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.

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.

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.

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.

Serum microRNA in patients undergoing atrial fibrillation ablation.

MicroRNAs mediate posttranscriptional gene regulation. The aim of the study was to find a microRNA predictor of successful atrial fibrillation (AF) ablation. A total of 109 patients undergoing first-time AF ablation were included. Nineteen patients were selected to undergo serum microRNA sequencing (study group). The sequencing data were used to select several microRNAs that correlated with 12-month recurrences after AF ablation. Those microRNAs were validated by digital droplet PCR in samples from remaining 90 patients. All patients underwent pulmonary vein isolation (RF ablation, contact force catheter, electroanatomical system). The endpoint of the study was the 12-month AF recurrence rate; the overall recurrence rate was 42.5%. In total, levels of 34 miRNAs were significantly different in sera from patients with AF recurrence compared to patients without AF recurrence. Six microRNAs (miR-183-5p, miR-182-5p, miR-32-5p, miR-107, miR-574-3p, and miR-144-3p) were validated in the whole group. Data from the validation group did not confirm the observations from the study group, as no significant differences were found between miRNAs serum levels in patients with and without recurrences 12 months after AF ablation.

Predictors of appropriate interventions and mortality in patients with implantable cardioverter-defibrillators.

INTRODUCTION: Additional risk assessment in patients with heart failure referred for implantable cardioverter­defibrillator (ICD) implantation as primary prevention is needed. A reduction in left ventricular ejection fraction (LVEF) seems to lack sufficient sensitivity and specificity to be used for identification of patients at the highest risk of sudden cardiac death. OBJECTIVES: The aim of this study was to identify short- and long­term predictors of appropriate implantable cardioverter­defibrillator therapy as well as predictors of long­term mortality in patients with an ICD or cardiac resynchronization therapy defibrillator (CRT­D). PATIENTS AND METHODS: In this retrospective study, data from 457 patients who had an ICD or CRT­D implanted between 2011 and 2017 were analyzed. RESULTS: During the median follow­up of 31 months (interquartile range, 17-52 months), 153 patients died (33.9%) and 140 had appropriate interventions (31%). In a multivariate Cox regression analysis, implantation for secondary prevention (hazard ratio [HR], 2.49; P <0.001), severe mitral valve disease (HR, 2.17; P <0.001), and previous myocardial infarction (HR, 1.68; P = 0.009) were predictors of appropriate intervention. Resynchronization therapy (HR, 0.59; P = 0.025) and severe mitral valve disease (HR, 2.42; P <0.001) were predictors of appropriate intervention in primary prevention. Body mass index, hemoglobin concentrations, LVEF, diabetes, and left atrial diameter were significant predictors of death. CONCLUSIONS: Implantation of ICD or CRT­D as secondary prevention was a potent predictor of appropriate intervention, while resynchronization therapy and severe mitral regurgitation predicted ICD therapy in primary prevention. In patients with ICD or CRT-D, independent predictors of mortality included: body mass index, hemoglobin concentrations, LVEF, diabetes, and left atrial diameter.

Comparison of sinoatrial conduction time measured by Holter method and premature stimulation method.

BACKGROUND: The reliability of noninvasive Holter method for the calculation of sinoatrial conduction time (SACT) has not been confirmed by results of invasive electrophysiological studies of sinus nodal function. The aim of this study was to compare the values of SACT obtained by Holter method with values estimated by premature atrial stimulation method. METHODS: The study population consisted of 61 patients, in whom the 24-hour ambulatory ECG monitoring had shown the occurrence of atrial premature beats. All these subjects were undergoing electrophysiological study including programmed atrial and ventricular stimulation. The measurements of SACT were obtained using spontaneous atrial premature beats (Holter method) and high right atrial stimulation (Strauss method). RESULTS: There was a good correlation between measurements of SACT by Holter method and Strauss method (r = 0.79; P < 0.001). There was no significant difference between values of SACT estimated by two compared methods. However, in certain patients, there were appreciable differences and SACT measured using spontaneous premature beats was shorter in 34 and longer in 23 patients than that estimated by the Strauss method. The values of SACT calculated by Holter method and Strauss method were significantly (P < 0.001) higher in patients with sick sinus syndrome than in those without evidence of sinus node dysfunction. CONCLUSIONS: Good correlation between values of SACT obtained by two compared methods suggests that single measurement performed using Holter method may be adequate for reliable calculation of SACT.

Minimizing right ventricular pacing in patients with sinus node disease and prolonged PQ interval: The impact on exercise capacity.

BACKGROUND: Several clinical and experimental studies have shown that unnecessary right ventricular pacing in sinus node disease can be detrimental. Inter- and intra-ventricular asynchrony imposed by right ventricular pacing may cause reduction in contractility and relaxation of left ventricle, worsening mitral regurgitation, regional redistribution of myocardial perfusion and oxygen consumption, and asymmetrical hypertrophy of left ventricular wall. In some patients, sinus node disease coexists with impaired atrioventricular conduction. The optimal pacing mode in this population is not determined. Minimizing right ventricular pacing can preserve inter- and intra-ventricular synchrony. On the other hand, longer atrioventricular delay may cause atrioventricular asynchrony. The aim of this study was to prospectively assess the impact of minimizing right ventricular pacing in patients with DDD pacemaker implanted for sinus node disease and prolonged PQ interval on exercise capacity, cardiac function and quality of life. METHODS: The study enrolled 50 consecutive patients with prolonged PQ interval who were implanted with DDD pacemaker because of sinus node disease. Each patient was treated alternately with 2 pacing modes in random order for 4-month periods: conventional dualchamber pacing and dual-chamber minimal ventricular pacing (prolonged atrioventricular delay). At the end of each phase the following tests were performed: cardiopulmonary exercise testing, echocardiographic evaluation and quality of life assessment (SF36). RESULTS: There was no significant relationship between pacing mode and cardiopulmonary parameters, echocardiographic parameters and quality of life. CONCLUSIONS: Sequential atrioventricular pacing may be a reasonable choice for treating patients with sinus node disease and prolonged PQ interval.

Cognitive impairment after appropriate implantable cardioverter-defibrillator therapy for ventricular fibrillation.

BACKGROUND: Short periods of cerebral ischaemia during ventricular defibrillation testing may be associated with neuropsychological impairment. However, the impact of out-of-hospital ventricular fibrillation (VF) converted by implantable cardioverter-defibrillator (ICD) shock on cognitive functioning is unknown. AIM: To assess the impact of out-of-hospital VF converted by ICD shock on cognitive functioning. METHODS: The study included 52 primary prevention ICD recipients. Patients with a history of stroke or other neurological impairment, previous head injury and individuals unable to see or speak to complete neuropsychological tests were not included.Initially, a Mini-Mental State Examination was performed in all patients and one patient with a result below 24 points was excluded from the study. The cognitive battery consisted of four tests (six measurements): 1) the Digit Span subtest of Wechsler Adult Intelligence Scale-Revised; 2) the Digit Symbol subtest of Wechsler Adult Intelligence Scale-Revised; 3) the Halstead-Reitan Trail-Making Test A and B; and 4) the Ruff Figural Fluency Test. RESULTS: The mean time from ICD implantation to cognitive assessment was 26 months. During this period, 15 appropriate shocks for VF were observed in seven (14%) patients. The patients with appropriate ICD therapy were significantly worse in two out of the six neuropsychological measurements and had a significantly lower aggregate result. In multivariate linear regression analysis, defibrillation therapy was an independent factor of poor cognitive functioning, along with age and education. CONCLUSIONS: Short periods of out-of-hospital VF converted by ICD are associated with cognitive impairment in the recipients of primary prevention ICD.

Sleep-disordered breathing in patients with heart failure: new trends in therapy.

Heart failure (HF) is a growing health problem which paradoxically results from the advances in the treatment of etiologically related diseases (especially coronary artery disease). HF is commonly accompanied by sleep-disordered breathing (SDB), which may directly exacerbate the clinical manifestations of cardiovascular disease and confers a poorer prognosis. Obstructive sleep apnoea predominates in mild forms while central sleep apnoea in more severe forms of heart failure. Identification of SDB in patients with HF is important, as its effective treatment may result in notable clinical benefits to the patients. Continuous positive airway pressure (CPAP) is the gold standard in the management of SDB. The treatments for central breathing disorders include CPAP, bilevel positive airway pressure (BPAP), and adaptive servoventilation (ASV), with the latter being the most modern method of treatment for the Cheyne-Stokes respiration and involving ventilation support with a variable synchronisation dependent on changes in airflow through the respiratory tract and on the patient's respiratory rate. ASV exerts the most favourable effect on long-term prognosis. In this paper, we review the current state of knowledge on the diagnosis and treatment of SDB with a particular emphasis on the latest methods of treatment.

[Do the guidelines always show us the ideal treatment of patients for cardiac resynchronisation therapy?]. / Czy standardy zawsze wskazuja idealne postepowanie z chorymi kwalifikowanymi do terapii resynchronizujacej?

We present a case of 80-year-old man with chronic atrial fibrillation and heart failure with mildly depressed left ventricular ejection fraction who deteriorated after implantation of pacemaker to right ventricular apex. The patient improved when pacemaker was upgraded to resynchronisation therapy (CRT). The question is raised if CRT should have been implanted primarily.

Is haemodynamic evaluation with impedance cardiography in patients with heart failure undergoing testing of the implanted cardioverter-defibrillator of clinical importance?

BACKGROUND: Identification of individual factors associated with high defibrillation threshold (DFT) seems to be of high clinical importance. Impedance cardiography (ICG) may be used for non-invasive evaluation of the haemodynamic status. Whether ICG parameters may improve identification of patients with high DFT has not yet been examined. AIM: To evaluate clinical risk factors of high DFT including ICG parameters. METHODS: The study group included 69 patients with heart failure (aged 62.7 ± 9.5 years, NYHA class: I-III) selected for implantation of a cardioverter-defibrillator (ICD). Clinical assessment included physical examination, echocardiography and ICG monitoring before and after defibrillation. RESULTS: Initial defibrillation was unsuccessful in 17 (36.6%) patients. High DFT group was characterised by higher left ventricular end-diastolic diameter (LVEDD ≥ 5.6 cm: 100.0% vs 70.2%; p = 0.01), lower left ventricular ejection fraction (LVEF < 30%: 76.5% vs 44.7%; p = 0.024), higher baseline thoracic fluid content (one of ICG parameters) (TFC ≥ 35 1/kOhm: 29.4% vs 6.4%; p = 0.014) and more frequent amiodarone treatment (41.2% vs 14.9%; p = 0.025). A proposed algorithm based on predefined values of TFC, LVEF and LVEDD was shown to be effective in predicting high DFT (area under curve: 0.771). CONCLUSIONS: Risk factors of high DFT include left ventricular enlargement, low LVEF, high TFC and amiodarone treatment. An algorithm including TFC measurement by ICG increases the efficacy of identification of patients with high DFT.

Resolution of exercise oscillatory ventilation with adaptive servoventilation in patients with chronic heart failure and Cheyne-Stokes respiration: preliminary study.

BACKGROUND: Exercise oscillatory ventilation (EOV) is a common pattern of breathing in heart failure (HF) patients, and indicates a poor prognosis. AIM: To investigate the effects of adaptive servoventilation (ASV) on ventilatory response during exercise. METHODS: We studied 39 HF patients with left ventricular ejection fraction (LVEF) £ 45. Cardiorespiratory polygraphy, cardiopulmonary exercise testing (CPET), echocardiography, and measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration were performed. Twenty patients with Cheyne-Stokes respiration and apnoea-hypopnoea index (AHI) ≥ 15/h were identified. Of these, 11 patients were successfully titrated on ASV and continued therapy. In the third month of ASV treatment, polygraphy, CPET, echocardiography, and measurement of NT-proBNP concentration were performed again. RESULTS: The EOV was detected at baseline in 12 (31%) HF patients, including eight (67%) who underwent ASV. The EOV was associated with significantly lower LVEF, peak oxygen uptake (VO(2)), and ventilatory anaerobic threshold (VAT), and a significantly higher left ventricular diastolic diameter (LVDD), slope of ventilatory equivalent for carbon dioxide (VE/VCO(2)), AHI, central AHI and NT-proBNP concentration. In seven patients with EOV, reversal of EOV in the third month of ASV therapy was observed; only in one patient did EOV persist (p = 0.0156). CONCLUSIONS: The EOV can be reversed with ASV therapy. The EOV in association with central sleep apnoea and Cheyne- -Stokes respiration (CSA/CSR) is prevalent in HF patients and correlates with severity of the disease.

[Evaluation of motivation to quit smoking in outpatients attending smoking cessation clinic]. / Ocena motywacji do rzucenia palenia u pacjentów poradni antynikotynowej.

INTRODUCTION: The success in smoking cessation depends not only on a method of treatment but also on patient motivation. The aim of this study was to estimate the motivation and the main reason to quit smoking among outpatients attending smoking cessation clinic. MATERIAL AND METHODS: One hundred and eleven patients (50 men and 61 women), mean age 58, filled in a motivation test, nicotine dependence test and a questionnaire of the clinic. RESULTS: The main motivation to quit was for the health reasons (83%). Mean motivation test result was 6.93; mean nicotine addiction evaluated in dependence test was 5.49. Eighty seven percent of patients were ready to quit smoking during one month (36% in 24 hours; 23% in one week; 28% in four weeks). There was no significant difference between men and women. CONCLUSIONS: The main motivation to quit smoking were the health reasons as well among men as women. There was no correlation between the readiness to quit smoking determined as time to quit attempt and the motivation test.

[Inappropriate therapy of an implantable cardioverter-defibrillator--is it always an undesired event? A case report]. / Nieuzasadnione wyladowanie wszczepialnego kardiowertera-defibrylatora--dzialanie niepozadane czy pozadane?

Inappropriate implantable cardioverter defibrillator (ICD) therapy is the commonest adverse event in patients with ICD. We present a case of sinus rhythm restoration after an inappropriate shock in a man with permanent atrial fibrillation and dilated cardiomyopathy. During follow-up, clinical improvement has been observed.