Risk of Stroke or Systemic Embolism According to Baseline Frequency and Duration of Subclinical Atrial Fibrillation: Insights From the ARTESiA Trial.

BACKGROUND: In the ARTESiA trial (Apixaban for the Reduction of Thromboembolism in Patients With Device-Detected Subclinical Atrial Fibrillation), apixaban, compared with aspirin, reduced stroke or systemic embolism in patients with device-detected subclinical atrial fibrillation (SCAF). Clinical guidelines recommend considering SCAF episode duration when deciding whether to prescribe oral anticoagulation for this population. METHODS: We performed a retrospective cohort study in ARTESiA. Using Cox regression adjusted for CHA2DS2-VASc score and treatment allocation (apixaban or aspirin), we assessed frequency of SCAF episodes and duration of the longest SCAF episode in the 6 months before randomization as predictors of stroke risk and of apixaban treatment effect. RESULTS: Among 3986 patients with complete baseline SCAF data, 703 (17.6%) had no SCAF episode ≥6 minutes in the 6 months before enrollment. Among 3283 patients (82.4%) with ≥1 episode of SCAF ≥6 minutes in the 6 months before enrollment, 2542 (77.4%) had up to 5 episodes, and 741 (22.6%) had ≥6 episodes. The longest episode lasted <1 hour in 1030 patients (31.4%), 1 to <6 hours in 1421 patients (43.3%), and >6 hours in 832 patients (25.3%). Higher baseline SCAF frequency was not associated with increased risk of stroke or systemic embolism: 1.1% for 1 to 5 episodes versus 1.2%/patient-year for ≥6 episodes (adjusted hazard ratio, 0.89 [95% CI, 0.59-1.34]). In an exploratory analysis, patients with previous SCAF but no episode ≥6 minutes in the 6 months before enrollment had a lower risk of stroke or systemic embolism than patients with at least one episode during that period (0.5% versus 1.1%/patient-year; adjusted hazard ratio, 0.48 [95% CI, 0.27-0.85]). The frequency of SCAF did not modify the reduction in stroke or systemic embolism with apixaban (Pinteraction=0.1). The duration of the longest SCAF episode in the 6 months before enrollment was not associated with the risk of stroke or systemic embolism during follow-up (<1 hour: 1.0%/patient-year [reference]; 1-6 hours: 1.2%/patient-year [adjusted hazard ratio, 1.27 (95% CI, 0.85-1.90)]; >6 hours: 1.0%/patient-year [adjusted hazard ratio, 1.02 (95% CI, 0.63-1.66)]). SCAF duration did not modify the reduction in stroke or systemic embolism with apixaban (Ptrend=0.1). CONCLUSIONS: In ARTESiA, baseline SCAF frequency and longest episode duration were not associated with risk of stroke or systemic embolism and did not modify the effect of apixaban on reduction of stroke or systemic embolism. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01938248.

Thorax Percutaneous Approach for Epicardial Ventricular Ablation in a Patient with Electrical Storm.

Subxiphoid puncture is considered the standard approach for epicardial ablation of ventricular arrhythmia, but in some cases this access is impracticable due to the patient's anatomy. We describe the case of a patient with electrical storm and abnormal subdiaphragmatic anatomy that precluded the usual subxiphoid approach. In this patient the pericardial space was gained through a direct thorax puncture at the fifth intercostals space close to the mammary line. The tools and technique utilized in this case were similar to what is usually used for traditional subxiphoid puncture. The thorax percutaneous puncture was successfully carried out without complication.

[Conduction disorders after transcatheter aortic valve implantation: incidence, characteristics, and clinical management]. / I disturbi di conduzione dopo impianto transcatetere di protesi aortica: incidenza, caratteristiche e gestione clinica.

Transcatheter aortic valve implantation may be complicated by the development of conduction disturbances, including left bundle branch block and high-grade atrioventricular blocks, especially in patients with predisposing risk factors, such as pre-existing right bundle branch block. Permanent pacemaker implantation is a procedure with potential short- and long-term complications, and it should be reserved to patients with appropriate indications. Electrophysiological testing and/or prolonged ambulatory ECG monitoring are valuable tools for stratifying the risk of pacemaker implantation. However, the management of new-onset conduction disorders is not always straightforward, and there are different approaches depending on the center's attitude. Therefore, the purpose of this review is to define clinical management based on current evidence, while awaiting data from randomized trials.

[Atrial tachycardia degenerating into atrial fibrillation during recurrence of ischemic stroke: prolonged ECG monitoring in appropriately selected patients with embolic stroke of undetermined source]. / Tachicardia atriale che degenera in fibrillazione atriale durante recidiva di ictus ischemico: utilità diagnostica del monitoraggio ECG prolungato in pazienti con ictus embolico ad eziologia indeterminata adeguatamente selezionati.

The search for silent atrial tachyarrhythmias remains one of the cornerstones in patients suffering from embolic stroke of undetermined source. We report the case of a 76-year-old female patient suffering from recurrence of ischemic stroke, adequately selected based on the presence of predictors of atrial fibrillation (AF), to perform prolonged ECG monitoring. This recording allowed to document long-lasting AF triggered by atrial tachycardia. It was also possible to demonstrate a direct correlation between AF and new cerebral stroke.

Catheter Ablation of Well Tolerated Ventricular Tachycardia in Patients With Structural Heart Disease and Without Automatic Defibrillator Implantation: Long Term Follow-up.

The occurrence of a sustained monomorphic ventricular tachycardias (SMVT) in patients with underlying structural heart disease (SHD) is considered related to poor prognosis. The purpose of our work was to evaluate if these patients could benefit from radiofrequency (RF) ablation, and the defibrillator (ICD) implantation could be deferred during follow-up. We reviewed consecutive patients with well-tolerated SMVT, SHD and left ventricular ejection fraction over 30%. These patients were treated by RF ablation and were discharged without ICD. The primary outcome was a composite of all-cause death and recurrence of SMVT; the secondary outcome was death from all causes. Sixty-two patients were selected. After a median follow-up of 38.8 months, the primary outcome occurred in 24 (38.7%) and the secondary in 11 (17.7%) patients. The annual mortality rate was 4.3% and no patient died from sudden death. RF ablation as a first-choice therapy seems to represent an effective and beneficial therapeutic approach.

[Premature ventricular beats: are they always benign? Diagnostic and therapeutic aspects]. / Extrasistolia ventricolare: è sempre benigna? Aspetti diagnostici e terapeutici.

Premature ventricular complexes (PVCs) are usually benign, and commonly only severely symptomatic patients are treated. In the literature, frequent PVCs have been reported to cause ventricular dysfunction, which may improve after PVC treatment. PVCs can also worsen the prognosis in patients with structural heart disease. Catheter PVC ablation is often the treatment of choice considering the high success rates. Ventricular dysfunction due to frequent PVCs is not always easy to identify as patients can be asymptomatic and the interpretation of imaging tests may be challenging in the presence of frequent PVCs. Treatment of patients with mild ventricular dysfunction is still a matter of debate.

Percutaneous occlusion of the left atrial appendage for systemic embolism prevention in patients with atrial fibrillation: state of the art and report of two cases.

Atrial fibrillation is a benign arrhythmia but it is associated with an elevated thromboembolic risk. The treatment of choice is oral anticoagulation. However not all the patients can benefit from oral anticoagulation, due to bleeding risk or other contraindications. Considering that the most common embolic source in patients with atrial fibrillation is the left atrial appendage, different surgical techniques have been suggested for its closure. For patients at high risk, since August 2001 a device is available for percutaneous occlusion of the left atrial appendage (PLAATO). The PLAATO device consists of a self-expandable nitinol cage with small anchors on its surface to avoid systemic migration. The implantation procedure is performed with local anesthesia. It requires transseptal puncture and the device is delivered to the appendage through a specially designed sheath. The maneuver is performed under transesophageal and fluoroscopic guidance. At present more than 250 patients have been implanted, and the results, as far as the safety and the effectiveness are concerned, are really promising. We report 2 cases of recently successfully implanted at our Center.

Ablation of left atrial flutter in a patient surgically treated for atrial fibrillation. Does it indicate a possible hybrid approach?

Surgical treatment of atrial fibrillation (AF) has a high success rate and nowadays simpler and faster procedures have been proposed. The following is a description of the case of a patient who, after a modified Maze procedure, developed an atypical left atrial flutter and underwent a successful radiofrequency ablation procedure. A 71-year-old male underwent surgical biological valve replacement and a concomitant modified Maze procedure. After surgery the patient developed a persistent atrial arrhythmia with severe symptoms and refractory to any drug. For this reason, an electrophysiological study was planned. We performed a three-dimensional atrial mapping using the real-time position management system (Boston Scientific). Right atrial mapping indicated an early activation area on the septum. After transseptal puncture, left atrial mapping showed a reentry circuit around the mitral annulus with positive entrainment. A linear lesion was made between the mitral annulus and the superior right pulmonary vein and sinus rhythm was restored. After 7 months of follow-up the patient is asymptomatic and still in stable sinus rhythm. In conclusion, the follow-up of surgical AF may be improved by close collaboration between the surgeon and electrophysiologist. The available data suggest that a combined surgical and percutaneous approach could be the strategy of choice.

Transseptal approach for left atrial arrhythmia ablation in patients with valve prostheses.

OBJECTIVE: Atrial transseptal puncture is nowadays routinely performed in the electrophysiology laboratory in order to map and ablate the left atrium. Some concerns, however, exist as to whether to perform atrial transseptal puncture in patients with heart valve prostheses, because of the risk of damaging the valve and of prosthetic valve-related thromboembolic complications. Only a few data are available on transseptal puncture for catheter ablation in patients with heart valve prostheses. We report our experience with atrial transseptal puncture carried out during an electrophysiological procedure in patients with prosthetic valves. METHODS: Between January 2003 and January 2006, we performed 227 transseptal punctures in order to map and ablate the left atrium. Among these, nine patients (3.9%) had a heart valve prosthesis. The safety and feasibility of the procedure are reported as well as results at 6-month follow-up. RESULTS: Atrial transseptal puncture was successful in all patients. In four patients the procedure was performed under transoesophageal guidance after failure of the first attempt. The clinical arrhythmia was successfully ablated in eight patients (88.8%) and one procedure was interrupted because of atrial fibrillation. In seven cases the arrhythmia was successfully ablated in the left atrium; in one patient the arrhythmia was ablated on the right side of the septum after exclusion of a left atrial origin of the arrhythmia following completion of the mapping procedure. One patient had transient vision loss after the procedure, but no other complications were documented during or after atrial transseptal puncture. CONCLUSIONS: Patients with valve prostheses and severely symptomatic drug-refractory arrhythmias can be considered candidates for atrial transseptal puncture and left atrial mapping and ablation. Atrial transseptal puncture is feasible, even though it requires experienced operators.