Implementation of an on-demand app-based heart rate and rhythm monitoring infrastructure for the management of atrial fibrillation through teleconsultation: TeleCheck-AF.

During the coronavirus 2019 (COVID-19) pandemic, outpatient visits in the atrial fibrillation (AF) clinic of the Maastricht University Medical Centre (MUMC+) were transferred into teleconsultations. The aim was to develop anon-demand app-based heart rate and rhythm monitoring infrastructure to allow appropriatmanagement of AF through teleconsultation. In line with the fundamental aspects of integrated care, including actively involving patients in the care process and providing comprehensive care by a multidisciplinary team, we implemented a mobile health (mHealth) intervention to support teleconsultations with AF patients: TeleCheck-AF. The TeleCheck-AF approach guarantees the continuity of comprehensive AF management and supports integrated care through teleconsultation during COVID-19. It incorporates three important components: (i) a structured teleconsultation ('Tele'), (ii) a CE-marked app-based on-demand heart rate and rhythm monitoring infrastructure ('Check'), and (iii) comprehensive AF management ('AF'). In this article, we describe the components and implementation of the TeleCheck-AF approach in an integrated and specialized AF-clinic through teleconsultation. The TeleCheck-AF approach is currently implemented in numerous European centres during COVID-19.

QTc interval evaluation in patients with right bundle branch block or bifascicular blocks.

BACKGROUND: The right bundle branch block (RBBB) and the bifascicular blocks affect QRS duration in the right precordial leads, which are usually used for QT interval determination. Up to now, there is no clear recommendation how to determine QT interval in patients with RBBB or bifascicular block. HYPOTHESIS: The hypothesis of the present study was to evaluate the feasibility of a simple formula for RBBB and bifascicular block correction, thereby making it easier to determine the QTc interval. METHODS: In patients with intrinsic QRS duration <120 ms, artificial RBBB with either left posterior (LPFB) or left anterior fascicular block (LAFB), created by left ventricular pacing maneuvers, were corrected using the Bogossian formula (QTm) and afterward were heart rate corrected (QTmc). Heart rate correction was performed using different heart rate formulas in comparison to each other. The QTmc intervals were compared in each patient with the QTc interval during intrinsic rhythm. RESULTS: A total of scheduled 71 patients were included in this prospective multicenter observational comparative study. Compared to intrinsic QTc interval, the mean ΔQTmc interval by combination of the Bogossian and the Hodge formulas was -3 ± 24 ms in RBBB + LPFB (P = .44) and -6 ± 25 ms in RBBB + LAFB (P = .15). The Bogossian formula showed a significant deviation from the actual QTc interval with both the Bazett and the Fridericia formulas. CONCLUSION: In combination with the Hodge formula, the Boggosian formula delivered the best results in comparing the true QTc interval in narrow QRS with the QTmc interval in the presence of a bifascicular block.

Bicuspid Aortic Valve Stenosis and the Effect of Vitamin K2 on Calcification Using 18F-Sodium Fluoride Positron Emission Tomography/Magnetic Resonance: The BASIK2 Rationale and Trial Design.

BASIK2 is a prospective, double-blind, randomized placebo-controlled trial investigating the effect of vitamin K2 (menaquinone-7;MK7) on imaging measurements of calcification in the bicuspid aortic valve (BAV) and calcific aortic valve stenosis (CAVS). BAV is associated with early development of CAVS. Pathophysiologic mechanisms are incompletely defined, and the only treatment available is valve replacement upon progression to severe symptomatic stenosis. Matrix Gla protein (MGP) inactivity is suggested to be involved in progression. Being a vitamin K dependent protein, supplementation with MK7 is a pharmacological option for activating MGP and intervening in the progression of CAVS. Forty-four subjects with BAV and mild-moderate CAVS will be included in the study, and baseline 18F-sodiumfluoride (18F-NaF) positron emission tomography (PET)/ magnetic resonance (MR) and computed tomography (CT) assessments will be performed. Thereafter, subjects will be randomized (1:1) to MK7 (360 mcg/day) or placebo. During an 18-month follow-up period, subjects will visit the hospital every 6 months, undergoing a second 18F-NaF PET/MR after 6 months and CT after 6 and 18 months. The primary endpoint is the change in PET/MR 18F-NaF uptake (6 months minus baseline) compared to this delta change in the placebo arm. The main secondary endpoints are changes in calcium score (CT), progression of the left ventricularremodeling response and CAVS severity (echocardiography). We will also examine the association between early calcification activity (PET) and later changes in calcium score (CT).

Epicardial and endocardial electrophysiological guided thoracoscopic surgery for atrial fibrillation: a multidisciplinary approach of atrial fibrillation ablation in challenging patients.

INTRODUCTION: Patients with atrial fibrillation (AF) with enlarged atria or previous pulmonary vein isolation (PVI) are challenging patients for catheter ablation. Thoracoscopic surgery is an effective treatment for these patients but comes at the cost of an increase in adverse events. Recently, electrophysiological (EP) guided approaches to thoracoscopic surgery have been described which consist of EP guidance by measurement of conduction block across ablation lines. In this study we describe the efficacy and safety of EP-guided thoracoscopic surgery for AF in patients with enlarged atria and/or prior failed catheter ablation. METHODS & RESULTS: A total of 72 patients were included. Two different approaches to EP-guided thoracoscopic surgery were implemented: epicardial or endocardial EP-guidance at the time of surgery. Residual intraoperative conduction requiring additional ablation was detected with epicardial or endocardial mapping techniques in 50% and 11%, respectively. Additional epicardial or endocardial ablation was performed until bidirectional block was confirmed. Follow-up consisted of an ECG and a 24h Holter at 3, 6 and 12 months after the procedure. A total of 57 patients (79%) had freedom of AF and were off anti-arrhythmic drugs at one year follow-up (30 paroxysmal (83%), 27 persistent AF (75%)). Adverse events occurred in 13 patients (6 major). None of our patients died and all events were reversible. CONCLUSION: EP-guidance of thoracoscopic surgery can be safely performed both epicardially and endocardially and is associated with a high rate of long-term maintenance of sinus rhythm in patients with enlarged atria and/or a previously failed ablation.

The effect of a nurse-led integrated chronic care approach on quality of life in patients with atrial fibrillation.

AIMS: Quality of life (QoL) is often impaired in patients with atrial fibrillation (AF). A novel nurse-led integrated chronic care approach demonstrated superiority compared with usual care in terms of cardiovascular hospitalization and mortality. Consequently, we hypothesized that this approach may also improve QoL and AF-related knowledge, which in turn may positively correlate with QoL. METHODS AND RESULTS: In this randomized controlled trial, 712 patients were randomly assigned to nurse-led care vs. usual care. Nurse-led care consisted of guidelines-based, software supported care, supervised by cardiologists. Usual care was provided by cardiologists in the regular outpatient setting. Quality of life was assessed by means of the Medical Outcomes Study 36-Item Short-Form Survey (SF-36). The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression scores. The AF knowledge scale was used to gain an insight into the patients' AF knowledge levels. Baseline QoL scores were relatively high in both groups, with median scores ranging from 55 to 100. Quality of life significantly improved over time in both groups with no significant differences between the two groups. Atrial fibrillation-related knowledge improved over time and was significantly higher at follow-up in the intervention group, compared with the usual care group (8.23 ± 2.16 vs. 7.66 ± 2.09; P < 0.05). Quality of life was correlated with gender (rs: -5.819 to -2.960), anxiety (rs: -0.746 to -0.277), depression (rs: -0.596 to -0.395), and knowledge (rs: 0.145-0.245), expressed in Spearman's rank correlation coefficient (rs). CONCLUSION: Quality of life including anxiety and depression improved over time, regardless of the treatment group. The AF-related knowledge level was better in the nurse-led care group at follow-up. Trial registration information: Clinicaltrials.gov identifier number: NCT00753259.

Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation.

AIMS: The management of patients with atrial fibrillation (AF) is often inadequate due to deficient adherence to the guidelines. A nurse-led AF clinic providing integrated chronic care to improve guideline adherence and activate patients in their role, may effectively reduce morbidity and mortality but such care has not been tested in a large randomized trial. Therefore, we performed a randomized clinical trial to compare the AF clinic with routine clinical care in patients with AF. METHODS AND RESULTS: We randomly assigned 712 patients with AF to nurse-led care and usual care. Nurse-led care consisted of guidelines based, software supported integrated chronic care supervised by a cardiologist. The primary endpoint was a composite of cardiovascular hospitalization and cardiovascular death. Duration of follow-up was at least 12 months. Adherence to guideline recommendations was significantly better in the nurse-led care group. After a mean of 22 months, the primary endpoint occurred in 14.3% of 356 patients of the nurse-led care group compared with 20.8% of 356 patients receiving usual care [hazard ratio: 0.65; 95% confidence interval (CI) 0.45-0.93; P= 0.017]. Cardiovascular death occurred in 1.1% in the nurse-led care vs. 3.9% in the usual care group (hazard ratio: 0.28; 95% CI: 0.09-0.85; P= 0.025). Cardiovascular hospitalization amounted (13.5 vs. 19.1%, respectively, hazard ratio: 0.66; 95% CI: 0.46-0.96, P= 0.029). CONCLUSION: Nurse-led care of patients with AF is superior to usual care provided by a cardiologist in terms of cardiovascular hospitalizations and cardiovascular mortality. Trial registration information: Clinicaltrials.gov identifier number: NCT00391872.

Reduced ventricular proarrhythmic potential of the novel combined ion-channel blocker AZD1305 versus dofetilide in dogs with remodeled hearts.

BACKGROUND: AZD1305 is an investigational antiarrhythmic agent for management of atrial fibrillation. It blocks various cardiac ion currents at different potencies and has atrial-predominant electrophysiological effects. We investigated the electrophysiological and proarrhythmic effects of AZD1305 versus dofetilide in dogs with chronic complete atrioventricular block and myocardial hypertrophic remodeling. METHODS AND RESULTS: AZD1305 was administered to anesthetized mongrel dogs before and >2 weeks after the induction of atrioventricular block and ventricular and atrial electrophysiological parameters were assessed. In all dogs, the selective I(Kr) blocker dofetilide was used to examine susceptibility to acquired torsades de pointes in chronic atrioventricular block and for comparison. At normal sinus rhythm, AZD1305 increased QT and RR intervals from 290±7 to 397±15 ms (+37%, P<0.0001) and from 603±22 to 778±32 ms (+29%, P=0.002), respectively. In the same animals at chronic atrioventricular block, AZD1305 increased the QT interval from 535±28 to 747±36 ms (+40%, P<0.0001), similar to the QT prolongation by dofetilide (511±22 to 703±45 ms [+38%, P<0.0001]). AZD1305 slightly slowed the idioventricular rhythm. Whereas all (n=14) chronic atrioventricular block animals exhibited torsades de pointes on dofetilide, the arrhythmia was induced in only 4 of 11 dogs after AZD1305. Beat-to-beat variability of left-ventricular monophasic-action-potential duration increased after dofetilide (2.3±0.2 to 6.3±0.7 ms; P<0.0001) but not after AZD1305 (2.8±0.3 to 3.7±0.3 ms; P=0.20) despite similar left-ventricular monophasic-action-potential duration prolongations. CONCLUSIONS: Despite causing similar degrees of repolarization delay as the selective I(Kr) blocker dofetilide, the combined ion-channel blocker AZD1305 induces less repolarization instability and has a lower ventricular proarrhythmic potential in the remodeled dog heart.

Idiopathic left bundle-branch block-shaped ventricular tachycardia may originate above the pulmonary valve.

BACKGROUND: Idiopathic left bundle-branch block (LBBB)-like ventricular tachycardia (VT) is considered to originate in the right ventricular outflow tract (RVOT) or from the aortic root. Both regions are derived from the embryonic outflow tract. We now report that also the pulmonary trunk can give rise to VT, suggesting a common etiology of these tachycardias. METHODS AND RESULTS: We studied 6 patients with symptomatic idiopathic LBBB-VT using electrophysiological mapping techniques. The VT origin was determined by analyzing the electrograms and the angiographic location of the catheter tip at the successful ablation site or the earliest activation site. Eight VTs were induced. Two VTs, with a mean earliest endocardial activation time of -5 and -20 ms and optimal pace mapping, were successfully ablated in the RVOT. In the remaining 6 VTs, the earliest activation site was found in the pulmonary artery, and, at this site, a sharp potential was present -38+/-12 ms before the QRS in 5 VTs. The mean earliest endocardial activation time in the RVOT was -1+/-2 ms. Ablation was attempted in 5 of 6 VTs and resulted in an acutely successful procedure. After a mean follow-up of 10+/-4 months, 1 of 5 patients had a recurrence. CONCLUSIONS: The site of origin of idiopathic LBBB-VT can be in the root of the pulmonary artery, suggesting a myocardial connection from this site to the RVOT. If no good criteria for ablation in the RVOT are found, detailed mapping of the pulmonary artery should be performed.

Effects of nifedipine on carotid and femoral arterial wall thickness in previously untreated hypertensive patients.

BACKGROUND: Experimental and clinical evidence suggests that calcium-channel blockers may retard the atherosclerotic process after long-term treatment. Whether these effects exist after intermediate-term treatment in hypertensive patients is mainly unknown. OBJECTIVE: To determine the 26-week effects of the long-acting calcium-channel blocker nifedipine on intima media thickness (IMT) in newly found hypertensive patients. DESIGN: Open-label study with blinded end-point analysis. METHODS: From a population survey, 131 previously untreated mild hypertensives (4 x systolic blood pressure between 160 and 220 mmHg and/or diastolic blood pressure between 95 and 115 mmHg) were included. Patients were treated with long-acting nifedipine 30-60 mg targeted to reach a predetermined drop in blood pressure. Prior to and after 26 weeks of treatment, IMT was measured by ultrasonography in the carotid and femoral artery. The combined mean maximal far wall IMT was used as primary endpoint. Change from baseline was evaluated by paired t-test in an intention-to-treat analysis. RESULTS: The mean maximal far wall IMT at baseline was 1.03 +/- 0.23 mm, and decreased by 0.078 mm (95% confidence interval, CI 0.044-0.111) after treatment. Regression analysis, including baseline IMT and changes of blood pressure, showed that reduction of IMT was mostly influenced by baseline IMT (p < 0.001; model R2 = 0.1). CONCLUSION: Our observations show that 26 weeks of nifedipine treatment inhibits IMT progression in these newly found hypertensive patients. This effect was mostly seen in arterial walls with highest IMT before treatment, suggesting that patients with highest cardiovascular risk benefit most of antihypertensive treatment.