Thrombus in the left atrial appendage in patients with atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants in clinical practice-A multicenter registry.

BACKGROUND: The prevalence and predictors of left atrial appendage thrombus (LAAT) in patients with non-valvular atrial fibrillation (AF) who have been treated with non-vitamin K antagonist oral anticoagulants (NOACs) are not well defined. We aimed to assess the occurrence and predictors of LAAT on transesophageal echocardiography (TOE) in patients with non-valvular AF treated with NOACs for at least 3 weeks. METHODS: Consecutive patients with non-valvular AF who underwent TOE before catheter ablation or electrical cardioversion in three high-reference centers between 2014 and 2018 were included. Patients on apixaban were excluded from the study due to low numbers in this category. All patients received NOACs for at least 3 weeks before TOE. RESULTS: A total of 1148 patients (female, 38.1%; mean age, 62.1 years) referred to our centers for catheter ablation of AF (52.1%) or electrical cardioversion (47.9%) were included. Patients were on rivaroxaban (51.9%) or dabigatran (48.1%). Preprocedural TOE revealed LAAT in 4.4% of all patients. Multivariable logistic regression analysis showed the CHA2DS2-VASc score ≥2 points (OR = 2.11; 95% CI, 1.15-3.88; P = .0161), non-paroxysmal AF (OR = 6.30; 95% CI, 2.22-17.91; P = .0005), and GFR <60 mL/min/1.73 m2 (OR = 2.05; 95% CI, 1.14-3.67; P = .0160) were independent predictors of LAAT in patients treated with NOACs. CONCLUSIONS: In non-valvular AF patients treated with NOACs, the prevalence of LAAT was 4.4% before electrical cardioversion or ablation. In addition to the CHA2DS2-VASc score, the type of AF and renal function should be considered in the stratification of thromboembolism risk in AF patients and qualification for a preprocedural TOE.

Decreased left atrial appendage emptying velocity as a link between atrial fibrillation type, heart failure and older age and the risk of left atrial thrombus in atrial fibrillation.

INTRODUCTION: Decreased left atrial appendage emptying velocity (LAAV) is a known predictor of LAA thrombus in atrial fibrillation (AF). The aim of our study was to identify which of the clinical risk factors for LAA thrombus are associated with decreased LAAV. METHODS: The study included 1476 consecutive AF patients who underwent transesophageal echocardiography (TEE) before AF direct current cardioversion or ablation in two high-reference cardiology departments. Patients were divided into two groups: 71 (4.8%) patients with LAAV < 20 cm/s and 1405 patients (95%) with LAAV ≥ 20 cm/s. RESULTS: Compared with patients with LAAV ≥ 20 cm/s, those with decreased LAAV were older, more often had non-paroxysmal AF, were burdened with more concomitant diseases (including hypertension, diabetes, vascular disease, and heart failure [HF]) with higher median CHA2 DS2 -VASc score (3 [2-4] vs 2 [1-3], P < .0001), and had lower glomerular filtration rate (GFR). Prevalence of LAA thrombus was higher in patients with decreased LAAV compared with those with LAAV ≥ 20cm/s (20% vs 4.6%, P < .0001). In patients with decreased LAAV, there was no difference in the frequency of LAA thrombus between those treated with VKA and those receiving NOAC, while in patients with LAAV ≥ 20 cm/s a trend was observed towards a benefit with NOAC. In multivariate logistic regression, non-paroxysmal AF, HF and age ≥ 65 years predicted both LAAV < 20 cm/s and LAA thrombus, while GFR < 60 mL/min/1.73 m2 predicted only the presence of LAA thrombus. CONCLUSION: One in five AF patients with decreased LAAV had LAA thrombus, regardless of the type of OAC. Non-paroxysmal AF, HF and age ≥ 65 years might increase LAA thrombus risk via reduced LAAV.

Management of ventricular tachycardia in the ablation era: results of the European Heart Rhythm Association Survey.

Patients with sustained ventricular tachycardia (VT) are at risk of sudden death. Treatment options for VT include antiarrhythmic drug therapy, insertion of an implantable cardioverter-defibrillator, and catheter ablation. Evidence on indications for VT ablation, timing, ablation strategies, and periprocedural management is sparse. The aim of this European Heart Rhythm Association (EHRA) survey was to evaluate clinical practice regarding management of VT among the European countries. An electronic questionnaire was sent to members of the EHRA Electrophysiology Research Network. Responses were received from 88 centres in 12 countries. The results have shown that management of VTs is very heterogeneous across the participating centres. Indications, periprocedural management, and ablation strategies vary substantially. This EP Wire survey has revealed that catheter ablation is the first-line therapy for the treatment of recurrent monomorphic stable VT in patients without structural heart disease as well as in patients with ischaemic cardiomyopathy and impaired left ventricular ejection fraction in the majority of centres. Furthermore, in patients with ischaemic cardiomyopathy and the first episode of monomorphic VT, most centres (62.0%) performed catheter ablation. On the contrary, in patients with non-ischaemic cardiomyopathy, amiodarone (41.4%) and catheter ablation (37.1%) are used in a very similar proportion. Ablation strategies, endpoints, and post-ablation antithrombotic management vary substantially among European centres.

Approach to cardio-oncologic patients with special focus on patients with cardiac implantable electronic devices planned for radiotherapy: results of the European Heart Rhythm Association survey.

The aim of this European Heart Rhythm Association (EHRA) survey was to evaluate clinical practice regarding cardio-oncologic patients, with special focus on patients with cardiac implantable electronic devices (CIEDs) planned for anticancer radiotherapy (RT), among members of the EHRA electrophysiology research network. Of the 36 responding centres, 89% managed patients who were diagnosed or treated oncologically, and this diagnosis affected 1-5% of cardiovascular patients in majority of centres (57%). The main side effects of anticancer therapy in patients treated by cardiologists were thromboembolic complications and left ventricular dysfunction (both reported as 'frequent' by 43% of the centres). The main agents associated with complications were anthracyclines, RT, and monoclonal antibodies. Echocardiography was the most common method of screening for cardiovascular complications (93%), and 10% of the centres did not routinely screen for treatment-induced cardiotoxicity. Opinions on the safe radiation dose, methods of device shielding, and risk calculation prior to RT in CIED patients differed among centres. Precaution measures in high-risk CIED patients were very heterogeneous among centres. Our survey has shown that the awareness of cardiac consequences of anticancer therapy is high, despite relatively low proportion of patients treated oncologically among all cardiovascular patients. There is a consensus of which screening methods should be used for cardiotoxicity of anticancer treatment, but the apprehension of screening necessity is low. Methods of risk assessment and safety measures in CIED patients undergoing RT are very heterogeneous among the European centres, underscoring the need for standardization of the approach to cardio-oncologic patients.

The 9p21 polymorphism is linked with atrial fibrillation during acute phase of ST-segment elevation myocardial infarction.

The aim of the study was to find whether patients carrying polymorphic allele of the rs10757278 polymorphism from 9p21 locus have changed risk of arrhythmia (atrial fibrillation, AF; sustained ventricular tachycardia or ventricular fibrillation, sVT/VF) during acute phase of myocardial infarction. Retrospective analysis of data collected prospectively from two independent centers was performed. The clinical data were pooled from two independent cardiac registries: (1) the Warsaw ACS genetic registry (STEMI and NSTEMI/UA patients hospitalized in the years 2008-2011; only STEMI patients were analyzed); (2) the Bialystok STEMI genetic registry (STEMI patients hospitalized in years 2001-2005, who survived the first 48 h from hospital admission). Data regarding sVT/VF and AF within first 24 h were analyzed. The patients were genotyped with rs10757278 polymorphism. 1083 patients were included in the analysis; 62 (5.7 %) patients had sVT/VF during acute phase and 78 (7.2 %) patients had AF, 46 (4.2 %) patients had new-onset AF. Minor allele frequency in all patients with AF was significantly different from those without AF (0.40 vs 0.51, p = 0.0096). When only new-onset AF was analyzed, the trend was the same, with significant protective effect in recessive model [OR 0.41 (95 % CI 0.17-0.97), p = 0.025]. The effect was independent of age and GRACE score. No relationship was found between sVT/VF and rs10757278. Patients with STEMI, who survived until hospitalization with polymorphic allele of 9p21 rs10757278 SNP have less AF during acute phase of STEMI. SNP rs10757278 is not linked with sVT/VF in acute phase of STEMI.

Presence and severity of obstructive sleep apnea and remote outcomes of atrial fibrillation ablations - a long-term prospective, cross-sectional cohort study.

BACKGROUND: Prior studies suggested that obstructive sleep apnea (OSA) promotes recurrence of arrhythmia in patients after atrial fibrillation (AF) ablation. METHODS: In this prospective, long-term, observational study, we enrolled 290 consecutive patients admitted for AF ablation. Prior to the ablation, all patients underwent a polygraphy sleep study for the diagnosis of OSA. After the procedure, patients were followed up for mean time of 30 months for AF reoccurrence. OSA was diagnosed when apnea-hypopnea index (AHI) was ≥5. Patients were subsequently divided into groups according to the OSA severity: mild OSA (AHI 5-15/h), moderate OSA (AHI >15 and ≤30/h), and severe (AHI >30/h). RESULTS: After excluding patients disqualified from the procedure, and those with central sleep apnea, the study population consisted of 251 patients, mean age 57.6 years [163 (64.9%) male]. OSA was present in 115 (45.8%) patients, while in 137 (54.6%) cases, we observed reoccurrence of AF. Recurrence was more often in patients with, than without, OSA (65.2 vs. 45.6%; p = 0.003). We also observed that along with rising OSA severity rose also the number of patients in whom AF was detected during the follow-up period (45.6 vs. 66.2 vs. 57.6 vs. 81.8%; p = 0.005; for non-OSA, mild, moderate, and severe, respectively). CONCLUSIONS: OSA is highly prevalent in AF patients. The presence of OSA lowers chances on successful AF ablation. Early screening, and treatment for OSA in AF patients, may improve low success rates of AF ablation procedures.

Predicting reduced left atrial appendage velocity from echocardiographic left atrial function parameters in patients with atrial fibrillation undergoing catheter ablation.

Decreased left atrial appendage velocity (LAAV) is considered a significant risk factor thrombus formation in the left atrial appendage (LAA). The aim of this study was to assess the role of echocardiographic left atrial (LA) function parameters in predicting LAAV in patients with persistent atrial fibrillation (AF) undergoing catheter ablation. We prospectively enrolled consecutive patients with persistent AF undergoing transesophageal echocardiography (TEE) directly before the first AF ablation in 2019-2022. Of the 150 patients enrolled in the study, 29.3% (n = 44) had reduced LAAV values defined as < 25 cm/s. Patients with decreased LAAV values exhibited significantly reduced left atrial reservoir and conduit strain (LASr and LAScd), LA emptying fraction, and average e' values. This group also presented with a high LA stiffness index (LASI), high LA and right atrial area, and high LA volume index (LAVI) and E/e' ratio. In multivariable logistic regression analysis, LASI and LAVI remained significant predictors of the reduced LAAV. The threshold values were 1.6 for LASI and 44.47 ml/m2 for LAVI, with area under the curve values of 0.809 and 0.755, respectively. Among all noninvasive echocardiographic parameters, LASI and LAVI were found to be the best predictors of reduced LAAV, with good sensitivity and specificity. Moreover, LASI was found to be the only significant predictor of reduced LAAV defined as < 20 cm/s as well as < 25 cm/s.

Will global transcriptome analysis allow the detection of novel prognostic markers in coronary artery disease and heart failure?

Coronary artery disease (CAD) is one of the leading causes of death in the developed countries. Myocardial infarction (MI) is an acute episode of CAD that results in myocardial injury and subsequent heart failure (HF). In the acute phase of MI several risk factors for future cardiovascular events have been found. The molecular mechanisms of these disorders are still unknown, but altered gene expression may play an important role in the development and progression of cardiovascular diseases. High-throughput techniques should greatly facilitate the elucidation of the mechanisms and provide novel insights into the pathophysiology of cardiovascular diseases. In this review we focus on the perspectives of gene-expression profiling conducted on cardiac tissues and blood for the determination of novel diagnostic and prognostic markers and therapeutic targets.

Value of Left Atrial Strain in Predicting Recurrence after Atrial Fibrillation Ablation.

This study tested the relationship between left atrial (LA) function parameters and the results of pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Consecutive patients undergoing PVI for the first time between 2019 and 2021 were included. Patients underwent radiofrequency ablation using contact force catheters and an electroanatomical system. Follow-up consisted of ambulatory visits/televisits and 7-day Holter monitoring (at 6 and 12 months after ablation). On the day of ablation, all patients underwent transesophageal and transthoracic echocardiography with LA strain analysis. The primary endpoint was atrial tachyarrhythmia recurrence during the follow-up period. Of 221 patients, 22 did not meet the echocardiographic quality criteria, leaving 199 patients. The median follow-up period was 12 months, and 12 patients were lost to follow-up. Recurrences were observed in 67 patients (35.8%) after a mean of 1.06 procedures per patient. The patients were divided into a sinus rhythm (SR, n = 109) group and an AF (n = 90) group based on their cardiac rhythm at the time of echocardiography. In the SR group, univariable analysis showed that LA reservoir strain, LA appendage emptying velocity (LAAV), and LA volume index predicted AF recurrence, with only LAAV being significant in the multivariable analysis. In AF patients, univariable analysis revealed no LA strain parameters predicting AF recurrence.

The Importance of a Distance between the Lines Encircling Pulmonary Veins in Atrial Fibrillation Ablation on First-Pass Isolation Ratio and Clinical Outcomes.

INTRODUCTION: How wide the encircling line is made may influence the outcomes of pulmonary vein isolation (PVI). In the present study we hypothesised that the distance between the lines encircling the pulmonary veins may correspond with the extent of wide antral circumferential ablation (WACA). The aim of the study was to assess the impact of the distance and the area between the lines on the posterior wall of the left atrium on first-pass isolation rate and 12-month freedom from atrial arrhythmia in patients undergoing PVI ablation. METHODS AND RESULTS: One hundred sixteen patients underwent circumferential ablation index (AI)-guided PVI. The distance between the encircling ablation lines was measured off-line between the uppermost points (right and left) and the lowest points and as the area between the encircling lines on the posterior wall. The first-pass isolation rate and 12-month freedom from atrial arrhythmia were 59% and 73%, respectively. Distance between the encircling lines measured linearly or as the area of the posterior wall, assessed as direct values or indexed to left atrial dimensions, did not differ between patients with and without first-pass isolation or between patients with and without recurrences of atrial arrhythmia. CONCLUSIONS: The distance between the ablation lines did not influence the rate of first-pass isolation and arrhythmia recurrence in the long-term follow-up after PVI procedures incorporating the ablation index protocol.

Heart failure in patients with atrial fibrillation: Insights from Polish part of the EORP-AF general long-term registry.

AIMS: This study aimed to determine the impact of heart failure (HF) on clinical outcomes in patients with atrial fibrillation (AF). METHODS AND RESULTS: We analysed data from Polish participants of the EURObservational Research Programme-AF General Long-Term Registry. The primary endpoint was all-cause death, and the secondary endpoints included hospital readmissions, cardiovascular (CV) interventions, thromboembolic and haemorrhagic events, rhythm control interventions, and other CV or non-CV diseases development during one-year follow up. Overall, 688 patients with available data on HF were included into analysis; 51% (n = 351) had HF; of these 48% (n = 168) had reduced ejection fraction (HFrEF), 22% (n = 77) mid-range EF (HFmrEF), and 30% (n = 106) preserved EF (HFpEF). Compared with patients without HF, those with HF had higher mortality rate (aHR 5.61; 95% CI 1.94-16.22, P < 0.01). Patients with HF (vs. without HF) had more often CV interventions (10% vs. 5.4%, P = 0.046) and events (14% vs. 7.1%, P = 0.02), and had less often atrial arrhythmia-related hospital admissions (6.8% vs. 15%, P < 0.01). Over follow-up, patients with HFmrEF and HFpEF had similar mortality rate versus HFrEF (aHR 0.45, 95% CI 0.13-1.57, P = 0.45 for HFmrEF and aHR 0.54, 95% CI 0.20-1.48, P = 0.54 for HFpEF). Mortality rate was similar among rhythm versus rate control group (aHR 0.34; 95% CI 0.10-1.16; P = 0.34). CONCLUSIONS: AF patients with HF have greater mortality rate and more CV interventions/events. No statistically significant difference in long-term outcomes between patients with HFrEF, HFmrEF, and HFpEF highlights the need to develop therapeutic strategies targeting functional status and survival for patients with HF and AF.

Risk of left atrial appendage thrombus in older patients with atrial fibrillation.

Introduction: We aimed to compare the prevalence of left atrial appendage (LAA) thrombus and its predictors between old and young patients with atrial fibrillation (AF). Material and methods: The study included 1970 patients aged ≥ 65 (n = 822 (41.7%)) and < 65 (n = 1148 (58.3%)) referred for AF cardioversion or ablation preceded by transoesophageal echocardiography (TEE). Results: Oral anticoagulation (OAC) was prescribed in 799 (97.2%) patients aged ≥ 65 years and in 1054 (91.8%) of those aged < 65 years (p < 0.001). In patients treated with OAC, those aged ≥ 65 years less often received vitamin K antagonist (VKA) (267 (33.4%) vs. 416 (39.5%)) and more often non-VKA-OAC (NOAC) (532 (66.6%) vs. 638 (60.5%), p = 0.008, p = 0.008) compared to patients < 65 years. On TEE, LAA thrombus was more often observed in patients aged ≥ 65 years than those aged < 65 years (63 (7.7%) vs. 46 (4.0%), p < 0.001), with an absolute but not statistically significant difference between patients aged 65-74 and ≥ 75 years (47 (7.3%) vs. 16 (8.8%), p = 0.528). In patients aged ≥ 65 years, there was no difference in the prevalence of LAA thrombus between patients treated with VKA and NOAC, in contrast to patients aged < 65 years, in whom such a difference was observed (27 (6.5%) vs. 16 (2.5%), p = 0.002). In multivariate logistic regression, predictors of LAA thrombus in both age groups were older age, non-paroxysmal AF, and heart failure, whereas only in patients aged < 65 years - VKA use, and in those aged ≥ 65 years - lower glomerular filtration rate and platelet count. Conclusions: Despite OAC use, older patients with AF remain at high risk of LAA thrombus formation. Older age, non-paroxysmal AF, and heart failure are predictors of LAA thrombus, irrespective of age.

Risk of left atrial appendage thrombus in patients with atrial fibrillation and chronic kidney disease.

BACKGROUND: Atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with an increased risk of ischemic stroke. The aim of this study was to compare the clinical characteristics, the incidence of left atrial appendage (LAA) thrombus and its predictors, and spontaneous echo contrast (SEC) in a population of patients with AF depending on estimated glomerular filtration rate (eGFR) values. METHODS: This study included 1962 patients who underwent transesophageal echocardiographic examination prior to cardioversion or ablation in the years 2014-2018 in three cardiac centers. RESULTS: More than a quarter of AF patients had decreased eGFR (< 60 mL/min/1.73 m2) and were characterized as a high-risk population, with more comorbidities, higher thromboembolic and bleeding risk compared to those with normal renal function. Oral anticoagulation (OAC) was prescribed in 97% and 93% of patients with decreased and normal eGFR, respectively, with a higher prevalence of prescribed non-vitamin K antagonist oral anticoagulants (NOACs). The incidence of LAA thrombus (24%, 9% and 4%) and SEC (25%, 25% and 19%) increases simultaneously with a decrease in eGFR (< 30, 30-59 and ≥ 60 mL/min/1.73 m2, respectively). Among patients prescribed reduced doses of NOAC, those with decreased eGFR were more often observed with LAA thrombus (10% vs. 2.5%). Non-paroxysmal AF, heart failure and previous bleeding were predictors of LAA thrombus, irrespective of eGFR value. CKD was the predictor of LAA thrombus in all patients including those with non-paroxysmal AF, males, without diabetes, without hypertension and with CHA2DS2-VASc < 2. CONCLUSIONS: Despite OAC, patients with concomitant AF and CKD remain at high risk for LAA thrombus formation.

Increased Body Mass Index and Risk of Left Atrial Thrombus in Nonvalvular Atrial Fibrillation Patients-Data from the Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) Registry.

An increased body mass index (BMI) is associated with a higher incidence of atrial fibrillation (AF) and a higher risk of thromboembolic complications in AF patients. The aim of this study was to investigate the effect of BMI on the risk of left atrial thrombi (LATs) in patients with nonvalvular AF/atrial flutter (AFl) (NV AF/AFl). Patients diagnosed with NVAF/AFl (between November 2018 and May 2020) were selected from the multicenter, prospective, observational Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry that included AF/AFl patients referred for cardioversion or ablation followed by transesophageal echocardiography. A total of 2816 AF/AFl patients (63.6% males; mean age 65.8 years; mean BMI 29.8 kg/m2) were included in the study. Two hundred and twenty-two of them (7.9%) had LATs. Compared with normal-weight patients, those with BMIs ≥ 25 kg/m2 more frequently presented clinical factors potentially provoking LATs, such as non-paroxysmal AF/AFl (p = 0.04), hypertension (p < 0.001), and diabetes (p < 0.001); had higher CHA2DS2 scores (p < 0.001); and had larger LA dimensions (LA diameter and LA area) (p < 0.001 for both parameters). On the other hand, they showed some features negatively related to thromboembolic risk; for example, they were younger (p < 0.001) and were more often male (p = 0.002). In addition, patients with abnormal BMIs were more likely to be smokers (p = 0.006) and to be treated with oral anticoagulants (p = 0.005). Despite these differences in the prevalence of thromboembolic risk factors, the incidence of LATs was not increased in patients with abnormal body weight (overweight and obese compared to normal-weight patients) in this large real-life cohort of AF/AFl patients. This is probably due to the balanced composition regarding the prevalence of positive and negative thromboembolic risk factors.

Correlations between left atrial strain and left atrial pressures values in patients undergoing atrial fibrillation ablation.

BACKGROUND: We aimed to investigate the correlations between left atrial strain (LAS) assessed by speckle tracking echocardiography and directly measured left atrial pressures (LAP) values and to estimate the features of patients with lower LAS values. METHODS: A prospective, observational study was performed on patients with atrial fibrillation (AF) undergoing ablation. Detailed transthoracic echocardiography with the speckle tracking method was used to estimate the LAS reservoir (LASr) and direct measurements of LAP during ablation in all patients. RESULTS: A total of 172 patients were included (98 with sinus rhythm [SR] and 74 with AF). The patients with lower LASr (first tercile) compared to those with higher (third tercile), were older, more often female, presented with a larger left atrium (LA) (per the LA area and volume index), and had more impaired left ventricular (LV) diastolic function parameters (e', E/e'). The correlation analysis of the echocardiographic parameters with the LAP revealed the most significant correlations in the SR group, where the E/e' ratio, LASr, and LAS contraction (LASct) values were all associated with LAP. The cut-off value of LASr estimating high elevated mean LAP (≥15 mm Hg) was 21.88 (Area Under Curve [AUC], 0.81; 95% confidence interval [CI], 0.72-0.90; P <0.0001) for the SR group and 11.25 (AUC, 0.66; 95% CI, 0.53-0.80; P = 0.016) for the AF group. CONCLUSIONS: AF patients with lower LASr are older, more often female, have a larger LA, and have more impaired LV diastolic function. Low LASr and LASct and high E/e' ratio values are associated with higher LAP in AF patients with SR.

Symptomatic and Asymptomatic Patients in the Polish Atrial Fibrillation (POL-AF) Registry.

BACKGROUND: Atrial fibrillation (AF) can cause severe symptoms, but it is frequently asymptomatic. We aimed to compare the clinical features of patients with asymptomatic and symptomatic AF. METHODS: A prospective, observational, multicenter study was performed (the Polish Atrial Fibrillation (POL-AF) registry). Consecutive hospitalized AF patients over 18 years of age were enrolled at ten centers. The data were collected for two weeks during each month of 2019. RESULTS: A total of 2785 patients were analyzed, of whom 1360 were asymptomatic (48.8%). Asymptomatic patients were more frequently observed to have coronary artery disease (57.5% vs. 49.1%, p < 0.0001), heart failure with preserved ejection fraction (39.8% vs. 26.5%, p < 0.0001), a previous thromboembolic event (18.2% vs. 13.1%, p = 0.0002), and paroxysmal AF (52.3% vs. 45.2%, p = 0.0002). In multivariate analysis, history of electrical cardioversion, paroxysmal AF, heart failure, coronary artery disease, previous thromboembolic event, and higher left ventricular ejection fraction were predictors of a lack of AF symptoms. First-diagnosed AF was a predictor of AF symptoms. CONCLUSIONS: In comparison to symptomatic patients, more of those hospitalized with asymptomatic AF had been previously diagnosed with this arrhythmia and other cardiovascular diseases. However, they presented with better left ventricular function and were more frequently treated with cardiovascular medicines.

Evaluation of safety and the success rate of cryoballoon ablation of the pulmonary vein ostia in patients with atrial fibrillation--a preliminary report.

BACKGROUND: Cryoballon isolation of the pulmonary veins has recently emerged as a promissing technique for ablation of atrial fibrillation (AF). AIM: To present our initial experience in cryoballon isolatin of the pulmonary veins in patients with AF. METHODS: Eight patients (5 males; age 59+/-2 years) with AF: 2 with persistent and 6 with paroxysmal (5 of them after unsuccessful RF ablation) with >or=6 month follow-up after the procedure were included. One patient after myocardial infarction was treated with primary angioplasty with stent implantation. Another one had biatrial pacemaker. The procedure was performed with cryobaloon with 28 mm diameter (Arctic Front--Cryocath). After transseptal puncture mapping of the pulmonary vein ostia was performed with Lasso catheter (Johnson and Johnson). At each pulmonary vein ostium with pulmonary vein potentials 2 cryoapplications of 300 s duration was performed. Correct balloon placement before cryoapplication was checked using contrast injection into the pulmonary veins. During cryoapplication in the right pulmonary vein ostia permanent pacing of the phrenic nerve 30 beats per minute was performed to prevent its paralysis. After cryoapplications in all veins remapping with Lasso catheters was performed. In the absence of pulmonary vein potentials the procedure was finished, otherwise next cryoapplications were performed. During follow-up ECG was performed if any palpitations occurred, and 24-hour Holter monitoring was performed 1, 2 ,4, 6, 8, 10 and 12 months after the procedure. A 2-month blanking period after the procedure was used. The lack of symptomatic AF and the absence of AF>30 s on Holter ECG monitoring were defined as successful procedure. An improvement was defined as reduction of frequency/duration of AF paroxysm and reduction of the EHRA index>or=1. RESULTS: During 8 procedures isolation of 31 pulmonary vein was performed. Procedure duration was 3.5+/-0.85 h, fluoroscopy time--33.55+/-15.44 min, and total cryoapplication time--38.33+/-4.1 min. There were no complications. After the follow-up of 8.5+/-0.99 months 6 (75%) patients were free from arrhythmia, including the patient after myocardial infarction and one patient with permanent AF prior ablation. In another patient an improvement was observed (EHRA score II/III to I) whereas in one patient with permanent AF the procedure was unsuccessful. CONCLUSION: Cryoballoon ablation of pulmonary vein ostia is effective and safe, and can be an alternative to RF ablation. Easier procedure technique make possible shortening of the learning curve and increase the number of treated patients.

The value of the ablation index in patients undergoing ablation for atrial fibrillation.

BACKGROUND: Data on the results of ablation for atrial fibrillation (AF) in Poland are scarce. AIMS: The aim of the study was to compare the efficacy of ablation index (AI)-guided pulmonary vein isolation (PVI) with that of conventional contact force-based PVI. METHODS: Consecutive patients undergoing PVI for the first time were included in the study. A nonrandomized retrospective comparison was made between patients ablated with contact force before AI was introduced (non -AI group) and patients ablated with the use of AI (AI group). The AI threshold for the anterior wall / roof of left veins was 500 and 380 elsewhere. The maximal interlesion distance was 6 mm. The follow -up included outpatient visits and 7-day Holter monitoring 6 and 12 months after ablation. RESULTS: A total of 275 patients were included in the analysis: 133 in the AI group and 142 in the non--AI group. The duration of AF ablation was slightly longer in the AI group, but the fluoroscopy time and the radiofrequency ablation time were shorter in the same group. During the 12-month follow -up period, 25.8% and 40.6% of patients from the AI and non -AI groups, respectively, experienced recurrences (P = 0.02). The log -rank test with an extended follow -up period of up to 18 months confirmed the difference between the AI and non -AI groups, both in the whole group and in the paroxysmal AF and nonparoxysmal AF subgroups (P = 0.001, P = 0.04, and P = 0.006, respectively). CONCLUSION: The AI -based protocol provides a significant advantage over traditional contact force-based radiofrequency ablation in nonselected patients undergoing PVI.

Factors determining elective cardioversion preceded by transesophageal echocardiography: experiences of 2 cardiology centers.

INTRODUCTION: Although guidelines endorse cardioversion after adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE), the majority of patients still undergo this examination. OBJECTIVES: The aim of this study was to assess factors determining the decision to perform TEE in patients with atrial fibrillation (AF) who are eligible for elective cardioversion. PATIENTS AND METHODS: In this study, we evaluated the medical records of consecutive patients with AF who were admitted for elective cardioversion after prior NOAC treatment. RESULTS: Of a total of 668 patients included in the study, 362 individuals (54%) underwent TEE before cardioversion. In the univariable analysis, paroxysmal AF, hypertension, coronary artery disease (CAD), thromboembolic events, a history of percutaneous coronary intervention, a history of bleeding, left ventricular ejection fraction, left ventricular end­ diastolic diameter, a reduced dose of NOACs, hemoglobin levels, impaired renal filtration, and a high CHA2DS2­VASc score were significant predictors of the decision to perform TEE. In the multivariable logistic regression analysis, a history of CAD, bleeding, and stroke / transient ischemic attack / thromboembolism remained independent predictors of referring a patient for TEE (odds ratio [OR], 3.92, P <0.001; OR, 7.92, P <0.001; and OR, 2.36, P = 0.02, respectively). In contrast, paroxysmal AF (OR, 0.31; P = 0.02) and hypertension (OR, 0.28; P <0.001) were indicators of refraining from TEE. CONCLUSIONS: Transesophageal echocardiography before cardioversion was more frequently performed in patients with a history of CAD, bleeding, or thromboembolic events. Patients with paroxysmal AF and hypertension more often received cardioversion without prior TEE.