Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study.

BACKGROUND: Atrial fibrillation (AF) and left ventricular systolic dysfunction (LVSD) frequently co-exist despite adequate rate control. Existing randomized studies of AF and LVSD of varying etiologies have reported modest benefits with a rhythm control strategy. OBJECTIVES: The goal of this study was to determine whether catheter ablation (CA) for AF could improve LVSD compared with medical rate control (MRC) where the etiology of the LVSD was unexplained, apart from the presence of AF. METHODS: This multicenter, randomized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy (left ventricular ejection fraction [LVEF] ≤45%). After optimization of rate control, patients underwent cardiac magnetic resonance (CMR) to assess LVEF and late gadolinium enhancement, indicative of ventricular fibrosis, before randomization to either CA or ongoing MRC. CA included pulmonary vein isolation and posterior wall isolation. AF burden post-CA was assessed by using an implanted loop recorder, and adequacy of MRC was assessed by using serial Holter monitoring. The primary endpoint was change in LVEF on repeat CMR at 6 months. RESULTS: A total of 301 patients were screened; 68 patients were enrolled between November 2013 and October 2016 and randomized with 33 in each arm (accounting for 2 dropouts). The average AF burden post-CA was 1.6 ± 5.0% at 6 months. In the intention-to-treat analysis, absolute LVEF improved by 18 ± 13% in the CA group compared with 4.4 ± 13% in the MRC group (p < 0.0001) and normalized (LVEF ≥50%) in 58% versus 9% (p = 0.0002). In those undergoing CA, the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF (10.7%; p = 0.0069) and normalization at 6 months (73% vs. 29%; p = 0.0093). CONCLUSIONS: AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control. The restoration of sinus rhythm with CA results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on CMR. This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD. (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction [CAMERA-MRI]; ACTRN12613000880741).

Successful percutaneous closure of an extremely large secundum atrial septal defect during pregnancy.

Atrial septal defects (ASDs) are one of the most of the most common acyanotic congenital heart lesions. Awareness of potential clinical presentations and complications during pregnancy is essential for those managing these patients. We report successful percutaneous closure of an extremely large secundum ASD, using the largest available percutaneous ASD closure device in a 27-year-old pregnant female. Large ASDs may have their initial clinical presentation and diagnosis during pregnancy. If indicated, percutaneous closure can be performed safely. Only a very small number of cases have previously reported this being performed safely during pregnancy.

Comparison of Self-Expanding and Mechanically Expanded Transcatheter Aortic Valve Prostheses.

OBJECTIVES: The aim of this study was to determine whether transcatheter aortic valve replacement (TAVR) with the mechanically expanded Lotus valve (Boston Scientific, Natick Massachusetts) offers potential benefits over treatment with the self-expanding CoreValve (Medtronic, Minneapolis, Minnesota). BACKGROUND: New-generation transcatheter aortic valve systems are emerging in clinical trials and practice with design features aimed at improving safety and efficacy. To date, these devices have not been compared systematically with current-generation devices. METHODS: A total of 100 patients (83.4 ± 4.8 years of age, 44% male, Society of Thoracic Surgeons Predicted Risk of Mortality score of 5.5 ± 2.4) were assessed. Fifty consecutive patients undergoing a Lotus transcatheter aortic valve replacement were enrolled and compared with 50 matched patients treated with a CoreValve. An independent core laboratory reviewed all echocardiographic data, and an independent clinical events committee adjudicated all events. RESULTS: Valve Academic Research Consortium 2-defined device success was 84% and 64% in the Lotus and CoreValve cohorts, respectively (p = 0.02). This difference was driven by lower rates of moderate or greater aortic regurgitation (4% vs. 16.7%, respectively; p = 0.04) and higher rates of successfully implanting a single device in the correct anatomic position (100% vs. 86%, respectively; p = 0.06). Cardiovascular mortality rate (0% vs. 4%, respectively; p = 0.32), major stroke rate (4% vs. 2%, respectively; p = 0.56), and permanent pacemaker insertion rate (28% vs. 18%, respectively; p = 0.23) were not different at 30 days in the Lotus and CoreValve cohorts. CONCLUSIONS: In this matched comparison of high surgical risk patients undergoing transcatheter aortic valve replacement, the use of the Lotus device was associated with higher rates of Valve Academic Research Consortium 2-defined device success compared with the CoreValve. This was driven by higher rates of correct anatomic positioning and lower incidences of moderate paraprosthetic regurgitation. The clinical significance of these differences needs to be tested in a large randomized, controlled trial.