAO view were risk factors for lead impingement. Mid and septal positions were associated with higher risks of significant TR and lead impingement. Lead impingement was associated with a high risk of significant TR. Pacemaker-mediated TR remains a significant problem after lead implantation.

Genetic factors associated with patient-specific warfarin dose in ethnic Indonesians.

BACKGROUND: CYP2C9 and VKORC1 are two major genetic factors associated with inter-individual variability in warfarin dose. Additionally, genes in the warfarin metabolism pathway have also been associated with dose variance. We analyzed Single Nucleotide Polymorphisms (SNPs) in these genes to identify genetic factors that might confer warfarin sensitivity in Indonesian patients. METHODS: Direct sequencing method was used to identify SNPs in CYP2C9, VKORC1, CYP4F2, EPHX1, PROC and GGCX genes in warfarin-treated patients. Multiple linear regressions were performed to model the relationship warfarin daily dose requirement with genetic and non-genetic variables measured and used to develop a novel algorithm for warfarin dosing. RESULTS: From the 40 SNPs analyzed, CYP2C9 rs17847036 and VKORC1 rs9923231 showed significant association with warfarin sensitivity. In our study population, no significant correlation could be detected between CYP2C9*3, CYP2C9C-65 (rs9332127), CYP4F2 rs2108622, GGCX rs12714145, EPHX1 rs4653436 and PROC rs1799809 with warfarin sensitivity. CONCLUSIONS: VKORC1 rs9923231 AA and CYP2C9 rs17847036 GG genotypes were associated with low dosage requirements of most patients (2.05 ± 0.77 mg/day and 2.09 ± 0.70 mg/day, respectively). CYP2C9 and VKORC1 genetic variants as well as non-genetic factors such as age, body weight and body height account for 15.4% of variance in warfarin dose among our study population. Additional analysis of this combination could allow for personalized warfarin treatment in ethnic Indonesians.

Combination of Oral Anticoagulants and Single Antiplatelets versus Triple Therapy in Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome: Stroke Prevention among Asians.

Atrial fibrillation (AF), the most prevalent arrhythmic disease, tends to foster thrombus formation due to hemodynamic disturbances, leading to severe disabling and even fatal thromboembolic diseases. Meanwhile, patients with AF may also present with acute coronary syndrome (ACS) and coronary artery disease (CAD) requiring stenting, which creates a clinical dilemma considering that majority of such patients will likely receive oral anticoagulants (OACs) for stroke prevention and require additional double antiplatelet treatment (DAPT) to reduce recurrent cardiac events and in-stent thrombosis. In such cases, the gentle balance between bleeding risk and atherothromboembolic events needs to be carefully considered. Studies have shown that congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, and previous stroke or transient ischemic attack (TIA; doubled)-vascular disease, age 65 to 74 years, sex category (female; CHA 2 DS 2 -VASc) scores outperform other scoring systems in Asian populations and that the hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly (>65 years), drugs/alcohol concomitantly (1 point each; HAS-BLED) score, a simple clinical score that predicts bleeding risk in patients with AF, particularly among Asians, performs better than other bleeding scores. A high HAS-BLED score should not be used to rule out OAC treatment but should instead prompt clinicians to address correctable risk factors. Therefore, the current review attempted to analyze available data from patients with nonvalvular AF who underwent stenting for ACS or CAD and elaborate on the direct-acting oral anticoagulant (DOAC) and antiplatelet management among such patients. For majority of the patients, "triple therapy" comprising OAC, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS. However, the optimal duration for "triple therapy" would depend on the patient's ischemic and bleeding risks, with DOACs being obviously safer than vitamin-K antagonists.

Longer diagnosis-to-ablation time is associated with recurrence of atrial fibrillation after catheter ablation-Systematic review and meta-analysis.

BACKGROUND: Diagnosis-to-ablation time (DTAT) has been postulated to be one of the predictors of atrial fibrillation (AF) recurrence, and it is a "modifiable" risk factor unlike that of many electrocardiographic or echocardiographic parameters. This development may change our consideration for ablation. In this systematic review and meta-analysis, we aim to analyze the latest evidence on the importance of DTAT and whether they predict the AF recurrence after catheter ablation. METHODS: We performed a comprehensive search on topics that assess diagnosis-to-ablation time (DTAT) and AF recurrence from inception up until August 2019 through PubMed, EuropePMC, Cochrane Central Database, and http://ClinicalTrials.gov. RESULTS: There was a total of 3548 patients from six studies. Longer DTAT was associated with increased risk for AF recurrence in all studies included. Meta-analysis of these studies showed that DTAT had a hazard ratio (HR) of 1.19 [1.02, 1.39], P = .03; I 2: 92% for AF recurrence. Upon sensitivity analysis by removing a study, HR became 1.24 [1.16, 1.32], P < .001; I 2: 29%. Meta-analysis on DTAT time >3 years had HR 1.73 [1.54, 1.93], P < .001; I 2: 45% for the recurrence of AF. Upon subgroup analysis of data that compared >6 years to <1 year, the HR was 1.93 [1.62, 2.29], P < .001; I 2: 0%. CONCLUSION: Longer DTAT time is associated with an increased risk of AF recurrence. Hence, determining management at the earliest possible moment to avoid delay is of utmost importance.

Left atrial appendage closure device implantation guided with fluoroscopy only: Long-term results.

BACKGROUND: Left atrial appendage (LAA) closure device is an alternative to anticoagulants for stroke prevention in selected atrial fibrillation (AF) patients. The LAA device implantation is safe with short period of learning curve. The standard implantation technique warrants a transesophageal echocardiography (TEE) guided and general anesthesia. In region of Asia Pacific as well as Indonesia, both TEE and general anesthesia are not always available in district hospital. We studied the safety and efficacy of Amplatzer Cardiac Plug (ACP) implantation guided by fluoroscopy only and without general anesthesia. METHODS: Consecutive nonvalvular AF patients with CHA2DS2VASc score of ≥2 and HASBLED score of ≥3 are participated. Patients requiring long-life anticoagulant for any other indication are excluded. The choice of implanted first or second-generation ACP is that with excess size of 2-4 mm of measured landing zone diameter. RESULTS: Twenty-five subjects were implanted ACP by means fluoroscopy only (Group A) and 28 subjects using standard technique group (Group B). The median AF duration was 36 months (6-276 months) and majority of patients (49%) are having permanent AF. The mean CHA2DS2VASc score is 3.9 ± 1.63. Successful implantation of ACPs was 96% in both groups. Nonfatal pericardial effusion occurred in three patients. During 75 weeks of follow-up period, there were no significant differences of stroke event and death between groups. CONCLUSION: ACP implantation guided with fluoroscopy only is feasible and safe.

Amplatzer Cardiac Plug for Stroke Prevention in Patients with Atrial Fibrillation and Bigger Left Atrial Appendix Size.

Left atrial appendage (LAA) dimensions have been shown as an independent predictor of higher risk for stroke in AF patients. Little data exist on the outcomes after LAA closure in patients with nonvalvular atrial fibrillation (NVAF) who have relatively bigger LAA size. This study aims to evaluate the results associated with LAA closure with the Amplatzer cardiac plug (ACP, AGA, St. Jude Medical, Minneapolis, MN) in bigger LAA size. A total of 25 patients with NVAF underwent LAA closure with the ACP device. All patients received short-term (up to 3 months) dual-antiplatelet therapy (clopidogrel and aspirin) after the procedure and aspirin only thereafter. A transesophageal echocardiography was performed in all patients at the 3- and 6-month follow-ups. No patient was lost to follow-up (≥ 12 months in all patients). The mean age, CHA2DS2-VASc score, and HAS-BLED score were 66.2 ± 8.79 years; 3.2 ± 1.46 and 2.4 ± 1.0, respectively. The average sizes of the LAA landing zone and ostium were 23.08 ± 5.0 and 24.9 ± 4.4 mm, respectively. The procedure was successful in 23 (92%) patients and was canceled in 2 (8%) patients due to huge LAA dimensions. In 56% of the patients "pull and release" technique is needed to appropriately implant the ACP. During a mean follow-up of 12 months, no cases of periprocedural stroke and no mortality were observed. In patients with NVAF at high risk of cardioembolic events and big LAA size, LAA closure using the ACP device is safe and effective.