Incidence of Atrial Fibrillation After Radiofrequency Catheter Ablation for Atrial Tachycardia in Congenital Heart Disease.

BACKGROUND: Atrial tachycardia (AT) and atrial fibrillation (AF) coexist in 30% of congenital heart disease (CHD) patients. Successful atrial tachycardia catheter ablation (ATCA) might prevent AF. Data on new-onset AF after ATCA in CHD is scarce. OBJECTIVES: This study aimed to evaluate the incidence of new-onset AF after ATCA and to assess clinical characteristics associated with new-onset AF after ATCA in CHD. METHODS: CHD patients referred for ATCA to 3 European centers were included. New occurrence of AF was defined as electrocardiographic documentation of AF after any ATCA procedure in patients without history of AF. RESULTS: In 277 CHD patients (median age 37 years [Q1, Q3: 23, 49 years], 58% men, 59 [21%] simple, 111 [40%] moderate, and 107 [39%] complex CHD), AF occurred in 25 patients (9%) a median of 8 months (Q1, Q3: 4, 27 months) after ATCA. New-onset AF was persistent in the majority of the patients (17 of 25 [63%]). Patients with new-onset AF were older (44 years [Q1, Q3: 29, 55 years] vs 36 years [Q1, Q3: 23, 49 years]; P = 0.009) and more frequently had simple CHD (13 of 25 [52%] vs 46 of 252 [18%], respectively; P < 0.0001). Acute ATCA success rates were similar in patients with and without AF (52% vs 48%; P = 0.429). Simple CHD was an independent predictor of new-onset AF during follow-up. CONCLUSIONS: In our large cohort of patients with congenital heart disease, new-onset AF after ablation for AT occurred in only 9% of the patients. AF occurred without AT recurrence and was persistent in the majority of patients.

Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation.

BACKGROUND: Subclinical atrial fibrillation is short-lasting and asymptomatic and can usually be detected only by long-term continuous monitoring with pacemakers or defibrillators. Subclinical atrial fibrillation is associated with an increased risk of stroke by a factor of 2.5; however, treatment with oral anticoagulation is of uncertain benefit. METHODS: We conducted a trial involving patients with subclinical atrial fibrillation lasting 6 minutes to 24 hours. Patients were randomly assigned in a double-blind, double-dummy design to receive apixaban at a dose of 5 mg twice daily (2.5 mg twice daily when indicated) or aspirin at a dose of 81 mg daily. The trial medication was discontinued and anticoagulation started if subclinical atrial fibrillation lasting more than 24 hours or clinical atrial fibrillation developed. The primary efficacy outcome, stroke or systemic embolism, was assessed in the intention-to-treat population (all the patients who had undergone randomization); the primary safety outcome, major bleeding, was assessed in the on-treatment population (all the patients who had undergone randomization and received at least one dose of the assigned trial drug, with follow-up censored 5 days after permanent discontinuation of trial medication for any reason). RESULTS: We included 4012 patients with a mean (±SD) age of 76.8±7.6 years and a mean CHA2DS2-VASc score of 3.9±1.1 (scores range from 0 to 9, with higher scores indicating a higher risk of stroke); 36.1% of the patients were women. After a mean follow-up of 3.5±1.8 years, stroke or systemic embolism occurred in 55 patients in the apixaban group (0.78% per patient-year) and in 86 patients in the aspirin group (1.24% per patient-year) (hazard ratio, 0.63; 95% confidence interval [CI], 0.45 to 0.88; P = 0.007). In the on-treatment population, the rate of major bleeding was 1.71% per patient-year in the apixaban group and 0.94% per patient-year in the aspirin group (hazard ratio, 1.80; 95% CI, 1.26 to 2.57; P = 0.001). Fatal bleeding occurred in 5 patients in the apixaban group and 8 patients in the aspirin group. CONCLUSIONS: Among patients with subclinical atrial fibrillation, apixaban resulted in a lower risk of stroke or systemic embolism than aspirin but a higher risk of major bleeding. (Funded by the Canadian Institutes of Health Research and others; ARTESIA ClinicalTrials.gov number, NCT01938248.).

Social determinants of health and recurrence of atrial fibrillation after catheter ablation: a Danish nationwide cohort study.

AIMS: To examine the associations between three social determinants of health (SDOH) and recurrence of AF after ablation. METHODS AND RESULTS: We selected patients who underwent a first ablation after an incident hospital diagnosis of AF between 2005 and 2018 from the entire Danish population. Educational attainment, family income, and whether the patient was living alone were assessed at the time of ablation. We used cause-specific proportional hazard models to estimate hazard ratios (HR) with 95% confidence interval (CI) adjusted for age and sex. In secondary analyses, we adjusted for comorbidities, antiarrhythmic medication, and prior electrical cardioversion.We selected 9728 patients (mean age 61 years, 70% men), and 5881 patients had AF recurrence over an average of 1.37 years after ablation (recurrence rate 325.7 (95% CI 317.6-334.2) per 1000 person-years). Lower education (HR 1.09 [1.02-1.17] and 1.07 [1.01-1.14] for lower and medium vs. higher), lower income [HR 1.14 (1.06-1.22) and 1.09 (1.03-1.17) for lower and medium vs. higher], and living alone [HR 1.07 (1.00-1.13)] were associated with increased rates of recurrence of AF. We found no evidence of interaction between sex or prior HF with SDOH. The association between family income and AF recurrence was stronger among patients < 65 years compared with those aged ≥ 65 years. The associations between SDOH and AF recurrence did not persist in the multivariable model. CONCLUSION: AF was more likely to recur among patients with lower educational attainment, lower family income, or those living alone. Multidisciplinary efforts are needed to reduce socioeconomic inequity in the effect of ablation.

Social determinants of health and catheter ablation after an incident diagnosis of atrial fibrillation: a Danish nationwide cohort study.

AIMS: To examine (i) the sex-specific associations between three social determinants of health (SDOH) and use of ablation after incident atrial fibrillation (AF), and (ii) the temporal trends in these associations. METHODS AND RESULTS: We conducted a nationwide cohort study of patients with an incident hospital diagnosis of AF between 2005 and 2018. SDOH at the time of AF diagnosis included three levels of educational attainment, tertile groups of family income, and whether the patient was living alone. Outcome was catheter ablation for AF. We used cause-specific proportional hazard models to estimate hazard ratios (HR) with 95% CI and adjusted for age. To examine temporal trends, we included an interaction term between the exposure and calendar years. Among 122 276 men, those with lower education [HR 0.49 (95%CI 0.45-0.53)] and 0.72 (0.68-0.77) for lower and medium vs. higher], lower income [HR 0.31 (0.27-0.34) and 0.56 (0.52-0.60) for lower and medium vs. higher], and who lived alone [HR 0.60 (0.55-0.64)] were less likely to receive AF ablation. Among 98 476 women, those with lower education [HR 0.45 (0.40-0.50) and 0.83 (0.75-0.91) for lower and medium vs. higher], lower income [HR 0.34 (0.28-0.40) and 0.51 (0.46-0.58) for lower and medium vs. higher], and who lived alone [HR 0.67 (0.61-0.74)] were less likely to receive AF ablation. We found no evidence of temporal trends in the associations. CONCLUSION: In the Danish universal healthcare system, patients with AF who had lower educational attainment, lower family income, or were living alone were less likely to undergo AF ablation.

Contemporary Patients With Congenital Heart Disease: Uniform Atrial Tachycardia Substrates Allow for Clear Ablation Endpoints With Improved Long-Term Outcome.

[Figure: see text].

Optimized Implementation of cardiac resynchronization therapy - a call for action for referral and optimization of care.

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heartfailure hospitalization rates and reduces all-cause mortality. Nevertheless, up to two-thirds ofeligible patients are not referred for CRT. Furthermore, post implantation follow-up is oftenfragmented and suboptimal, hampering the potential maximal treatment effect. This jointposition statement from three ESC Associations, HFA, EHRA and EACVI focuses onoptimized implementation of CRT. We offer theoretical and practical strategies to achievemore comprehensive CRT referral and post-procedural care by focusing on four actionabledomains; (I) overcoming CRT under-utilization, (II) better understanding of pre-implantcharacteristics, (III) abandoning the term 'non-response' and replacing this by the concept ofdisease modification, and (IV) implementing a dedicated post-implant CRT care pathway.

Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology.

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.

Rationale and design of AXAFA-AFNET 5: an investigator-initiated, randomized, open, blinded outcome assessment, multi-centre trial to comparing continuous apixaban to vitamin K antagonists in patients undergoing atrial fibrillation catheter ablation.

AIMS: Catheter ablation is the most efficacious rhythm control therapy in atrial fibrillation (AF) patients. There is growing evidence that catheter ablation procedures are best performed during continuous oral anticoagulation, but outcomes are variable depending on the anticoagulation strategy or agent chosen. Specifically, there is a need to evaluate the peri-procedural use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients undergoing catheter ablation of AF. The AXAFA-AFNET 5 trial will test whether peri-procedural anticoagulation therapy using apixaban is a safe alternative to vitamin K antagonist (VKA) therapy for patients undergoing catheter ablation of AF. METHODS AND RESULTS: AXAFA-AFNET 5 is a randomized, prospective multi-centre study conducted in Europe and the USA. A total of 650 patients scheduled for AF ablation will be randomized 1:1 to undergo AF ablation on continuous treatment with the NOAC apixaban or with a VKA. Patients can undergo AF ablation after at least 30 days of continuous effective anticoagulation or after exclusion of atrial thrombi by transoesophageal echocardiogram. The trial includes a post-ablation magnetic resonance imaging substudy that will quantify silent brain lesions that can occur in neurologically asymptomatic patients after AF ablation. Patients will be followed on continuous anticoagulation for 3 months after the ablation. The primary outcome parameter of AXAFA-AFNET 5 is a composite of all-cause death, stroke, and major bleeding events. CONCLUSION: The results of AXAFA-AFNET 5 will provide evidence informing about the safety of apixaban in ablation patients and on its efficacy including effects on silent brain lesions. AXAFA - AFNET 5 is an investigator-initiated trial sponsored by AFNET. The trial is supported by the DZHK (German Centre for Cardiovascular Research) and by the BMBF (German Ministry of Education and Research) and by Bristol-Myers Squibb/Pfizer Alliance.

Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation.

BACKGROUND: There are limited data comparing radiofrequency catheter ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation. METHODS: We randomly assigned 294 patients with paroxysmal atrial fibrillation and no history of antiarrhythmic drug use to an initial treatment strategy of either radiofrequency catheter ablation (146 patients) or therapy with class IC or class III antiarrhythmic agents (148 patients). Follow-up included 7-day Holter-monitor recording at 3, 6, 12, 18, and 24 months. Primary end points were the cumulative and per-visit burden of atrial fibrillation (i.e., percentage of time in atrial fibrillation on Holter-monitor recordings). Analyses were performed on an intention-to-treat basis. RESULTS: There was no significant difference between the ablation and drug-therapy groups in the cumulative burden of atrial fibrillation (90th percentile of arrhythmia burden, 13% and 19%, respectively; P=0.10) or the burden at 3, 6, 12, or 18 months. At 24 months, the burden of atrial fibrillation was significantly lower in the ablation group than in the drug-therapy group (90th percentile, 9% vs. 18%; P=0.007), and more patients in the ablation group were free from any atrial fibrillation (85% vs. 71%, P=0.004) and from symptomatic atrial fibrillation (93% vs. 84%, P=0.01). One death in the ablation group was due to a procedure-related stroke; there were three cases of cardiac tamponade in the ablation group. In the drug-therapy group, 54 patients (36%) underwent supplementary ablation. CONCLUSIONS: In comparing radiofrequency ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation, we found no significant difference between the treatment groups in the cumulative burden of atrial fibrillation over a period of 2 years. (Funded by the Danish Heart Foundation and others; MANTRA-PAF ClinicalTrials.gov number, NCT00133211.).

n-3 Fatty acids and ventricular arrhythmias in patients with ischaemic heart disease and implantable cardioverter defibrillators.

AIM: To investigate the relationship between serum content of n-3 polyunsaturated fatty acids (PUFA) and the incidence of ventricular arrhythmias in patients with an implantable cardioverter defibrillator (ICD). METHODS: We included 98 patients with ischaemic heart disease and an ICD. The numbers of ventricular fibrillation (VF) and ventricular tachycardia (VT) events were assessed during a 12-month period and related to the concentration of n-3 PUFA in serum phospholipids. RESULTS: Patients with more than one arrhythmic event had significantly lower n-3 PUFA levels compared with patients without arrhythmias (mean 7.1% vs 9.2%, P<0.01). Dividing the patients into quintiles according to their n-3 PUFA level those with the lowest content of n-3 PUFA had more ventricular arrhythmias than patients with the highest concentration of n-3 PUFA (mean 1.3 event vs 0.2 event, P<0.05). CONCLUSION: Patients with a low content of n-3 PUFA in serum had a higher incidence of ventricular arrhythmias compared with patients with high serum levels of n-3 PUFA. The data suggest that the protection offered by n-3 PUFA against sudden cardiac death observed in previous studies is mediated by a direct antiarrhythmic effect of n-3 PUFA.