Early rhythm control vs. rate control in atrial fibrillation: A systematic review and meta-analysis.

Objective: It has long been debated whether rhythm control vs. rate control strategies have differing effects on mortality and morbidity for atrial fibrillation (AF). Recently, several randomized controlled studies (RCTs) and observational trials described that an early rhythm management method was linked to a lower likelihood of negative clinical outcomes in individuals with AF. We wanted to see if an early rhythm management method may help patients with AF. Methods: We performed a systematic search to retrieve studies assessing the outcomes of early rhythm control vs. rate control in AF by using PubMed, Web of Science, Cochrane Library, and Embase published between 01/01/2000 and 15/04/2022. Results: Finally, two RCTs, one retrospective analysis of RCTs, and four observational studies were identified. Compared with rate control, early rhythm control has been linked to lower all-cause mortality. [risk ratio (RR), 0.76; 95% CI 0.69-0.83; P < 0.00001; I 2 = 77%]. The early rhythm control group was also associated with a lower risk of cardiovascular mortality (RR, 0.68; 95% CI 0.63-0.74; P < 0.00001; I 2 = 33), stroke (RR, 0.77; 95% CI 0.67-0.87; P < 0.001; I 2 = 64), and heart failure hospitalization (RR, 0.74; 95% CI 0.59-0.93; P = 0.0009; I 2 = 93%). We found no significant difference in nights spent in hospital per year, acute coronary syndrome, major bleeding, and cardiac arrest/ventricular arrhythmia between the groups. Conclusion: In this meta-analysis, early rhythm therapy was linked to a lower risk of all-cause mortality, cardiovascular mortality, stroke, and heart failure hospitalization compared with the rate control group. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022333592.

Left atrial appendage function and structure predictors of recurrent atrial fibrillation after catheter ablation: A meta-analysis of observational studies.

Background: The results of studies evaluating the left atrial appendage (LAA) function and structure as predictors of atrial fibrillation (AF) recurrence after catheter ablation (CA) are contradictory. Therefore, we performed a meta-analysis to assess whether the LAA function and structure can predict the recurrence of AF after CA. Methods: The PubMed, EMBASE, Web of Science, and Cochrane library databases were used to conduct a comprehensive literature search. Finally, 37 studies encompassing 11 LAA parameters were included in this meta-analysis. Results: Compared with those in the non-recurrence group, the recurrence group had increased LAA volume (SMD 0.53, 95% CI [0.36, 0.71] p < 0.00001), LAA volume index, LAA orifice area, and LAA orifice short/long axis and decreased LAA emptying flow velocity (SMD -0.54, 95% CI [-0.68, -0.40], P < 0.00001), LAA filling flow velocity, and LAA ejection fraction, while there was no significant difference in LAA morphology or LAA depth. Conclusion: Large LAA structure of pre-ablation (LAA volume, orifice area, orifice long/short axis, and volume index) and decreased LAA function of pre-ablation (LAA emptying flow velocity, filling flow velocity, ejection fraction, and LASEC) increase the odds of AF recurrence after CA. Systematic review registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022324533].

Effects of the visualized steerable sheath applied to catheter ablation of paroxysmal atrial fibrillation.

PURPOSE: A new type of visualized steerable sheath (Vizigo sheath; Biosense Webster Inc., Irvine, CA, USA) has been employed in clinical treatment. This study aimed to compare the effectiveness and safety of the Vizigo sheath to a fixed sheath (Swartz sheath; St. Jude Inc., St. Paul, MN, USA) for catheter ablation of paroxysmal atrial fibrillation (PAF). METHODS: We analyzed the procedural time, fluoroscopy time, contact force (CF), and initial pulmonary vein isolation (PVI) rate. After 6 months of follow-up, the success rate of ablation between the two groups was compared. RESULTS: Compared to the Swartz sheath, using the Vizigo sheath can significantly reduce the total procedural time and fluoroscopy time and increase the overall average CF, especially in the anterior left pulmonary vein (LPV), superior LPV, posterior right pulmonary vein (RPV), and superior RPV. The proportion of CF within a reasonable range in the Vizigo group was significantly higher than that in the Swartz group, especially in the anterior LPV, posterior RPV, and superior RPV. Besides, the left, right, and bilateral initial PVI rates in the Vizigo group were significantly higher. CONCLUSIONS: The visualized steerable sheath for PAF catheter ablation not only reduced radiation exposure but also significantly improved CF and initial PVI rate, all of which indicated an increased rate of successful ablation.

EDIL3 deficiency ameliorates adverse cardiac remodelling by neutrophil extracellular traps (NET)-mediated macrophage polarization.

AIMS: After myocardial infarction (MI), injured cardiomyocytes recruit neutrophils and monocytes/macrophages to myocardium, which in turn initiates inflammatory and reparative cascades, respectively. Either insufficient or excessive inflammation impairs cardiac healing. As an endogenous inhibitor of neutrophil adhesion, EDIL3 plays a crucial role in inflammatory regulation. However, the role of EDIL3 in MI remains obscure. We aimed to define the role of EDIL3 in cardiac remodelling after MI. METHODS AND RESULTS: Serum EDIL3 levels in MI patients were negatively associated with MI biomarkers. Consistently, WT mice after MI showed low levels of cardiac EDIL3. Compared with WT mice, Edil3-/- mice showed improvement of post-MI adverse remodelling, as they exhibited lower mortality, better cardiac function, shorter scar length, and smaller LV cavity. Accordingly, infarcted hearts of Edil3-/- mice contained fewer cellular debris and lower amounts of fibrosis content, with decreased collagen I/III expression and the percentage of α-smooth muscle actin myofibroblasts. Mechanistically, EDIL3 deficiency did not affect the recruitment of monocytes or T cells, but enhanced neutrophil recruitment and following expansion of pro-inflammatory Mertk-MHC-IIlo-int (myeloid-epithelial-reproductive tyrosine kinase/major histocompatibility complex II) macrophages. The injection of neutrophil-specific C-X-C motif chemokine receptor 2 antagonist eliminated the differences in macrophage polarization and cardiac function between WT and Edil3-/- mice after MI. Neutrophil extracellular traps (NETs), which were more abundant in the hearts of Edil3-/- mice, contributed to Mertk-MHC-IIlo-int polarization via Toll-like receptor 9 pathway. The inhibition of NET formation by treatment of neutrophil elastase inhibitor or DNase I impaired macrophage polarization, increased cellular debris and aggravated cardiac adverse remodelling, thus removed the differences of cardiac function between WT and Edil3-/- mice. Totally, EDIL3 plays an important role in NET-primed macrophage polarization and cardiac remodelling during MI. CONCLUSION: We not only reveal that EDIL3 deficiency ameliorates adverse cardiac healing via NET-mediated pro-inflammatory macrophage polarization but also discover a new crosstalk between neutrophil and macrophage after MI.

Electrophysiological study and radiofrequency ablation of hemodynamically-instable ventricular arrhythmias in a patient with pulmonary hypertension: A case report.

INTRODUCTION: Hemodynamically-instable ventricular arrhythmias (VAs) are rare in patients with pulmonary hypertension (PH). To the best of our knowledge, only 1 case has been reported so far. Moreover, the pathogenesis of this kind of arrhythmia remains obscured and its treatment is challenging. Here we report another case and presented the substrate for VAs initiation and therapeutic effect of radiofrequency ablation. PATIENT CONCERNS: This is a 57-year-old man who presented paroxysmal palpitation associated with presyncope at rest. Surface electrocardiogram (ECG) revealed frequent ventricular premature contractions and non-sustained ventricular tachycardia when symptoms occurred. He also had a history of severe PH which was secondary to atrial septal defect and partial anomalous pulmonary venous drainage and suffered from obvious dyspnea when climbing stairs World Health Organization Class III (WHO Class III). DIAGNOSIS: Hemodynamically-instable VAs associated with severe PH. INTERVENTION: Echocardiography revealed enlargement of right ventricle (right ventricle [RV]: 43 mm). Electrophysiological examination showed the origin of VAs is next to a small low-voltage zone of RV. Radiofrequency delivery at the origin successfully terminated VAs without occurrence of complication. OUTCOME: The patient was free from arrhythmias and got an improvement of exercise tolerance, just with mild dyspnea when climbing stairs World Health Organization Class II (WHO class II), during six-month follow up. LESSONS: This case suggests the low-voltage zone of remodeled RV, which may be secondary to increased pulmonary artery pressure, serves as the substrate for VAs initiation in patient with PH. Radiofrequency ablation can successfully terminate VAs and the termination of VAs can significantly improve the patient's impaired exercise tolerance.

New oral anticoagulants for nonvalvular atrial fibrillation with peripheral artery disease: a meta-analysis.

BACKGROUND: New oral anticoagulants (NOACs) are as effective and safe as warfarin for patients with non-valvular atrial fibrillation (NVAF). Limited evidence is available regarding outcomes for NVAF patients with peripheral artery disease (PAD). METHODS: A systematic search of Medline, Embase, and the Cochrane Library was performed. Two reviewers independently performed data extraction and quality assessment using the Cochrane Collaboration tool for assessing risk of bias. All primary publications and secondary analyses comparing NOACs with other oral anticoagulation regimens for the prevention of stroke in patients with both NVAF and PAD from phase III clinical trials were evaluated. The primary outcomes were stroke, systemic embolism (SE), major bleeding, and intracranial hemorrhage (ICH), and the secondary outcomes were cardiovascular (CV) mortality, all-cause mortality, and myocardial infarction (MI). RESULTS: Three articles were included in this study. The pooled results showed a relative risk for stroke/SE with NOACs of 0.86 (95% confidence interval [CI]: 0.53-1.39), for major bleeding, 1.12 (95% CI: 0.70-1.81), for ICH, 0.47 (95% CI: 0.16-1.36), for CV mortality, 0.77 (95% CI: 0.57-1.04), for all-cause mortality, 0.91 (95% CI: 0.70-1.19), and for MI, 1.10 (95% CI: 0.64-1.90). CONCLUSION: The findings show that NOACs are effective and safe for preventing stroke/SE in patients with both NVAF and PAD.

Merging three-dimensional CT with electroanatomic mapping facilitates ablation of ventricular arrhythmias originating from aortic root and great cardiac vein.

PURPOSE: In radiofrequency ablation near coronary arteries (CA), coronary angiography is traditionally recommended to estimate distance between catheter and CA. This study aimed to investigate the feasibility of an alternative approach for intuitively demonstrating spatial location of catheter and CA during ablation of ventricular arrhythmias (VAs) originating from aortic root (AR) and great cardiac vein (GCV). METHODS: During mapping and ablation, 3D-reconstructed cardiac CT and electroanatomic mapping were merged, and distance between CA and catheter was monitored. Coronary angiography, for distance verification, was used when the distance was less than 5 mm in image integration model (IIM). RESULTS: Twenty-three patients (52.26 ± 17.89 years, 12 men) with ablation originating in left cusp (LCC, n = 8), right cusp (n = 2), and left-right cusp junction (LCC-RCC, n = 12) and GCV (n = 1) were enrolled. In IIM, the distance between origin and CA was less than 5 mm in 2 VAs originating in LCC and one in GCV (3/23), whereas distance for ablation was always safe (12.3-22.3 mm) for VAs of LCC-RCC origin. IIM avoided angiography use in 20 patients, reducing radiation exposure by 80.6% (650.18 ± 624.31 vs 3356.97 ± 1529.46uGycm2, P = 0.088). VA termination failed in two cases of LCC origin due to proximity to CA, and was achieved in all other patients (91.3%). No CA damage occurred during the procedures. CONCLUSION: Mapping and ablation under IIM guidance of VAs of AR and GCV origin appears feasible and safe, while avoiding angiography use particularly in VAs of LCC-RCC origin.

New oral anticoagulants for nonvalvular atrial fibrillation with stable coronary artery disease: A meta-analysis.

BACKGROUND: New oral anticoagulants (NOACs) are effective and safe in patients with nonvalvular atrial fibrillation (NVAF). Limited evidence is available regarding outcomes for NVAF patients with stable coronary artery disease (CAD). METHODS: A systematic search of Medline, Embase, and the Cochrane Register was performed. Two reviewers independently performed data extraction and quality assessment using the Cochrane Collaboration risk-of-bias assessment tool. We evaluated all primary publications and secondary analyses comparing NOACs with any other OAC agent for preventing stroke in patients with both NVAF and stable CAD from phase III clinical randomized control trials. The primary outcomes were stroke, systemic embolism (SE), major bleeding, and intracranial hemorrhage (ICH), and the secondary outcomes were cardiovascular (CV) death, all-cause death, and myocardial infarction (MI). RESULTS: Four articles with a total of 19 266 patients were included in this study. The pooled results showed a relative risk for stroke/SE with NOACs of 0.83 (95% confidence interval [CI]: 0.71-0.97), for major bleeding 0.85 (95% CI: 0.63-1.14), for ICH 0.36 (95% CI: 0.19-0.54), for MI 1.00 (95% CI: 0.82-1.20), for CV death 0.94 (95% CI: 0.83-1.06), and for all-cause death 0.95 (95% CI: 0.85-1.07). CONCLUSION: NOACs were effective in preventing stroke/SE and reducing the risk of ICH in patients with both NVAF and CAD.

Multi-electrode mapping of complex macroreentry atrial tachycardia.

BACKGROUND: Multi-electrode mapping (MEM) is increasingly applied in ablation of complex atrial arrhythmias. This study aimed to evaluate MEM for analysis and treatment of complex macroreentry atrial tachycardia (MAT). METHODS: Patients with MAT related to scarring, history of heart surgery or atrial linear ablation were studied. Patients were mapped with conventional activation mapping (CAM) or MEM. After characterizing the mechanism of atrial tachycardia (AT), the ablation was performed. RESULTS: The study consisted of 114 eligible patients, 74 in the CAM and 40 in MEM. Compared with CAM, MEM had a shorter procedure duration (156.7 ±â€¯59.1 ms vs. 127.3 ±â€¯59.3 ms, P = 0.003) and mapping duration (62.6 ±â€¯35.7 ms vs. 30.5 ±â€¯15.3 ms, P < 0.001) and more mapping points (1364.9 ±â€¯828.7 points vs. 148.3 ±â€¯79.6 points, P < 0.001). There were no significant differences between CAM and MEM in acute ablation success rate, complication, postoperative AADs, and ablation duration. The mean disease-free survival time in CAM versus MEM was 20.8 (95% CI: 17.6-24.1) months versus 26.6 (95% CI: 22.7-30.4) months. The median disease-free survival time in the CAM versus MEM was 20.0 (95% CI: 13.9-26.1) months versus 30.0 (95% CI: 26.7-36.3) months. The AT recurrence risk of MEM was 0.522 times that of CAM (HR 95% CI: 0.282-0.968; P = 0.039). CONCLUSION: MEM is strongly recommended in ablation of complex MAT.

The impact of renal function on efficacy and safety of new oral anticoagulant in atrial fibrillation patients: A systemic review and meta-analysis.

BACKGROUND AND OBJECTIVES: This meta-analysis was to investigate the efficacy and safety of new oral anticoagulant (NOAC) in atrial fibrillation (AF) patients with renal function insufficiency, and to explore whether renal decline occurs in AF patients with NOAC and its impact on outcomes. METHODS AND RESULTS: In AF patients with mild renal insufficiency, the NOAC was associated with significantly lower rates of stroke (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.67-0.91; P < .05). Lower rates of bleeding were significantly observed in NOAC group (OR, 0.85; 95% CI, 0.75-0.97; P < .05). In AF patients with moderate renal impairment, similar results were revealed (OR for stroke or systemic embolism, 0.80; 95% CI, 0.67-0.95, P < .05; OR for major bleeding, 0.78; 95% CI, 0.59-1.03; P = .07). During the follow-up, pooled data revealed that NOAC showed a less renal toxicity, but the difference did not reach statistical significance (creatinine clearance decline: -0.12 mL/min [-0.84, 0.61 mL/min]). We have revealed that the NOACs were associated with significantly lower rates of stroke or systemic embolism (hazard ratio [HR], 0.66; 95% CI, 0.42-0.89; P < .05) and lower rates of bleeding (HR, 0.93; 95% CI, 0.70-1.16; P = .153) in AF patients with worsening renal function. CONCLUSIONS: NOAC may have the potentiality to be at least as effective as warfarin and may equal safety outcomes in AF patients with renal impairment. Renal decline during therapeutics may be less likely happened in NOAC than warfarin dose. NOAC may reveal good efficacy and safety outcomes in these scenarios. Further detailed research is needed to gain more clear profile on this new anticoagulant.

MicroRNA-302b negatively regulates IL-1ß production in response to MSU crystals by targeting IRAK4 and EphA2.

BACKGROUND: Interleukin-1ß (IL-1ß) is a pivotal proinflammatory cytokine that is strongly associated with the inflammation of gout. However, the underlying mechanism through which the production of IL-1ß is regulated has not been fully elucidated. Our previous work identified that miR-302b had an important immune regulatory role in bacterial lung infections. This study was conducted to evaluate the function of miR-302b on monosodium urate (MSU) crystal-induced inflammation and its mechanism. METHODS: The expression pattern and the immune-regulatory role of miR-302b were evaluated both in vitro and in vivo. The functional targets of miR-302b were predicted by bioinformatics, and then validated by genetic approaches. In addition, the clinical feature of miR-302b was analyzed using serum samples of patients with gouty arthritis. RESULTS: The extremely high expression of miR-302b was observed in both macrophages and mouse air membranes treated with MSU. Intriguingly, overexpression of miR-302b regulated NF-κB and caspase-1 signaling, leading to significantly attenuate MSU-induced IL-1ß. By genetic analysis, miR-302b exhibited inhibitory function on IRAK4 and EphA2 by binding to their 3'-UTR regions. Corporately silencing IRAK4 and EphA2 largely impaired MSU-induced IL-1ß protein production. Moreover, it was also found that miR-302b and EphA2 suppressed the migration of macrophages. Finally, it was observed that high expression of miR-302b was a general feature in patients with gouty arthritis. CONCLUSIONS: These results suggest that miR-302b can regulate IL-1ß production in MSU-induced inflammation by targeting NF-κB and caspase-1 signaling, and may be a potential therapeutic target for gouty arthritis.