Meta-analysis of controlled studies on minimally interrupted vs. continuous use of non-vitamin K antagonist oral anticoagulants in catheter ablation for atrial fibrillation.

AIMS: At present, there are no guideline recommendations for minimally interrupted use of non-vitamin K antagonist oral anticoagulants (mi-NOAC) during catheter ablation (CA) for atrial fibrillation (AF). Current evidence is predominantly based on observational studies, with continuous use of vitamin K antagonist in the control arm. This quantitative summary reflects the first high-level evidence on contemporary regimens, with continuous NOAC use (c-NOAC) as the current gold standard. METHODS AND RESULTS: Meta-analysis (Pubmed, Embase, and Web of Science) on prospective, controlled studies comparing contemporary mi-NOAC (without bridging) with c-NOAC. Net adverse clinical events (major bleeding, thrombo-embolic events) were the primary outcome. In addition, we analysed total bleeding, minor bleeding, and silent cerebral embolism. Eight studies (six randomized, two observational) with 2168 patients were summarized. The primary endpoint occurred in 1.0% (18/1835): 1.1% (11/1005) vs. 0.8% (7/830) for the mi-NOAC and c-NOAC groups, respectively; odds ratio (OR) 1.20 [95% confidence interval (CI) 0.49-2.92, P = 0.64]. The OR for total bleeding on mi-NOAC was 1.26 (95% CI 0.97-1.63, P = 0.07). ORs for minor bleeding and silent cerebral embolism were 1.17 (95% CI 0.80-1.70, P = 0.34) and 2.62 (95% CI 0.54-12.61, P = 0.12), respectively. CONCLUSION: This synopsis provides a quantitative synthesis of high-level evidence on a contemporary strategy of mi-NOAC in CA for AF, and overall clinical outcomes were not different from continuous NOAC use. Despite preprocedural interruption, there was no sign of lower bleeding rates. Additional higher volume datasets are warranted for more precise treatment effect estimations of this everyday alternative anticoagulation strategy in AF ablation.

Two presentations of acute coronary syndrome with progression of giant right coronary artery aneurysm; a case report.

Background: Giant coronary aneurysms are a rare finding on coronary angiography. Given its very low prevalence, little is known about optimal management of this coronary pathology. Case summary: In this case report, we review the two presentations of a patient with acute coronary syndrome during a 6-year period. With regard to the second presentation, we review the investigations that demonstrate the progression of a coronary aneurysm in the right coronary artery as well as the Heart Team evaluations that resulted in surgical treatment of the coronary aneurysm. Discussion: Following perspectives on prevalence and risk factors, we emphasize upon the available data with regard to interventional options in coronary aneurysms and describe the considerations with regard to interventional treatment in patients with giant coronary aneurysms. Finally, we discuss the available literature with regard to antithrombotic regimens in patients with coronary aneurysms.

Second-generation cryoballoon ablation for recurrent atrial fibrillation after an index cryoballoon procedure: a staged strategy with variable balloon size.

PURPOSE: Currently, information on the optimal approach of redo procedures for paroxysmal atrial fibrillation (PAF) is limited. Radiofrequency ablation is the preferred technique, with reported success rates of 50-70% at 1-2 years, whereas only few reports exist on redo cryoballoon (CB) ablations. We describe outcomes on a systematic approach of repeat procedures with a second-generation cryoballoon (CB-2) after a successful index CB ablation. METHODS: Cohort study of 40 consecutive patients with recurrent PAF (55% male), median CHA2DS2-VASc score 1 (IQR 0-3). Per protocol, a staged variable balloon size strategy was followed with a different balloon size during the redo as compared to the index procedure. Minimal follow-up was 12 months (median 17 months [IQR 14-39]). RESULTS: Overall, 120 pulmonary veins (PVs) (75%) showed chronic isolation: 64% (41/64) for first-generation cryoballoon (CB-1) and 82% (79/96) for CB-2 index procedures, respectively (p = 0.01). The overall mean number of reconnected PVs per patient was 1.0 (40/40): 1.4 for CB-1 and 0.7 for CB-2 index procedures (p = 0.008). Phrenic nerve palsies (n = 7) resolved before the end of the procedure. At 1 year, 70% of patients were free of recurrent AF. In multivariate analysis, the only independent predictor of recurrence was the number of prior cardioversions. CONCLUSIONS: A systematic approach of repeat procedures with a CB-2 using a different balloon size than during the index CB ablation is safe, with acceptable 1-year outcomes. Future comparative studies on the optimal redo technique and approach are warranted to further improve rhythm control in AF.