Outcomes of ventricular tachycardia ablation in patients with ischemic and non-ischemic cardiomyopathy: A propensity-score matched analysis.

INTRODUCTION AND OBJECTIVES: Catheter ablation (CA) is effective in the treatment of ventricular tachycardia (VT). Although some observational data suggest patients with non-ischemic cardiomyopathy (NICM) have less favorable outcomes when compared to those with an ischemic etiology (ICM), direct comparisons are rarely reported. We aimed to compare the outcomes of VT ablation in a propensity-score matched population of ICM or NICM patients. METHODS: Single-center retrospective study of consecutive patients undergoing VT ablation from 2012 to 2023. A propensity score (PS) was used to match ICM and NICM patients in a 1:1 fashion according to age, sex, left ventricular ejection fraction (LVEF), NYHA class, electrical storm (ES) at presentation, and previous endocardial ablation. The outcomes of interest were VT-free survival and all-cause mortality. RESULTS: The PS yielded two groups of 71 patients each (mean age 63±10 years, 92% male, mean LVEF 35±10%, 36% with ES at presentation, and 23% with previous ablation), well matched for baseline characteristics. During a median follow-up of 2.3 (interquartile range IQR 1.3-3.8) years, patients with NICM had a significantly lower VT-free survival (53.5% vs. 69.0%, log-rank p=0.037), although there were no differences regarding all-cause mortality (22.5% vs. 16.9%, log-rank p=0.245). Multivariate analysis identified NICM (HR 2.34 [95% CI 1.32-4.14], p=0.004), NYHA class III/IV (HR 2.11 [95% CI 1.11-4.04], p=0.024), and chronic kidney disease (HR 2.23 [95% CI 1.25-3.96], p=0.006), as independent predictors of VT recurrence. CONCLUSION: Non-ischemic cardiomyopathy patients were at increased risk of VT recurrence after ablation, although long-term mortality did not differ.

Bradyarrhythmia in a marathonist: Cardiac vagal denervation as alternative treatment.

Although not routinely used, cardioneuroablation or modulation of the cardiac autonomic nervous system has been proposed as an alternative approach to treat young individuals with enhanced vagal tone and significant atrioventricular (AV) disturbances. We report the case of a 42-year-old athlete with prolonged ventricular pauses associated with sinus bradycardia and paroxysmal episodes of AV block (maximum of 6.6 s) due to enhanced vagal tone who was admitted to our hospital for pacemaker implantation. Cardiac magnetic resonance and stress test were normal. Although he was asymptomatic, safety concerns regarding possible neurological damage and sudden cardiac death were raised, and he accordingly underwent electrophysiological study (EPS) and cardiac autonomic denervation. Mapping and ablation were anatomically guided and radiofrequency pulses were delivered at empirical sites of ganglionated plexi. Modulation of the parasympathetic system was confirmed through changes in heart rate and AV nodal conduction properties associated with a negative cardiac response to atropine administration. After a follow-up of nine months, follow-up 24-hour Holter revealed an increase in mean heart rate and no AV disturbances, with rare non-significant ventricular pauses, suggesting that this technique may become a safe and efficient procedure in this group of patients.

Outcomes of a combined vs non-combined endo-epicardial ventricular tachycardia ablation strategy.

BACKGROUND: Direct comparisons of combined (C-ABL) and non-combined (NC-ABL) endo-epicardial ventricular tachycardia (VT) ablation outcomes are scarce. We aimed to investigate the long-term clinical efficacy and safety of these 2 strategies in ischemic heart disease (IHD) and non-ischemic cardiomyopathy (NICM) populations. METHODS: Multicentric observational registry included 316 consecutive patients who underwent catheter ablation for drug-resistant VT between January 2008 and July 2019. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-day mortality and procedure-related complications. RESULTS: Most of the patients were male (85%), with IHD (67%) and mean age of 63 ± 13 years. During a mean follow-up of 3 ± 2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified electrical storm (ES) at presentation, IHD, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class III / IV, and C-ABL as independent predictors of VT recurrence. In 135 patients undergoing repeated procedures, only C-ABL and ES were independent predictors of relapse. The identified independent predictors of mortality were C-ABL, ES, LVEF, age, and NYHA class III / IV. C-ABL survival benefit was only seen in patients with a previous ablation (P for interaction = 0.04). Mortality at 30 days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P = 0.777), as was complication rate (10.3% vs. 15.1%, respectively, P = 0.336). CONCLUSION: A combined or sequential endo-epicardial VT ablation strategy was associated with lower VT recurrence and lower all-cause death in IHD and NICM patients undergoing repeated procedures. Both approaches seemed equally safe.

Relação entre Gordura Epicárdica e Fibrilação Atrial Não Pode Ser Totalmente Explicada pela Fibrose Atrial Esquerda / The Relationship between Epicardial Fat and Atrial Fibrillation Cannot Be Fully Explained by Left Atrial Fibrosis

Resumo Fundamento O tecido adiposo epicárdico (TAE) tem sido associado à fibrilação atrial (FA), mas seus mecanismos fisiopatológicos permanecem obscuros. Objetivos Medir a correlação entre TAE e fibrose do átrio esquerdo (AE), e avaliar sua capacidade de prever recidiva após o isolamento da veia pulmonar (IVP). Métodos Pacientes com FA inscritos para um primeiro procedimento de IVP foram submetidos à tomografia computadorizada (TC) cardíaca e ressonância magnética cardíaca (RMC) em menos de 48 horas. Quantificou-se o TAECE em imagens de TC realçadas com contraste no nível do tronco da coronária esquerda. Quantificou-se a fibrose do AE em RMC tridimensional com realce tardio isotrópico de 1,5 mm. Após o isolamento da veia pulmonar (IVP), os pacientes foram submetidos a seguimento para checar a recidiva da FA. A significância estatística foi definida com p<0,05. Resultados A maioria dos 68 pacientes (46 homens, idade 61±12 anos) tinha FA paroxística (71%, n=48). Os pacientes apresentavam volume TAECE mediano de 2,4 cm3/m2 (intervalo interquartil [IIQ] 1,6-3,2 cm3/m2) e um volume médio de fibrose do AE de 8,9 g (IIQ 5-15 g). A correlação entre TAECE e fibrose do AE foi estatisticamente significativa, mas fraca (coeficiente de correlação de postos de Spearman = 0,40, p=0,001). Durante um seguimento médio de 22 meses (IIQ 12-31), 31 pacientes (46%) tiveram recidiva da FA. A análise multivariada produziu dois preditores independentes de recidiva da FA: TAECE (FC 2,05, IC de 95% 1,51-2,79, p<0,001) e FA não paroxística (FC 2,36, IC de 95% 1,08-5,16, p=0,031). Conclusão A correlação fraca entre TAE e AE sugere que a fibrose do AE não é o principal mecanismo que liga o TAE e a FA. O TAE mostrou-se mais fortemente associado à recidiva da FA do que à fibrose do AE, corroborando a existência de outros mediadores mais importantes do TAE e da FA.

Abstract Background Epicardial adipose tissue (EAT) has been associated with atrial fibrillation (AF), but its pathophysiological mechanisms remain unclear. Objectives To measure the correlation between EAT and left atrium (LA) fibrosis, and to assess their ability to predict relapse after pulmonary vein isolation (PVI). Methods Patients with AF enrolled for a first PVI procedure underwent both cardiac computerized tomography (CT) and cardiac magnetic resonance (CMR) imaging within less than 48 hours. EATLMwas quantified on contrast-enhanced CT images at the level of the left main. LA fibrosis was quantified on isotropic 1.5 mm 3D delayed enhancement CMR. After pulmonary vein isolation (PVI), patients were followed up for AF relapse. Statistical significance was set at p<0.05. Results Most of the 68 patients (46 men, age 61±12 years) had paroxysmal AF (71%, n=48). Patients had a median EATLMvolume of 2.4 cm3/m2(interquartile range [IQR] 1.6-3.2 cm3/m2), and a median amount of LA fibrosis of 8.9 g (IQR 5-15 g). The correlation between EATLMand LA fibrosis was statistically significant but weak (Spearman's R=0.40, p=0.001). During a median follow-up of 22 months (IQR 12-31), 31 patients (46%) had AF relapse. Multivariate analysis yielded two independent predictors of AF relapse: EATLM(HR 2.05, 95% CI 1.51-2.79, p<0.001), and non-paroxysmal AF (HR 2.36, 95% CI 1.08-5.16, p=0.031). Conclusion The weak correlation between EAT and LA suggests that LA fibrosis is not the main mechanism linking EAT and AF. EAT was more strongly associated with AF relapse than LA fibrosis, supporting the existence of other more important mediators of EAT and AF.

The Relationship between Epicardial Fat and Atrial Fibrillation Cannot Be Fully Explained by Left Atrial Fibrosis. / Relação entre Gordura Epicárdica e Fibrilação Atrial Não Pode Ser Totalmente Explicada pela Fibrose Atrial Esquerda.

BACKGROUND: Epicardial adipose tissue (EAT) has been associated with atrial fibrillation (AF), but its pathophysiological mechanisms remain unclear. OBJECTIVES: To measure the correlation between EAT and left atrium (LA) fibrosis, and to assess their ability to predict relapse after pulmonary vein isolation (PVI). METHODS: Patients with AF enrolled for a first PVI procedure underwent both cardiac computerized tomography (CT) and cardiac magnetic resonance (CMR) imaging within less than 48 hours. EATLMwas quantified on contrast-enhanced CT images at the level of the left main. LA fibrosis was quantified on isotropic 1.5 mm 3D delayed enhancement CMR. After pulmonary vein isolation (PVI), patients were followed up for AF relapse. Statistical significance was set at p<0.05. RESULTS: Most of the 68 patients (46 men, age 61±12 years) had paroxysmal AF (71%, n=48). Patients had a median EATLMvolume of 2.4 cm3/m2(interquartile range [IQR] 1.6-3.2 cm3/m2), and a median amount of LA fibrosis of 8.9 g (IQR 5-15 g). The correlation between EATLMand LA fibrosis was statistically significant but weak (Spearman's R=0.40, p=0.001). During a median follow-up of 22 months (IQR 12-31), 31 patients (46%) had AF relapse. Multivariate analysis yielded two independent predictors of AF relapse: EATLM(HR 2.05, 95% CI 1.51-2.79, p<0.001), and non-paroxysmal AF (HR 2.36, 95% CI 1.08-5.16, p=0.031). CONCLUSION: The weak correlation between EAT and LA suggests that LA fibrosis is not the main mechanism linking EAT and AF. EAT was more strongly associated with AF relapse than LA fibrosis, supporting the existence of other more important mediators of EAT and AF.

FUNDAMENTO: O tecido adiposo epicárdico (TAE) tem sido associado à fibrilação atrial (FA), mas seus mecanismos fisiopatológicos permanecem obscuros. OBJETIVOS: Medir a correlação entre TAE e fibrose do átrio esquerdo (AE), e avaliar sua capacidade de prever recidiva após o isolamento da veia pulmonar (IVP). MÉTODOS: Pacientes com FA inscritos para um primeiro procedimento de IVP foram submetidos à tomografia computadorizada (TC) cardíaca e ressonância magnética cardíaca (RMC) em menos de 48 horas. Quantificou-se o TAECE em imagens de TC realçadas com contraste no nível do tronco da coronária esquerda. Quantificou-se a fibrose do AE em RMC tridimensional com realce tardio isotrópico de 1,5 mm. Após o isolamento da veia pulmonar (IVP), os pacientes foram submetidos a seguimento para checar a recidiva da FA. A significância estatística foi definida com p<0,05. RESULTADOS: A maioria dos 68 pacientes (46 homens, idade 61±12 anos) tinha FA paroxística (71%, n=48). Os pacientes apresentavam volume TAECE mediano de 2,4 cm3/m2 (intervalo interquartil [IIQ] 1,6­3,2 cm3/m2) e um volume médio de fibrose do AE de 8,9 g (IIQ 5­15 g). A correlação entre TAECE e fibrose do AE foi estatisticamente significativa, mas fraca (coeficiente de correlação de postos de Spearman = 0,40, p=0,001). Durante um seguimento médio de 22 meses (IIQ 12­31), 31 pacientes (46%) tiveram recidiva da FA. A análise multivariada produziu dois preditores independentes de recidiva da FA: TAECE (FC 2,05, IC de 95% 1,51­2,79, p<0,001) e FA não paroxística (FC 2,36, IC de 95% 1,08­5,16, p=0,031). CONCLUSÃO: A correlação fraca entre TAE e AE sugere que a fibrose do AE não é o principal mecanismo que liga o TAE e a FA. O TAE mostrou-se mais fortemente associado à recidiva da FA do que à fibrose do AE, corroborando a existência de outros mediadores mais importantes do TAE e da FA.

Persistent Left Superior Vena Cava: A Finding After Central Venous Catheterization.

INTRODUCTION: Persistence of the left superior vena cava (LSVC) is a rare anatomical variant in the general population, with an estimated incidence of 0.3-0.5% in healthy individuals. It may be diagnosed incidentally after imaging control of the placement of a central venous catheter (CVC) or other device. PATIENT AND METHODS: We present the case of a patient with acute disease who required central venous catheterization for the administration of intravenous chemotherapy. RESULTS: Central venous catheterization proved difficult and imaging control revealed the catheter tip in an unusual position. Computed tomography to verify the catheter tip position revealed the presence of a persistent left superior vena cava. The patient then underwent the planned treatment with no complications associated with the CVC. CONCLUSION: Although uncommon, persistence of the LSVC can have a significant impact in clinical practice, particularly when invasive procedures are required. Its recognition is important in order to minimize the potential complications inherent to such procedures. LEARNING POINTS: Persistence of the left superior vena cava is an uncommon anatomical variant of the central venous vascular anatomy.It is generally asymptomatic, and its diagnosis is often incidentally made after certain procedures (central venous catheterization).Diagnosis through chest x-ray alone is difficult and should be complemented with transthoracic echocardiography and computed tomography in order to minimize the complications inherent to central venous catheterization.

A new electrophysiologic triad for identification and localization of the critical isthmus in atrial flutter.

INTRODUCTION: Atypical atrial flutter (AFL) is a supraventricular arrhythmia that can be treated with catheter ablation. However, this strategy yields suboptimal results and the best approach is yet to be defined. Carto® electroanatomical mapping (EAM) version 7 displays a histogram of the local activation times (LAT) of the tachycardia cycle length (TCL), in addition to activation and voltage maps. Using these EAM tools, the study aimed to assess the ability of an electrophysiologic triad to identify and localize the critical isthmus in AFL. METHODS: Retrospective analysis using Carto® EAM of a single center registry of individuals who underwent left AFL ablation over one year. Subjects with non-left AFL, no high-density EAM, under 2000 points or no left atrium wall or structure mapping were excluded. Sites where arrhythmia is terminated via ablation were compared to an electrophysiologic triad comprising areas of low-voltage (0.05 to 0.3 mV), deep histogram valleys (LAT-valleys) with less than 20% density points relative to the highest density zone and a prolonged LAT-valley duration, which included 10% or more of the TCL. The longest LAT-valley was designated as the primary valley, while additional valleys were named as secondary. RESULTS: A total of nine subjects (six men, median age 75, interquartile range 71-76 years) were included. All patients presented with left AFL and 66% had a history of ablation for atrial fibrillation and/or flutter. The median TCL and collected points were 254 ms (220-290) and 3300 (IQR 2410-3926) points, respectively. All individuals with AFL presented with at least one LAT-valley on the analyzed histograms, which corresponded to heterogeneous low voltage areas (0.05 to 0.3 mV) and affected more than 10% of TCL. Six of the nine patients presented with a secondary LAT-valley. All arrhythmias were terminated successfully following radiofrequency ablation at the primary LAT-valley location. After a minimum three-month follow-up all patients remained in sinus rhythm. CONCLUSION: An electrophysiologic triad identified the critical isthmus in AFL for all patients. Further studies are needed to assess the usefulness of this algorithm in improving catheter ablation outcomes.

Analysis of a 10-year period of lead removal in a referral centre.

OBJECTIVES: Our goal was to analyse all lead extraction procedures (transvenous or open surgery) performed in our centre and the short- and long-term follow-up data from these patients. METHODS: All lead extractions performed from 2008 to 2017 were retrospectively reviewed for patient characteristics and indications for device implantation; indications for lead extraction; techniques used; peri- and postprocedural complications and short- and long-term follow-up data. RESULTS: A total of 159 patients (282 leads) were included [age 70 (62-78) years; 72% men]. The median follow-up time was 57 (25-90) months. Patients with lead explants were excluded. The most common indication for lead removal was infection (77%). A surgical approach was necessary in 14 patients (9%) owing to unsuccessful transvenous removal (n = 3), large vegetation in the lead (n = 4), concomitant valvular endocarditis (n = 2), other indications for open surgery (n = 4) and complicated transvenous removal (n = 1). Removal was tried for 282 leads. Of those, 256 were completely removed. Clinical success was achieved in 155 individual patients (98%). Complications occurred in 6 patients: 3 persistent infections, 1 stroke and 2 blood vessel ruptures. The procedure-related mortality rate was 2% (n = 3). CONCLUSIONS: Lead removal was associated with a high success rate and low all-cause complication and mortality rates. Emergency surgery because of acute complications was rare, and open-heart surgery was most frequently elective and not associated with a worse outcome.

Implantable Cardioverter-Defibrillators in Trials of Drug Therapy for Heart Failure: A Systematic Review and Meta-Analysis.

BACKGROUND Medical therapy for heart failure with reduced ejection fraction evolved since trials validated the use of implantable cardioverter-defibrillators (ICDs). We sought to evaluate the performance of ICDs in reducing mortality in the era of modern medical therapy by means of a systematic review and meta-analysis of contemporary randomized clinical trials of drug therapy for heart failure with reduced ejection fraction. METHODS AND RESULTS We systematically identified randomized clinical trials that evaluated drug therapy in patients with heart failure with reduced ejection fraction that reported mortality. Studies that enrolled <1000 patients, patients with left ventricular ejection fraction >40%, or patients in the acute phase of heart failure and study treatment with devices were excluded. We identified 8 randomized clinical trials, including 31 701 patients of whom 3631 (11.5%) had an ICD. ICDs were associated with a lower risk of all-cause mortality (relative risk [RR], 0.85; 95% CI, 0.78-0.94) and sudden cardiac death (RR, 0.49; 95% CI, 0.40-0.61). Results were consistent among studies published before and after 2010. In meta-regression analysis, the proportion of nonischemic etiology did not affect the associated benefit of ICD. CONCLUSIONS In our meta-analysis of contemporary randomized trials of drug therapy for heart failure with reduced ejection fraction, the rate of ICD use was low and associated with a decreased risk in both all-cause mortality and sudden cardiac death. This benefit was still present in trials with new medical therapy.

Pacemaker lead as an iatrogenic cause of right heart failure: Case report. / Electrocatéter como causa iatrogénica de insuficiência cardíaca direita ­ relato de um caso.

Technical advances in health care have improved patient survival and quality of life, but are not devoid of complications. We present the case of a 74-year-old woman with a history of hypertensive heart disease with preserved systolic function, atrial fibrillation and dyslipidemia. She had a DDDR pacemaker implanted in 2005 due to symptomatic complete atrioventricular block. The patient reported progressive fatigue, weakness, ascites with abdominal discomfort, and lower limb edema, accompanied by non-specific hepatic cholestasis on biochemical testing. Abdominal ultrasound revealed homogeneous hepatomegaly and dilatation of the inferior vena cava and upper hepatic veins, suggestive of congestive hepatopathy. Echocardiography revealed tricuspid regurgitation progressively worsening over the previous four years and dilatation and progressive dysfunction of the right ventricle, with preserved left ventricular function. The transesophageal echocardiogram revealed severe tricuspid regurgitation with flail septal leaflet and marked dilatation of the tricuspid annulus due to mechanical interference of the pacemaker lead, which was adhering to the septal leaflet. Minimally invasive surgical treatment was performed with partial resection of the leaflet, placement of a tricuspid annuloplasty ring and replacement of the pacemaker lead. Regression of the congestive symptoms was observed, and the postoperative echocardiogram showed the tricuspid annuloplasty ring with no evidence of stenosis and only slightly dilated right chambers with moderate pulmonary hypertension. Six months after the procedure, the patient suffered an acute neurological event and died.

Ascites in a Young Woman: A Rare Presentation of Eosinophilic Gastroenteritis.

INTRODUCTION: Eosinophilic gastroenteritis (EGE) is a rare idiopathic disease that can affect one or more organs of the digestive tract. It has an estimated incidence of 1-20 cases per 100,000 patients. Klein et al. classified EGE into 3 subtypes: predominant mucosal, muscular, or subserosal. CLINICAL CASE: We report a case of a 32-year-old woman, who presented with diffuse abdominal pain, nausea, postprandial infarction, diarrhea, and moderate ascites of three-week evolution. The rest of physical examination did not show alterations. The past medical history was unremarkable. Laboratory test results revealed peripheral blood eosinophilia. Abdominal CT scan revealed diffuse and concentric parietal thickening of the distal 2/3 of esophagus, moderate volume ascites, and small bowel wall thickening and distension on the left quadrants. The paracentesis revealed 93.3% of eosinophils. The colon biopsies evidenced an increase in the number of eosinophils. Secondary causes of eosinophilia were excluded. The patient was treated with oral prednisolone 40 mg/day with immediate clinical and analytical improvement. CONCLUSION: Eosinophilic gastroenteritis is a rare condition with a nonspecific and highly variable clinical presentation, which requires a high level of clinical suspicion. It is a diagnosis of exclusion. Secondary causes of eosinophilia such as intestinal tuberculosis, parasitosis, and malignant neoplasms should be excluded.

Very long-term outcomes after a single catheter ablation procedure for the treatment of atrial fibrillation-the protective role of antiarrhythmic drug therapy.

BACKGROUND: Pulmonary vein isolation (PVI) is the cornerstone of AF ablation, but its long-term clinical outcomes, predictors of relapse, and optimal pharmacological treatment remain controversial. OBJECTIVE: The objectives of this paper were to (1) assess very long-term AF recurrence, (2) identify predictors of relapse, and (3) evaluate the impact of continued antiarrhythmic drug (AAD) treatment after ablation. METHODS: Multicenter observational registry including all consecutive patients with drug-resistant AF who underwent a first PVI between 2006 and 2008 (n = 253 (age 55 years (IQR 48-63)), 80% males, 64% with paroxysmal AF. Endpoint was AF/AT/AFL relapse after a 3-month blanking period. Predictors and protective factors of AF relapse were assessed with multivariate Cox regression. RESULTS: A total of 144 patients (57%) relapsed over a median 5-year (IQR 2-9) follow-up-annual relapse rate of 10%/year. Female sex (aHR 1.526, 95% CI 1.037-2.246, P = 0.032), non-paroxysmal AF (aHR 1.410, 95% CI 1.000-1.987, P = 0.050), and LA volume/BSA (aHR 1.012, 95% CI 1.003-1.021, P = 0.008) were identified as independent predictors of relapse. A total of 139 patients (55%) continued AAD (55% on amiodarone) after blanking period. One-year overall PVI success rate of patients under AAD was 86 vs 76% with no AAD (P < 0.001)-annual relapse rates were 8%/year vs 14%/year (P < 0.001), respectively. AAD was associated with a long-term reduction in AF relapse (aHR 0.673, 95% CI 0.509-0.904 P = 0.004). CONCLUSION: Half the patients remained free from AF 5 years after a single procedure. Female sex, non-paroxysmal AF, and LA volume/BSA independently predicted recurrence, whereas continuing AAD after the 3-month blanking period reduced relapse. In a multicenter registry of AF patients undergoing a first PVI, 57% relapsed over a median 5-year follow-up. Female sex, non-paroxysmal AF and LA volume/BSA were identified as independent predictors of relapse. Maintaining AAD therapy after the blanking period was associated with a long-term reduction in AF relapse.

Impact of prophylactic cavotricuspid isthmus ablation in atrial fibrillation recurrence after a first pulmonary vein isolation procedure.

INTRODUCTION: PVI is a well-established therapy for patients with drug refractory atrial fibrillation (AF). However, it remains unclear whether prophylactic cavotricuspid isthmus (CTI) ablation at the time of PVI improves long-term freedom from AF. OBJECTIVE: To compare the outcomes of patients who underwent PVI alone vs. PVI + prophylactic CTI ablation. METHODS: Propensity score (PS) matching analysis based on a registry dataset of 1931 consecutive patients who underwent a first AF catheter ablation. After excluding those with documented/inducible atrial flutter (n = 233), 1698 individuals were available for matching. Following adjustment for age, gender, body mass index (BMI), hypertension, smoking, diabetes, LA volume, type of AF, and type of navigation (magnetic vs. manual), PS matched 411 patients who underwent PVI + CTI ablation with 411 receiving PVI alone. RESULTS: PS analysis yielded a study population of 822 matched patients (58 ±â€¯11 years, 69% males, 64% with paroxysmal AF). Over a median 2 years follow-up period there were 278 AF recurrences (34%). Survival free of AF (Log rank p = .965) and annual relapse rates were similar in the two groups - 10.9%/year vs 10.1%/year (PVI vs PVI + CTI, respectively, p = .97). CTI ablation remained unassociated with AF-free survival (HR 1.09, 95%CI: 0.84-1.41, p = .54) after Cox regression adjustment for age, sex, type of AF, LA volume, hypertension, diabetes, BMI and center. Female gender, current smoking, indexed LA volume and non-paroxysmal AF were identified as independent predictors of relapse after matching. CONCLUSIONS: Prophylactic CTI ablation at the time of a first PVI does not seem to improve long-term freedom from AF.

Development and validation of a risk score for predicting atrial fibrillation recurrence after a first catheter ablation procedure - ATLAS score.

Aims: Several predictors of relapse after catheter ablation of atrial fibrillation (AF) have been established, but assessing each patient's individual risk remains challenging. Our aim was to develop and validate a score to estimate the risk of AF recurrence after the first radiofrequency pulmonary vein isolation (PVI) procedure. Methods and results: Independent predictors of AF relapse were identified retrospectively in a two-centre registry of 1934 patients who underwent a first PVI procedure. Using the Cox regression hazard ratios of designated variables, a risk score was developed in a random sample of 50% of the patients (development cohort) and validated in the remaining (validation cohort) half. The accuracy and discriminative power of the predictive model were assessed in both subgroups. During a follow-up of 4.2 ± 2.7 years, 522 patients (27%) relapsed. Five independent predictors of AF recurrence were identified and included in the score: age >60 years (1 point), female sex (4 points), non-paroxysmal AF (2 points), current smoking (7 points) and indexed left atrial volume (1 point for each 10 mL/m2). The score showed good discriminative power (censored c-statistic of 0.75 in both cohorts). In the development group, AF relapse rates were 8, 11, and 17%/year for low (<6 points), intermediate (6-10 points), and high-risk patients (>10 points), respectively (P < 0.001). In the validation group, AF recurrence rates were 8, 11, and 18%/year, respectively (P < 0.001). Conclusion: A simple risk score to estimate the rate of AF recurrence after ablation was developed and validated. An external assessment of its usefulness as a patient selection tool seems warranted.

Brugada syndrome is associated with scar and endocardial involvement: Insights from high-density mapping with the Rhythmia™ mapping system.

The authors report the first catheter ablation of Brugada syndrome in the literature using the Rhythmia™ mapping system. Learning points include: (1) low voltage areas can be documented while mapping in some individuals, suggesting that Brugada syndrome may not be a pure ion channel disorder; (2) typical long fractionated potentials can also be identified in the endocardium, supporting the need to map the endocardium in all Brugada patients requiring ablation; (3) disappearance of the typical coved pattern following ablation does not necessarily predict cure, as the patient we present experienced ventricular fibrillation recurrence a few months later.

Non-vitamin K antagonist oral anticoagulants compared with warfarin at different levels of INR control in atrial fibrillation: A meta-analysis of randomized trials.

BACKGROUND: The efficacy and safety of warfarin for stroke prevention in atrial fibrillation (AF) depend on the time in the therapeutic range (TTR) with an international normalised ratio (INR) of 2.0-3.0. This meta-analysis focused the relative efficacy and safety of non-VKA oral anticoagulants (NOAC) compared with warfarin at different thresholds of centre's TTR (cTTR). METHODS: We searched PubMed, Embase, CENTRAL and websites of regulatory agencies, limiting searches to randomized phase 3 trials. Primary outcomes were stroke or systemic embolism (SSE) and major or non-major clinically relevant (NMCR) bleeding. We used a random-effects model to pool effect on outcomes according to different thresholds of cTTR. RESULTS: Four TTR sub-studies with a total of 71,222 patients were included. The benefit of NOAC in reducing SSE compared with warfarin was significantly higher in patients at cTTR<60% (HR 0.79, 95% CI 0.68-0.90) and at 60% to <70% (0.82, 0.71-0.95) but not at ≥70% (1.00, 0.82-1.23) with a significant interaction for cTTR<70% or ≥70% (p=0.042). The risk of major or NMCR bleeding was significantly lower with NOAC as compared with warfarin in patients at all sub-groups (0.67, 0.54-0.83 for patients at cTTR<60% and 0.75, 0.63-0.89 at 60% to <70%) except for cTTR≥70% (HR 0.84, 0.64-1.11), but the interaction for cTTR<70% or ≥70% was not statistically significant (p=0.271). CONCLUSIONS: The superiority in efficacy of NOAC compared with warfarin for stroke prevention is lost above a cTTR threshold of approximately 70%, but the relative safety appears to be less modified by the centre-based quality of INR control.

Relationship between rotors and complex fractionated electrograms in atrial fibrillation using a novel computational analysis.

INTRODUCTION: Rotors and complex fractionated atrial electrograms (CFAEs) have been suggested as possible therapeutic targets in ablation of atrial fibrillation (AF). The aim of this study was to assess the relationship between rotors and CFAEs in patients with AF. METHODS: We studied 18 patients with AF (mean age 69±8 years, 33% female) who underwent rotor ablation and pulmonary vein isolation. Endocardial mapping was performed with a basket catheter to identify the presence, number and location of rotors and CFAEs. The FIRM™ (Abbott) and CARTO™ (Biosense) systems were used with overlapping of frames from continuous 30-s recordings. CFAEs were classified as stable if present in >15 frames, moderately stable if present in 10-15 frames and unstable if present in 5-9 frames. RESULTS: A total of 44 rotors and 60 CFAEs (39 of them stable) were identified. The mean number of rotors and stable CFAEs per patient was 2.6±1.4 and 2.2±1.5, respectively. In 27 of the 44 identified rotors, CFAEs were found in the same location. Conversely, in 20 of the 39 stable CFAEs identified, a focal rotor was found in the same location. The majority of CFAEs found at the same location as a focal rotor were stable (63% vs. 37%, p=0.001). CONCLUSION: Rotors and CFAEs are frequently found in the same location within the atria, particularly when only stable CFAEs are considered. This relationship may have implications in the selection of substrate targets for ablation.