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BACKGROUND: Ablation Index (AI) software has allowed better atrial fibrillation (AF) ablation results, but recurrence rates remain significant. Specific serum biomarkers have been associated with this recurrence. OBJECTIVES: To evaluate whether certain biomarkers could be used (either individually or combined) to predict arrhythmia recurrence after AI-guided AF ablation. METHODS: Prospective multicenter observational study of consecutive patients referred for AF ablation from January 2018 to March 2021. Hemoglobin, brain natriuretic peptide (BNP), C-reactive protein, high sensitivity cardiac troponin I, creatinine clearance, thyroid-stimulating hormone (TSH) and free thyroxine (FT4) were assessed for their ability to predict arrhythmia recurrence during follow-up. Statistical significance was accepted for p values of<0.05. RESULTS: A total of 593 patients were included - 412 patients with paroxysmal AF and 181 with persistent AF. After a mean follow-up of 24±6 months, overall single-procedure freedom from atrial arrhythmia was 76.4%. Individually, all biomarkers had no or only modest predictive power for recurrence. However, a TSH value >1.8 µUI/mL (HR=1.82 [95% CI, 1.89-2.80], p=0.006) was an independent predictor of arrhythmia recurrence. When assessing TSH, FT4 and BNP values in combination, each additional "abnormal" biomarker value was associated with a lower freedom from arrhythmia recurrence (87.1 % for no biomarker vs. 83.5% for one vs. 75.1% for two vs. 43.3% for three biomarkers, p<0.001). Patients with three "abnormal" biomarkers had a threefold higher risk of AF recurrence compared with no "abnormal" biomarker (HR=2.88 [95% CI, 1.39-5.17], p=0.003). CONCLUSIONS: When used in combination, abnormal TSH, FT4 and BNP values can be a useful tool for predicting arrhythmia recurrence after AI-guided AF ablation.
FUNDAMENTO: O software ablation index (AI) permitiu melhorar os resultados da ablação de fibrilação atrial (FA), mas as taxas de recorrência permanecem significativas. Biomarcadores séricos específicos têm sido associados a essa recorrência. OBJETIVOS: Avaliar se certos biomarcadores podem ser utilizados (individualmente ou combinados) para predizer a recorrência de FA pós ablação guiada pelo AI. MÉTODOS: Estudo multicêntrico, observacional, prospectivo de pacientes consecutivos, encaminhados para ablação de FA de janeiro de 2018 a março de 2021. Hemoglobina, peptídeo natriurético cerebral (BNP), proteína C reativa, troponina I ultrassensível, clearance de creatinina, Hormônio Tireoestimulante (TSH), e Tiroxina livre (T4) foram avaliados quanto à capacidade de prever a recorrência de arritmias durante o acompanhamento. Valores de p <0,05 foram aceitos como estatisticamente significativos. RESULTADOS: Um total de 593 pacientes foram incluídos 412 com FA paroxística e 181 com FA persistente. Durante o seguimento médio de 24±6 meses, 76,4% não apresentaram recidiva após ablação. Individualmente, os biomarcadores demonstraram um valor preditivo baixo ou nulo para recorrência. No entanto, TSH >1,8 µUI/mL [HR=1,82 (IC95%, 1,89-2,80), p=0,006] foi um preditor independente de recorrência. Avaliando-se a combinação de TSH, FT4 e BNP, a adição de cada valor "anormal" foi associada a uma menor sobrevida livre de recorrência (87,1% se nenhum vs. 83,5% se um vs. 75,1% se dois vs. 43,3% se três biomarcadores, p<0,001). Doentes com três biomarcadores "anormais" apresentaram três vezes maior probabilidade de recorrência de FA, comparativamente aos que não apresentaram nenhum biomarcador "anormal" (HR=2,88 [IC95%, 1,39-5,17], p=0,003). CONCLUSÕES: Quando combinados, valores anormais de TSH, FT4 e BNP podem ser uma ferramenta útil para prever a recorrência de FA pós ablação guiada pelo AI.
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Fibrilación Atrial , Biomarcadores , Ablación por Catéter , Recurrencia , Tirotropina , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/sangre , Biomarcadores/sangre , Masculino , Femenino , Estudios Prospectivos , Persona de Mediana Edad , Ablación por Catéter/métodos , Anciano , Tirotropina/sangre , Péptido Natriurético Encefálico/sangre , Valor Predictivo de las Pruebas , Proteína C-Reactiva/análisis , Resultado del Tratamiento , Tiroxina/sangre , Factores de Riesgo , Troponina I/sangreRESUMEN
INTRODUCTION: Studies suggest increased likelihood of atrial fibrillation (AF) recurrence after catheter ablation (CA) in women than in men, indicating that sex may be an independent risk factor for recurrence. Nevertheless, the influence of sex on AF recurrence and underlying mechanisms remains unclear. METHODS: Retrospective, single-centre study including patients undergoing AF CA between 2017 and 2021. Late recurrence (LR) was defined as AF recurrence ≥90 days after ablation, whereas early recurrence (ER) occurred within 90 days. RESULTS: 656 patients (32% women) were included, with a median follow-up period of 26 months. Compared to men, women undergoing CA were older, had higher body mass indexes, and had higher rates of hypertension, thyroid dysfunction, and valvular disease. Women also had increased LR risk after CA (HR 1.76, 95% CI [1.19, 2.59]). A time-split multivariable analysis at one year of follow-up showed no difference in LR risk during the first 12 months after CA (HR 1.19, 95% CI [0.73, 1.94]); however, LR risk increased in women (HR 2.90, 95% CI [1.68, 5.01]) after 12 months. In a sex-stratified analysis, coronary calcium score (CCS) >100 was associated with increased LR risk in men (HR 1.81, 95% CI [1.06, 3.08]), but not in women. Cardiac adipose tissue volume was not associated with increased LR risk. CONCLUSIONS: Fewer women underwent CA than men and LR was more frequent in women, particularly one year after the procedure. CCS was associated with increased LR risk in men.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Recurrencia , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/epidemiología , Fibrilación Atrial/fisiopatología , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Venas Pulmonares/cirugía , Ablación por Catéter/métodos , Ablación por Catéter/efectos adversos , Ablación por Catéter/tendencias , Anciano , Factores de Riesgo , Estudios de Seguimiento , Factores Sexuales , Caracteres SexualesRESUMEN
Resumo Fundamento: O software ablation index (AI) permitiu melhorar os resultados da ablação de fibrilação atrial (FA), mas as taxas de recorrência permanecem significativas. Biomarcadores séricos específicos têm sido associados a essa recorrência. Objetivos: Avaliar se certos biomarcadores podem ser utilizados (individualmente ou combinados) para predizer a recorrência de FA pós ablação guiada pelo AI. Métodos: Estudo multicêntrico, observacional, prospectivo de pacientes consecutivos, encaminhados para ablação de FA de janeiro de 2018 a março de 2021. Hemoglobina, peptídeo natriurético cerebral (BNP), proteína C reativa, troponina I ultrassensível, clearance de creatinina, Hormônio Tireoestimulante (TSH), e Tiroxina livre (T4) foram avaliados quanto à capacidade de prever a recorrência de arritmias durante o acompanhamento. Valores de p <0,05 foram aceitos como estatisticamente significativos. Resultados: Um total de 593 pacientes foram incluídos - 412 com FA paroxística e 181 com FA persistente. Durante o seguimento médio de 24±6 meses, 76,4% não apresentaram recidiva após ablação. Individualmente, os biomarcadores demonstraram um valor preditivo baixo ou nulo para recorrência. No entanto, TSH >1,8 μUI/mL [HR=1,82 (IC95%, 1,89-2,80), p=0,006] foi um preditor independente de recorrência. Avaliando-se a combinação de TSH, FT4 e BNP, a adição de cada valor "anormal" foi associada a uma menor sobrevida livre de recorrência (87,1% se nenhum vs. 83,5% se um vs. 75,1% se dois vs. 43,3% se três biomarcadores, p<0,001). Doentes com três biomarcadores "anormais" apresentaram três vezes maior probabilidade de recorrência de FA, comparativamente aos que não apresentaram nenhum biomarcador "anormal" (HR=2,88 [IC95%, 1,39-5,17], p=0,003). Conclusões: Quando combinados, valores anormais de TSH, FT4 e BNP podem ser uma ferramenta útil para prever a recorrência de FA pós ablação guiada pelo AI.
Abstract Background: Ablation Index (AI) software has allowed better atrial fibrillation (AF) ablation results, but recurrence rates remain significant. Specific serum biomarkers have been associated with this recurrence. Objectives: To evaluate whether certain biomarkers could be used (either individually or combined) to predict arrhythmia recurrence after AI-guided AF ablation. Methods: Prospective multicenter observational study of consecutive patients referred for AF ablation from January 2018 to March 2021. Hemoglobin, brain natriuretic peptide (BNP), C-reactive protein, high sensitivity cardiac troponin I, creatinine clearance, thyroid-stimulating hormone (TSH) and free thyroxine (FT4) were assessed for their ability to predict arrhythmia recurrence during follow-up. Statistical significance was accepted for p values of<0.05. Results: A total of 593 patients were included - 412 patients with paroxysmal AF and 181 with persistent AF. After a mean follow-up of 24±6 months, overall single-procedure freedom from atrial arrhythmia was 76.4%. Individually, all biomarkers had no or only modest predictive power for recurrence. However, a TSH value >1.8 μUI/mL (HR=1.82 [95% CI, 1.89-2.80], p=0.006) was an independent predictor of arrhythmia recurrence. When assessing TSH, FT4 and BNP values in combination, each additional "abnormal" biomarker value was associated with a lower freedom from arrhythmia recurrence (87.1 % for no biomarker vs. 83.5% for one vs. 75.1% for two vs. 43.3% for three biomarkers, p<0.001). Patients with three "abnormal" biomarkers had a threefold higher risk of AF recurrence compared with no "abnormal" biomarker (HR=2.88 [95% CI, 1.39-5.17], p=0.003). Conclusions: When used in combination, abnormal TSH, FT4 and BNP values can be a useful tool for predicting arrhythmia recurrence after AI-guided AF ablation.
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The cardiovascular response to exercise has long been a focus of interest. Over a century ago, the first descriptions of electrocardiographic changes occurring during exercise highlighted the possible relevance of this dynamic assessment. In this background, the inception of the Bruce protocol circa 60 years ago allowed for a major leap in this field by providing a standardized framework with which to address this issue, by means of an integrated and structured methodology. Since then, exercise stress testing with electrocardiographic monitoring (ExECG) has become one of the most widely appraised tests in cardiovascular medicine. Notably, past few decades have been profoundly marked by substantial advances in the approach to cardiovascular disease, challenging prior notions concerning both its physiopathology and overall management. Among these, the ever-evolving presentations of cardiovascular disease coupled with the development and implementation of several novel diagnostic modalities (both invasive and noninvasive) has led to a shifting paradigm in the application of ExECG. This technique, however, has continuously shown to be of added value across various momentums of the cardiovascular continuum, as depicted in several contemporary guidelines. This review provides a pragmatical reflexion on the development of ExECG, presenting a comprehensive overview concerning the current role of this modality, its challenges, and its future perspectives.
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INTRODUCTION: There is a well-established association between atrial fibrillation (AF) and coronary artery disease. Coronary artery calcium score (CACS) is a helpful tool to refine cardiovascular (CV) risk stratification and inform on the best strategies for primary CV prevention. This study aims to evaluate the impact of opportunistic screening with CACS on risk stratification and decision of preventive therapies, in patients with AF. METHODS: Cross-sectional study including patients with AF or atrial flutter undergoing cardiac computed tomography for ablation procedure planning, from 2017 to 2019. Baseline clinical and demographical data were collected. CACS was assessed in patients without coronary artery disease using the Agatston method. RESULTS: A total of 474 patients were included (93% with AF, mean age of 58 ± 10 years, 62% male). CACS >0 was present in 254 (54%) patients. According to CACS and the Society of Cardiovascular Computed Tomography recommendations, 25% of the patients would be candidates for statin therapy and 17% would be candidates for changes in the current statin intensity; in 11 patients (8%), acetylsalicylic acid would be recommended. CONCLUSION: In our study, more than half of the patients undergoing cardiac computed tomography before AF catheter ablation had CACS above zero. Our findings suggest that an opportunistic evaluation of CACS at the time of ablation can be an important tool to improve CV risk stratification, with important clinical and therapeutic implications.
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Fibrilación Atrial , Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Humanos , Masculino , Persona de Mediana Edad , Anciano , Femenino , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Fibrilación Atrial/complicaciones , Fibrilación Atrial/cirugía , Fibrilación Atrial/tratamiento farmacológico , Enfermedades Cardiovasculares/etiología , Enfermedades Cardiovasculares/tratamiento farmacológico , Calcio , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Estudios Transversales , Factores de Riesgo , Medición de Riesgo , Angiografía Coronaria/métodos , Valor Predictivo de las PruebasRESUMEN
Introducción y objetivos: Estudios previos han sugerido que el tejido adiposo epicárdico (TAE) podría ejercer un efecto paracrino en el miocardio. Sin embargo, pocos estudios han evaluado su papel en el riesgo de recurrencia de la fibrilación auricular (FA). El objetivo de ese estudio fue evaluar la asociación entre el volumen de TAE y su atenuación con el riesgo de recurrencia de FA tras la ablación de FA. Métodos: Se incluyó un total de 350 pacientes consecutivos sometidos a ablación de FA - mediana de edad 57 años [RIC 48-65], 21% FA persistente. La grasa epicárdica se cuantificó mediante tomografía computarizada multidetector utilizando el software Syngo.via Frontier-Cardiac Risk Assessment, midiendo el volumen tejido adiposo pericárdico (VTAP), el volumen de TAE y la atenuación de TAE posterior a la aurícula izquierda. La recurrencia de FA se definió como cualquier episodio documentado de FA, aleteo auricular, o taquicardia auricular más de 3 meses después del procedimiento. Resultados: Tras una mediana de seguimiento de 34 meses [rango de 12 a 57 meses], 114 pacientes (33%) tuvieron recurrencia de FA. La regresión de Cox univariable mostró que los pacientes con un volumen de TAE ≥ 80ml tenían un mayor riesgo de recurrencia de FA (HR=1,65; IC95%, 1,14-2,39; p=0,007). Sin embargo, después del ajuste multivariable, el volumen de TAE no fue un predictor independiente de recurrencia de FA (HR=1,24; IC95%, 0,83-1,87; p=0,3). Se observaron resultados similares con VTAP. Los pacientes con menor atenuación de TAE no tenían un mayor riesgo de recurrencia de FA (prueba de rango logarítmico p=0,75). Conclusiones: Los parámetros de TAE, incluida la evaluación del volumen de TAE, VTAP y la atenuación de TAE, no fueron predictores independientes de recurrencia de FA después de la ablación con catéter. (AU)
Introduction and objectives: Previous studies have suggested that epicardial adipose tissue (EAT) could exert a paracrine effect in the myocardium. However, few studies have assessed its role in the risk of atrial fibrillation (AF) recurrence. This study aimed to evaluate the association between EAT volume, and its attenuation, with the risk of AF recurrence after AF ablation. Methods: A total of 350 consecutive patients who underwent AF ablation were included. The median age was 57 [IQR 48-65] years and 21% had persistent AF. Epicardial fat was quantified by multidetector computed tomography using Syngo.via Frontier-Cardiac Risk Assessment software, measuring pericardial fat volume (PATV), EAT volume, and attenuation of EAT posterior to the left atrium. AF recurrence was defined as any documented episode of AF, atrial flutter, or atrial tachycardia more than 3 months after the procedure. Results: After a median follow-up of 34 [range, 12-57] months, 114 patients (33%) had AF recurrence. Univariable Cox regression showed that patients with an EAT volume ≥ 80mL had an increased risk of AF recurrence (HR, 1.65; 95%CI, 1.14-2.39; P=.007). However, after multivariable adjustment, EAT volume did not remain an independent predictor of AF recurrence (HR, 1.24; 95%CI, 0.83-1.87; P=.3). Similar results were observed with PATV. Patients with lower attenuation of EAT did not have a higher risk of AF recurrence (log-rank test, P=.75). Conclusions: EAT parameters including the evaluation of EAT volume, PATV and EAT attenuation were not independent predictors of AF recurrence after catheter ablation. (AU)
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Tejido Adiposo/diagnóstico por imagen , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Recurrencia , Tomografía Computarizada por Rayos X , Ablación por Catéter , Estudios RetrospectivosRESUMEN
AIMS: Pulmonary vein isolation (PVI) guided by the Ablation Index (AI) has shown high acute and mid-term efficacy in the treatment of paroxysmal atrial fibrillation (AF). Previous data before the AI-era had suggested that wide-area circumferential ablation (WACA) was preferable to ostial ablation. However, with the use of AI, we hypothesize that ostial circumferential ablation is non-inferior to WACA and can improve outcomes in paroxysmal AF. METHODS AND RESULTS: Prospective, multicentre, non-randomized, non-inferiority study of consecutive patients were referred for paroxysmal AF ablation from January 2020 to September 2021. All procedures were performed using the AI software, and patients were separated into two different groups: WACA vs. ostial circumferential ablation. Acute reconnection, procedural data, and 1-year arrhythmia recurrence were assessed. During the enrolment period, 162 patients (64% males, mean age of 60 ± 11 years) fulfilled the study inclusion criteria-81 patients [304 pulmonary vein (PV)] in the WACA group and 81 patients (301 PV) in the ostial group. Acute PV reconnection was identified in 7.9% [95% confidence interval (CI), 4.9-11.1%] of PVs in the WACA group compared with 3.3% (95% CI, 1.8-6.1%) of PVs in the ostial group [P < 0.001 for non-inferiority; adjusted odds ratio 0.51 (95% CI, 0.23-0.83), P = 0.05]. Patients in the WACA group had longer ablation (35 vs. 29â min, P = 0.001) and procedure (121 vs. 102â min, P < 0.001) times. No significant difference in arrhythmia recurrence was seen at 1-year of follow-up [11.1% in WACA vs. 9.9% in ostial, hazard ratio 1.13 (95% CI, 0.44-1.94), P = 0.80 for superiority]. CONCLUSION: In paroxysmal AF patients treated with tailored AI-guided PVI, ostial circumferential ablation is not inferior to WACA with regard to acute PV reconnection, while allowing quicker procedures with less ablation time.
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Fibrilación Atrial , Venas Pulmonares , Masculino , Humanos , Persona de Mediana Edad , Anciano , Femenino , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Estudios Prospectivos , Oportunidad Relativa , Venas Pulmonares/cirugía , Programas InformáticosRESUMEN
INTRODUCTION AND OBJECTIVES: Cardioneuroablation (CNA), a technique based on radiofrequency ablation of cardiac vagal ganglia, was developed to treat recurrent vasovagal syncope (VVS) with a predominant cardioinhibitory component, as an alternative to pacemaker implantation. The aim of our study was to evaluate the safety and success rate of CNA guided by extracardiac vagal stimulation in patients with highly symptomatic cardioinhibitory VVS. METHODS: Prospective study of patients who underwent anatomically guided CNA at two cardiology centers. All patients had a history of recurrent syncope with a predominant cardioinhibitory component and refractory to conventional measures. Acute success was determined by the absence or significant reduction of cardiac parasympathetic response to extracardiac vagal stimulation. The primary endpoint was the recurrence of syncope during follow-up. RESULTS: In total, 19 patients (13 males; mean age 37.8±12.9 years) were included. Ablation was acutely successful in all patients. One patient had a convulsive episode after the procedure, which was deemed unrelated to the ablation, requiring admission to intensive care but without sequelae. No other complications occurred. At a mean follow-up of 21.0±13.2 months (range 3-42 months), 17 patients remained free of syncope. The remaining two patients had recurrence of syncope and, despite undergoing a new ablation procedure, required pacemaker implantation during follow-up. CONCLUSION: Cardioneuroablation, confirmed by extracardiac vagal stimulation, appears to be an effective and safe treatment option for highly symptomatic patients with refractory VVS with a predominant cardioinhibitory component, providing a new potential approach as an alternative to pacemaker implantation.
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Marcapaso Artificial , Síncope Vasovagal , Masculino , Humanos , Adulto Joven , Adulto , Persona de Mediana Edad , Síncope Vasovagal/cirugía , Estudios Prospectivos , Corazón , Progresión de la EnfermedadRESUMEN
BACKGROUND: Cryoballoon ablation (CBA) for pulmonary vein isolation (PVI) has been growing as an alternative technique, not only in patients with paroxysmal atrial fibrillation (PAF) but also in persistent atrial fibrillation (AF). Cryoballoon ablation has demonstrated encouraging acute and mid-term results. However, data on long-term follow-up of CB-based PVI are scarce. OBJECTIVE: We sought to examine efficacy, safety, and long-term outcomes of CBA in PAF and persistent AF in four Portuguese centers. METHODS: All patients that were treated with the cryoballoon catheter according to routine practices with a second-generation 28-mm CB in four centers were included. This was a retrospective, non-randomized analysis. Patients were followed-up for >12 months and freedom from atrial arrhythmias (AA) was evaluated at the end of follow-up. RESULTS: Four hundred and six patients (57.7±12.4 years, 66% men) participated. AF was paroxysmal in 326 patients (80.2%) and persistent in 80 (19.7%). The mean procedure time duration was 107.7±50.9 min, and the fluoroscopy time was 19.5±9.7 min. Procedural/periprocedural complications occurred in 30 cases (7.3%), being transient phrenic nerve palsy the most frequent incident (2 out of 3 complications). Anatomic variations of the PV were present in 16.1% of cases. At a mean follow-up of 22.0±15.0 months, 310 patients (76.3%) remained in stable sinus rhythm, with at least one AF episode recurrence documented in 98 cases (24.1%). The recurrence rate was 20.5% in the PAF group and 37.8% in the persistent AF group. CONCLUSION: In this multicenter experience, a single CBA procedure resulted in 75.9% freedom from AF at a 22-month follow-up. This technique was demonstrated to be a safe and effective option in experienced centers for the treatment of PAF and PersAF.
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Fibrilación Atrial , Ablación por Catéter , Criocirugía , Venas Pulmonares , Masculino , Humanos , Femenino , Fibrilación Atrial/complicaciones , Portugal , Resultado del Tratamiento , Estudios Retrospectivos , Ablación por Catéter/métodos , Venas Pulmonares/cirugía , RecurrenciaRESUMEN
INTRODUCTION AND OBJECTIVES: Previous studies have suggested that epicardial adipose tissue (EAT) could exert a paracrine effect in the myocardium. However, few studies have assessed its role in the risk of atrial fibrillation (AF) recurrence. This study aimed to evaluate the association between EAT volume, and its attenuation, with the risk of AF recurrence after AF ablation. METHODS: A total of 350 consecutive patients who underwent AF ablation were included. The median age was 57 [IQR 48-65] years and 21% had persistent AF. Epicardial fat was quantified by multidetector computed tomography using Syngo.via Frontier-Cardiac Risk Assessment software, measuring pericardial fat volume (PATV), EAT volume, and attenuation of EAT posterior to the left atrium. AF recurrence was defined as any documented episode of AF, atrial flutter, or atrial tachycardia more than 3 months after the procedure. RESULTS: After a median follow-up of 34 [range, 12-57] months, 114 patients (33%) had AF recurrence. Univariable Cox regression showed that patients with an EAT volume ≥ 80mL had an increased risk of AF recurrence (HR, 1.65; 95%CI, 1.14-2.39; P=.007). However, after multivariable adjustment, EAT volume did not remain an independent predictor of AF recurrence (HR, 1.24; 95%CI, 0.83-1.87; P=.3). Similar results were observed with PATV. Patients with lower attenuation of EAT did not have a higher risk of AF recurrence (log-rank test, P=.75). CONCLUSIONS: EAT parameters including the evaluation of EAT volume, PATV and EAT attenuation were not independent predictors of AF recurrence after catheter ablation.
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Fibrilación Atrial , Ablación por Catéter , Humanos , Persona de Mediana Edad , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Fibrilación Atrial/etiología , Atrios Cardíacos/diagnóstico por imagen , Medición de Riesgo , Tejido Adiposo/diagnóstico por imagen , Ablación por Catéter/métodos , Recurrencia , Resultado del TratamientoRESUMEN
AIMS: To compare the two different ablation strategies, both guided by the Ablation Index (AI), in the setting of atrial fibrillation (AF) ablation: high-power short-duration (HPSD) ablation using 40 W on the posterior wall and 50 W elsewhere versus low-power long-duration (LPLD) using 25 W posteriorly and 35 W elsewhere. METHODS: Prospective, multicenter nonrandomized, noninferiority study of consecutive patients referred for paroxysmal AF ablation from January 2018 to July 2019. Ablation was guided by the AI (≥500 for anterior segments, ≥450 for the roof and inferior segments and 400 posteriorly) and an interlesion distance (ILD) ≤ 6 mm. Patients were separated into two groups: HPSD vs LPLD. Acute reconnection (after adenosine trial) and 2-year outcomes were assessed. RESULTS: 160 patients (61% males, median age of 62 [IQR 51-69] years), fulfilled the study inclusion criteria - 80 patients (316 pulmonary veins [PV]) in the HPSD group and 80 patients (314 PV) in the LPLD. The probability of acute PV reconnection was similar between both groups: 2.2% in HPSD, 95%CI 0.6% to 3.8% vs. 3.4% in LPLD, 95%CI 1.4% to 5.4%; p < 0.001 for noninferiority. Median PV ablation time (20 min vs 30 min, p < 0.01) and procedure duration (80 min vs 100 min, p < 0.001) were shorter in the HPSD group. After a median follow-up of 26 months, arrhythmia recurrence was similar between groups (17.5% in HPSD group vs. 18.8% in LPLD group, p = 0.79). CONCLUSIONS: In paroxysmal AF patients treated with the Ablation Index, a HPSD strategy is noninferior to the more standard LPLD ablation, while allowing for quicker procedures with shorter ablation times.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Masculino , Humanos , Persona de Mediana Edad , Anciano , Femenino , Estudios Prospectivos , Resultado del Tratamiento , Venas Pulmonares/cirugía , Ablación por Catéter/métodos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Fibrilación Atrial/etiología , RecurrenciaRESUMEN
INTRODUCTION: Recurrence of atrial fibrillation (AF) within the blanking period after catheter ablation (CA) is traditionally classified as a transient and benign event. However, recent findings suggest that early recurrence (ER) is associated with late recurrence (LR), challenging the predefined "blanking period". We aimed to determine the clinical and procedural predictors of ER and LR after CA and establish the risk of LR in patients who experience ER. METHODS AND RESULTS: Retrospective single-centre study including all patients who underwent a first procedure of AF CA between 2017 and 2019. ER was defined as any recurrence of AF, atrial flutter or atrial tachycardia >30 s within 90 days after CA and LR as any recurrence after 90 days of CA. A total of 399 patients were included, 37% women, median age of 58 years [49-66] and 77% had paroxysmal AF. Median follow-up was 33 months (from 13 to 61). ER after CA was present in 14% of the patients, and LR was reported in 32%. Among patients who experienced ER, 84% also had LR (p < .001). Patients with ER had a higher prevalence of moderate/severe valvular heart disease, persistent AF, previous electrical cardioversion, a larger left atrium, higher coronary artery calcium score, and higher rates of intraprocedural electrical cardioversion and cardiac fibrosis on eletroanatomical mapping compared with patients without ER. After covariate adjustment, ER and female sex were defined as independent predictors of LR (hazard ratio [HR] 4.69; 95% confidence interval [CI], 2.99-7.35; p < .001 and HR 2.73; 95% CI, 1.47-5.10; p = .002, respectively). CONCLUSION: The risk of LR after an index procedure of CA was significantly higher in patients with ER (five-fold increased risk). These results support the imperative need to clarify the clinical role of the blanking period.
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Fibrilación Atrial , Ablación por Catéter , Humanos , Femenino , Persona de Mediana Edad , Masculino , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Fibrilación Atrial/etiología , Estudios Retrospectivos , Relevancia Clínica , Resultado del Tratamiento , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , RecurrenciaRESUMEN
BACKGROUND: Coronary artery calcium score (CACS) is associated with an increased risk of atrial fibrillation (AF) development, but scarce data are available regarding the impact on AF recurrence. This study aims to assess the impact of CACS on AF recurrence following catheter ablation. METHODS: Retrospective study of patients with AF undergoing cardiac computed tomography (CCT) before ablation (2017-2019). Patients with coronary artery disease (CAD), significant valvular heart disease and previous catheter ablation were excluded. A cut-off of CACS ≥ 100 was used according to literature. RESULTS: A total of 311 patients were included (median age 57 [48, 64] years, 65% men and 21% with persistent AF). More than half of the patients had a CACS > 0 (52%) and 18% a CACS ≥ 100. Patients with CACS ≥ 100 were older (64 [59, 69] vs 55 [46, 63] years, p â< â0.001), had more frequently hypertension (68% vs 42%, p â< â0.001) and diabetes mellitus (21% vs 10%, p â= â0.020). During a median follow-up of 34 months (12-57 months), 98 patients (32%) had AF recurrence. CACS ≥ 100 was associated with increased risk of AF recurrence (unadjusted Cox regression: hazard ratio [HR] 2.0; 95% confidence interval [CI], 1.3-3.1, p â= â0.002). After covariate adjustment, CACS ≥ 100 and persistent AF remained independent predictors of AF recurrence (HR, 1.7; 95% CI, 1.0-2.8, p â= â0.039 and HR, 2.0; 95% CI, 1.3-3.2, p â= â0.004, respectively). CONCLUSION: An opportunistic evaluation of CACS could be an important tool to improve clinical care considering that CACS ≥ 100 was independently associated with a 69% increase in the risk of AF recurrence after first catheter ablation.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Masculino , Humanos , Persona de Mediana Edad , Femenino , Estudios Retrospectivos , Calcio , Vasos Coronarios , Resultado del Tratamiento , Factores de Riesgo , Valor Predictivo de las Pruebas , Ablación por Catéter/efectos adversos , RecurrenciaRESUMEN
INTRODUCTION: Remote monitoring (RM) is a safe and effective alternative to in-office conventional follow-up. OBJECTIVE: We aimed to evaluate patient satisfaction with RM and its impact on healthcare resources in a population with cardiac implantable electronic devices. METHODS: Randomized, pragmatic, open-label controlled trial, with adult wearers of implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy with ICD (CRT-D), eligible for the CareLink® system. Patients newly implanted or with previous conventional follow-up were randomized to RM or conventional follow-up (control), and followed for 12 months, according to the centers' practice. The number of in-office visits and adverse events were compared between groups. Patient and healthcare professionals' satisfaction with RM were described. RESULTS: Of the 134 randomized patients (69 RM; 65 control, aged 60±13 years), 80% were male, 23% employed, 72% ICD wearers and 54% newly implanted. Most patients (70%) reported travel costs less than 15/visit, and 46% daily routine interference with in-office visits. Median physician/technician time with patient was 15 min/15 min, per in-office visit. Excluding baseline and final visits, control patients had more in-office visits in total: median 1 vs. 0, p<0.001. In 81% of the in-office visits, no clinical measures were taken. There were 10 adverse events, with no differences between groups. At the final visit, 95% of RM patients considered RM easy/very easy to use, and would all prefer to maintain RM and recommend it to others. All professionals found the CareLink website easy/very easy to use and were satisfied with transmission data. CONCLUSIONS: In a Portuguese population with ICD and CRT-D, RM safely reduced the burden of in-office visits, with high levels of satisfaction among patients and healthcare professionals.
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Terapia de Resincronización Cardíaca , Desfibriladores Implantables , Adulto , Humanos , Masculino , Femenino , Desfibriladores Implantables/efectos adversos , PortugalRESUMEN
Amiodarone is the most potent antiarrhythmic drug available and is commonly prescribed to treat and prevent not only life-threatening ventricular arrhythmias but also atrial fibrillation (AF). The latest European Society of Cardiology AF guidelines state that amiodarone is recommended for long-term rhythm control in all AF patients but that other antiarrhythmic drugs should be considered first whenever possible, due to its extracardiac toxicity. In patients without significant or with only minimal structural heart disease, amiodarone is not listed as a possibility in their therapeutic scheme. Still, amiodarone is widely and liberally used, and is the most prescribed antiarrhythmic drug for patients with AF despite its high toxicity profile. Non-cardiovascular death was more frequent with amiodarone treatment than with a rate control strategy in AFFIRM, while meta-analyses suggest an association between amiodarone use in patients without structural heart disease and increased non-cardiovascular mortality. Severe or even fatal outcomes due to amiodarone may occur years after treatment initiation and are often not acknowledged by the prescribing physician, who may no longer be following the patient. The lack of widely accepted diagnostic criteria and symptom definitions may lead to underestimation of the incidence of severe side effects and of its toxicity. Unlike the underestimated risk of toxicity with amiodarone, severe complications associated with catheter ablation are usually directly ascribed to the treatment even by non-medical personnel, possibly resulting in overestimation of risks. This brief review will address the issue of amiodarone overuse and the frequent underestimation of its toxicity, while suggesting scenarios in which its use is entirely reasonable, and compare it with catheter ablation.
RESUMEN
Background: The use of the Ablation Index (AI) software for paroxysmal atrial fibrillation (AF) has been associated with higher acute effectiveness and higher 1-year arrhythmia freedom. There is, however, a lack of data concerning longer follow-up. We aim to evaluate the 2-year outcomes after a standardized AI-guided pulmonary vein isolation (PVI). Methods: Prospective, multicenter study of consecutive patients referred for paroxysmal AF ablation from January 2018 to July 2019. PVI was guided by a tailored AI value (≥500 for anterior segment, ≥450 for the roof segments and inferior segments, and 400 for the posterior wall) and an ILD ≤6 mm. The primary endpoints were acute and long-term effectiveness. Results: The study included 218 (842 PV) patients (61% males, median age of 60 [IQR 49-68] years) with paroxysmal AF. First-pass isolation was obtained in 93% of the patients, with an acute reconnection occurring in 10.6% of the patients (3.2% of the PV) following adenosine trial. After a median follow-up of 26 (IQR 20-30) months, freedom from any documented atrial arrhythmia was 83.4%, off-AAD. The rate of adverse events was 1.4%. Although procedural parameters differ across centers (p < 0.001), the acute (p = 0.56) and long-term effectiveness (p = 0.83) were consistent between centers. Conclusions: Patients with paroxysmal AF submitted to an AI-guided PVI workflow presented high arrhythmia freedom at 2-years of follow-up.
RESUMEN
PURPOSE: Since the widespread availability of contact-force sensing catheters, the need for a waiting period after pulmonary vein isolation (PVI) has not been reassessed. We aim to evaluate whether a waiting period is still necessary after PVI guided by the ablation Index (AI). METHODS: Prospective, multicenter, randomized study of consecutive patients referred for paroxysmal atrial fibrillation (AF) ablation from May 2019 to February 2020. Patients were randomized in a 1:1 ratio to PVI with versus without a waiting period of 20 min. Acute pulmonary vein (PV) reconnection after adenosine challenge was the primary endpoint. A per-protocol analysis was designed to determine whether a strategy of dismissing the waiting period after PVI was noninferior to waiting for 20 min for identifying acute PV reconnection. PVI was guided by tailored AI values and an interlesion distance ≤6 mm. RESULTS: During the enrollment period, 167 patients (56% males, mean age of 57 ± 14 years) fulfilled the study inclusion criteria - 84 patients (308 PV) in the waiting period group (Group A) and 83 patients (314 PV) in the group without a waiting period (Group B). Acute PV reconnection was identified in 3.8% (95% confidence interval [CI], 1.7%-5.9%) of PVs in the study group B compared to 2.9% (95% CI, 1.0%-4.8%) of PVs in the Group A (p = .002 for non-inferiority). At 1-year follow-up, there was no significant difference in arrhythmia recurrence between groups (9.5% in Group A vs. 9.6% in Group B, hazard ratio: 1.03 [95% CI, 0.39-2.73], p = .98). CONCLUSION: In paroxysmal AF patients submitted to ablation, a tailored PVI guided by the AI rendered a 20-min waiting period unnecessary.