Comprehensive atrial fibrillation burden and symptom reduction post-ablation: insights from DECAAF II.

AIMS: Traditional atrial fibrillation (AF) recurrence after catheter ablation is reported as a binary outcome. However, a paradigm shift towards a more granular definition, considering arrhythmic or symptomatic burden, is emerging. We hypothesize that ablation reduces AF burden independently of conventional recurrence status in patients with persistent AF, correlating with symptom burden reduction. METHODS AND RESULTS: Ninety-eight patients with persistent AF from the DECAAF II trial with pre-ablation follow-up were included. Patients recorded daily single-lead electrocardiogram (ECG) strips, defining AF burden as the proportion of AF days among total submitted ECG days. The primary outcome was atrial arrhythmia recurrence. The AF severity scale was administered pre-ablation and at 12 months post-ablation. At follow-up, 69 patients had atrial arrhythmia recurrence and 29 remained in sinus rhythm. These patients were categorized into a recurrence (n = 69) and a no-recurrence group (n = 29). Both groups had similar baseline characteristics, but recurrence patients were older (P = 0.005), had a higher prevalence of hyperlipidaemia (P = 0.007), and had a larger left atrial (LA) volume (P = 0.01). There was a reduction in AF burden in the recurrence group when compared with their pre-ablation burden (65 vs. 15%, P < 0.0001). Utah Stage 4 fibrosis and diabetes predicted less improvement in AF burden. The symptom severity score at 12 months post-ablation was significantly reduced compared with the pre-ablation score in the recurrence group, and there was a significant correlation between the reduction in symptom severity score and the reduction in AF burden (R = 0.39, P = 0.001). CONCLUSION: Catheter ablation reduces AF burden, irrespective of arrhythmia recurrence post-procedure. There is a strong correlation between AF burden reduction and symptom improvement post-ablation. Notably, elevated LA fibrosis impedes AF burden decrease following catheter ablation.

Compliance Challenges in a Longitudinal COVID-19 Cohort Using Wearables for Continuous Monitoring: Observational Study.

BACKGROUND: The WEAICOR (Wearables to Investigate the Long Term Cardiovascular and Behavioral Impacts of COVID-19) study was a prospective observational study that used continuous monitoring to detect and analyze biometrics. Compliance to wearables was a major challenge when conducting the study and was crucial for the results. OBJECTIVE: The aim of this study was to evaluate patients' compliance to wearable wristbands and determinants of compliance in a prospective COVID-19 cohort. METHODS: The Biostrap (Biostrap USA LLC) wearable device was used to monitor participants' biometric data. Compliance was calculated by dividing the total number of days in which transmissions were sent by the total number of days spent in the WEAICOR study. Univariate correlation analyses were performed, with compliance and days spent in the study as dependent variables and age, BMI, sex, symptom severity, and the number of complications or comorbidities as independent variables. Multivariate linear regression was then performed, with days spent in the study as a dependent variable, to assess the power of different parameters in determining the number of days patients spent in the study. RESULTS: A total of 122 patients were included in this study. Patients were on average aged 41.32 years, and 46 (38%) were female. Age was found to correlate with compliance (r=0.23; P=.01). In addition, age (r=0.30; P=.001), BMI (r=0.19; P=.03), and the severity of symptoms (r=0.19; P=.03) were found to correlate with days spent in the WEAICOR study. Per our multivariate analysis, in which days spent in the study was a dependent variable, only increased age was a significant determinant of compliance with wearables (adjusted R2=0.1; ß=1.6; P=.01). CONCLUSIONS: Compliance is a major obstacle in remote monitoring studies, and the reasons for a lack of compliance are multifactorial. Patient factors such as age, in addition to environmental factors, can affect compliance to wearables.

Catheter ablation improved ejection fraction in persistent AF patients: a DECAAF-II sub analysis.

AIMS: The aim of our study was to assess differences in post-ablation atrial fibrillation (AF) recurrence and burden and to quantify the change in LVEF across different congestive heart failure (CHF) subcategories of the DECAAF-II population. METHODS AND RESULTS: Differences in the primary outcome of AF recurrence between CHF and non-CHF groups was calculated. The same analysis was performed for the three subgroups of CHF and the non-CHF group. Differences in AF burden after the 3-month blanking period between CHF and non-CHF groups was calculated. Improvement in LVEF was calculated and compared across the three CHF groups. Improvement was also calculated across different fibrosis stages. There was no significant differences in AF recurrence and AF burden after catheter ablation between CHF and non-CHF patients and between different CHF subcategories. Patients with heart failure with reduced ejection fraction (HFrEF) experienced the greatest improvement in EF following catheter ablation (CA, 16.66% ± 11.98, P < 0.001) compared to heart failure with moderately reduced LVEF, and heart failure with preserved EF (10.74% ± 8.34 and 2.00 ± 8.34 respectively, P-value < 0.001). Moreover, improvement in LVEF was independent of the four stages of atrial fibrosis (7.71 vs. 9.53 vs. 5.72 vs. 15.88, from Stage I to Stage IV respectively, P = 0.115). CONCLUSION: Atrial fibrillation burden and recurrence after CA is similar between non-CHF and CHF patients, independent of the type of CHF. Of all CHF groups, those with HFrEF had the largest improvement in LVEF after CA. Moreover, the improvement in ventricular function seems to be independent of atrial fibrosis in patients with persistent AF.

The association of disparities in neighborhood median household income and mortality in patients admitted to the hospital with atrial fibrillation.

BACKGROUND: Lower neighborhood median household income (nMHI) is associated with increased adverse outcomes in patients with atrial fibrillation (AF). However, its effect on mortality is yet unknown. METHODS: Data from the regional United States (U.S.) electronic medical records database, Research Action for Health Network (REACHnet), was extracted for adult patients with AF at Tulane Medical Center over 10 years. Annual nMHI & neighborhood high school graduation (HSG) data was collected from the US Census bureau. Only African Americans (AA) and Caucasians (CC) who had socioeconomic data were included. Low nMHI and low HSG were defined as ≤$25,000 & <90% respectively. High nMHI and HSG were defined as >$50,000 & ≥90% respectively. Primary endpoints were all cause and cardiovascular (CV) mortality. Cox-proportional hazard ratios were used to evaluate the endpoints. RESULTS: We included 4616 patients diagnosed with AF. During a median follow up of 4.6 years, 434 patients died of which 32.7% patients had CV mortality. There was a stepwise decrease in incidence of both all-cause and CV mortality as nMHI increased. Patients with low nMHI had the greatest risk of all-cause mortality (HR 1.9, C.I. 1.2-3.2, P 0.004). The association between low nMHI and all-cause mortality persisted after adjusting for age, sex, race, HSG and stroke risk factors using CHA2DS2VASC, delta CHA2DS2VASC scores and oral anticoagulant use. CV mortality followed a similar trend as all-cause mortality, however, this association was not significant after adjusting for the above variables. Apart from low nMHI, CHA2DS2VASC delta CHA2DS2VASC were statistically significant independent predictors of both all-cause and CV mortality. CONCLUSION: Low nMHI is an independent risk factor for all cause and CV mortality in AF. Higher burden of co-morbidities is the driving force behind this disparity. Future studies should evaluate the role of educational and therapeutic intervention in these populations to reduce mortality.

Predictors of Lesions Contiguity and Transmurality in Canine Ventricular Models After Catheter Ablation.

Background: Interlesion gaps and transmurality of lesions after catheter ablation can precipitate suboptimal efficacy in preventing arrhythmias. Aims: We aim to assess predictors of acute transmural lesion formation and the interlesion distance threshold for creating a continuous, chronic scar after ventricular ablation. Materials and Methods: Ablation procedures were performed on 7 canines followed by late gadolinium enhancement MRI (LGE-MRI). Transmurality of lesions was assessed by 2 independent operators. Ablation parameters such as duration (s), power (W), temperature (C), contact force (CF) (g), were collected for each ablation point. After 7-12 weeks, LGE-MRI was performed, followed by euthanasia, and heart excision. Some lesions were created in pair. Lesion pairs were spaced 7-21 mm apart as measured by Electroanatomic mapping (EAM), with different operating parameters (power 35 or 50W, duration of energy delivery 10, 20 or 30s and contact force of 10g or above). We performed a logistic regression analysis to determine predictors of transmural lesion formation. Results: Eighty-one radiofrequency ablation were performed in total [33 in the Left ventricle (LV) and 48 in the Right ventricle (RV)]. Higher CF was a significant predictor of transmural lesion formation (ß = 0.15, OR = 1.16, 95% CI [1.03 - 1.3], p = 0.01), and lesions delivered in the RV were more frequently transmural than lesions delivered in the LV (ß = -2.43, OR = 0.09, 95%CI [0.02 - 0.34], p < 0.001). For the paired analysis, thirty-eight lesions were created contiguously: fourteen connected lesions and twenty-four unconnected lesions. EAM distance was significantly larger in unconnected lesions than connected lesions (16.17 ± 0.92 mm vs. 11.51 ± 0.68 mm, respectively, p < 0.05). We concluded that an interlesion distance of less than 10 mm is required to prevent gap formation. Average volumes in unconnected lesions (n = 24) at the acute and chronic stages were 0.55 ± 0.11 cm3 and 0.20 ± 0.02 cm3, respectively. On average, lesion volumes were 64% (p < 0.05) smaller at the chronic stage compared to the acute stage. Among connected lesions (n = 14), we observed a volume of 1.19 ± 0.8 cm3 and 0.39 ± 0.15 cm3 at the acute and chronic stages, respectively. These connected lesions reduced in volume by 67% on average. Conclusion: To create contiguous scars on the ventricular endocardial surface, paired lesions should be spaced less than ten millimeters apart. Higher contact force should be used in ventricular ablation to create transmural lesions.

Atrial Fibrillation and Acute Ischemic Stroke: Evaluation of the Contemporary 2018 National Inpatient Sample Database.

Background: Atrial fibrillation (AF) in acute ischemic stroke (AIS) is considered a binary entity regardless of AF type. We aim to investigate in-hospital morbidity and mortality among patients with nonparoxysmal AF-related AIS. Methods: Patients hospitalized for AIS with associated paroxysmal or persistent AF were identified from the 2018 national inpatient sample database. We compared in-hospital mortality, stroke-related morbidity, hospital cost, length of stay, and discharge disposition in patients hospitalized with paroxysmal or persistent AF. Results: A total of 26,470 patients were hospitalized for AIS with paroxysmal or persistent AF. Patient with AIS with persistent AF had a longer hospital length of stay (paroxysmal AF, mean [M] 5.7 days, standard deviation [SD] ±6.8 days; persistent AF, M 7.4 days, SD ±11.9 days, P < 0.001) and in-hospital costs (paroxysmal AF, M $15,449, SD ±$18,320; persistent AF, M $19,834 SD ±$23,312, P < 0.001). Patients with AIS with permanent AF had higher in-hospital mortality (paroxysmal AF, 4.6%, vs permanent AF, 6.2%, P < 0.001). Indirect markers of stroke-related disability, like intracranial hemorrhage (odds ratio [OR]: 1.9, 95% confidence interval (CI): 1.6-2.2), need for gastrostomy (OR: 2.1, 95% CI: 1.8-2.4), and tracheostomy (OR: 3.1, 95% CI: 2.1-4.4) were more associated with AIS from persistent AF. Conclusions: Persistent AF is associated with poor in-hospital stroke-related outcome, possibly due to a worse thrombo-embolic phenomenon. AF pattern may be a harbinger of worse stroke-related morbidity.

Contexte: La fibrillation auriculaire (FA) dans l'accident vasculaire cérébral (AVC) ischémique aigu est considérée comme une entité binaire, quel que soit le type de FA. Nous voulons étudier la morbidité et la mortalité chez les patients hospitalisés pour un AVC ischémique aigu lié à une FA non paroxystique. Méthodologie: Des patients hospitalisés pour un AVC ischémique aigu accompagné d'une FA paroxystique ou persistante ont été répertoriés à partir d'une base de données d'échantillons de patients hospitalisés à l'échelle du pays en 2018. Nous avons comparé la mortalité à l'hôpital, la morbidité liée à l'AVC, le coût de l'hospitalisation, la durée du séjour et les dispositions du congé chez les patients hospitalisés pour une FA paroxystique ou persistante. Résultats: Au total, 26 470 patients ont été hospitalisés pour un AVC ischémique aigu accompagné d'une FA paroxystique ou persistante. Le séjour à l'hôpital était plus long pour les patients atteints d'un AVC ischémique aigu accompagné d'une FA persistante (FA paroxystique, moyenne [M] de 5,7 jours, écart-type [ET] ±6,8 jours; FA persistante, M de 7,4 jours, ET ±11,9 jours, p < 0,001) et les coûts d'hospitalisation ont été plus élevés dans ce groupe de patients (FA paroxystique, M de 15 449 $, ET ±18 320 $; FA persistante, M de 19 834 $, ET ±23 312 $, p < 0,001). La mortalité à l'hôpital était plus élevée chez les patients atteints d'un AVC ischémique aigu accompagné d'une FA permanente (FA paroxystique, 4,6 % vs FA permanente, 6,2 %, p < 0,001). Des marqueurs indirects d'incapacité liée à l'AVC, comme une hémorragie intracrânienne (rapport des cotes [RC] : 1,9, intervalle de confiance [IC] à 95 % : 1,6-2,2), la nécessité d'une gastrostomie (RC : 2,1, IC à 95 % : 1,8-2,4) ou d'une trachéostomie (RC : 3,1, IC à 95 % : 2,1-4,4) ont été davantage associés à l'AVC ischémique aigu découlant d'une FA persistante. Conclusions: La FA persistante est associée à une issue défavorable liée à l'AVC chez les patients hospitalisés, possiblement en raison d'un phénomène thrombo-embolique aggravé. La forme de la FA peut être annonciatrice d'une plus grande morbidité liée à l'AVC.

Studying the Effect of Long COVID-19 Infection on Sleep Quality Using Wearable Health Devices: Observational Study.

BACKGROUND: Patients with COVID-19 have increased sleep disturbances and decreased sleep quality during and after the infection. The current published literature focuses mainly on qualitative analyses based on surveys and subjective measurements rather than quantitative data. OBJECTIVE: In this paper, we assessed the long-term effects of COVID-19 through sleep patterns from continuous signals collected via wearable wristbands. METHODS: Patients with a history of COVID-19 were compared to a control arm of individuals who never had COVID-19. Baseline demographics were collected for each subject. Linear correlations among the mean duration of each sleep phase and the mean daily biometrics were performed. The average duration for each subject's total sleep time and sleep phases per night was calculated and compared between the 2 groups. RESULTS: This study includes 122 patients with COVID-19 and 588 controls (N=710). Total sleep time was positively correlated with respiratory rate (RR) and oxygen saturation (SpO2). Increased awake sleep phase was correlated with increased heart rate, decreased RR, heart rate variability (HRV), and SpO2. Increased light sleep time was correlated with increased RR and SpO2 in the group with COVID-19. Deep sleep duration was correlated with decreased heart rate as well as increased RR and SpO2. When comparing different sleep phases, patients with long COVID-19 had decreased light sleep (244, SD 67 vs 258, SD 67; P=.003) and decreased deep sleep time (123, SD 66 vs 128, SD 58; P=.02). CONCLUSIONS: Regardless of the demographic background and symptom levels, patients with a history of COVID-19 infection demonstrated altered sleep architecture when compared to matched controls. The sleep of patients with COVID-19 was characterized by decreased total sleep and deep sleep.

A cardiovascular clinic patients' survey to assess challenges and opportunities of digital health adoption during the COVID-19 pandemic.

BACKGROUND: COVID-19 boosted healthcare digitalization and personalization in cardiology. However, understanding patient attitudes and engagement behaviors is essential to achieve successful acceptance and implementation of digital health technologies in personalized care. OBJECTIVE: This study aims to understand current and future trends in wearable device and telemedicine use in the cardiology clinic patient population, recognize patients' attitude towards digital health before and after COVID-19, and identify potential socioeconomic and racial/ethnic differences in adoption of digital health tools in a New Orleans patient population. METHODS: A cross-sectional survey was distributed to Tulane Cardiology Clinic patients between September 2020 and January 2021. Basic demographic information, medical comorbidities, device usage, and opinions on digital health tools were collected. RESULTS: Survey responses from 299 participants (average age = 54 years, 50.8% female, 24.4% African American) showed that digital health use was more prevalent in younger, healthier, and more educated individuals. Wearable use was also higher among White patients compared to African American patients. Patients cited costs and technology knowledge as primary deterrents for using wearables, despite being more inclined to use wearables for disease monitoring (41%). While wearable use did not increase after COVID-19 (36.6% pre-COVID vs 35.4% post-COVID, P = .77), telemedicine use rose significantly (10.8% pre-COVID vs 24.3% during COVID, P < .0001). Patients mostly noted telemedicine's effectiveness in overcoming difficult healthcare access barriers. Additionally, most patients are in support of wearables and telemedicine either complementing or replacing routine tests and traditional clinical visits. CONCLUSION: Demographic and socioeconomic disparities negatively impact wearable health device and telemedicine adoption within cardiovascular clinic patients. Although telemedicine use increased after COVID-19, this effect was not observed for wearables, reflecting significant economic and digital literacy challenges underlying wearable acceptance.

Effect of DrOnedarone on atrial fibrosis progression and atrial fibrillation recurrence postablation: Design of the EDORA randomized clinical trial.

BACKGROUND: Atrial fibrillation (AF) recurrence after catheter ablation is associated with worse outcomes and quality of life. Left atrial (LA) structural remodeling provides the essential substrate for AF perpetuation. Baseline extent and the progression of LA fibrosis after ablation are strong predictors of postprocedural AF recurrence. Dronedarone is an antiarrhythmic drug proven to efficiently maintain sinus rhythm. OBJECTIVE: We sought to investigate the effect of the antiarrhythmic drug Dronedarone in decreasing LA fibrosis progression and AF recurrence after ablation of AF patients. METHODS: EDORA (NCT04704050) is a multicenter, prospective, randomized controlled clinical trial. Patients with persistent or paroxysmal AF undergoing AF ablation will be randomized into Dronedarone versus placebo/standard of care. The co-primary outcomes are the recurrence of atrial arrhythmias (AA) within 13 months of follow-up after ablation and the progression of left atrial fibrosis postablation. All patients will receive a late-gadolinium enhancement magnetic resonance imaging at baseline, 3- and 12-month follow-up for the quantification of LA fibrosis and ablation-related scarring. AA recurrence and burden will be assessed using a 30-day ECG patch every 3 months with daily ECG recordings in between. Quality of life improvement is assessed using the AFEQT and AFSS questionnaires. CONCLUSION: EDORA will be the first trial to assess the progression of LA structural remodeling after ablation and its association with Dronedarone treatment and ablation success in a randomized controlled fashion. The trial will provide insight into the pathophysiology of AF recurrence after ablation and may provide potential therapeutic targets to optimize procedural outcomes.

Esophageal temperature during atrial fibrillation ablation poorly predicts esophageal injury: An observational study.

BACKGROUND: Esophageal injury (EI) remains a concern when performing pulmonary vein isolation (PVI) using the high-power short-duration (HPSD) technique. OBJECTIVE: We aim to indicate that high esophageal temperature during HPSD PVI does not correlate with positive esophageal endoscopy (EGD) findings. METHODS: A retrospective observational study was performed on 43 patients undergoing PVI using HPSD (50 W for 6-7 seconds per lesion) at Tulane Medical Center from July 2020 to January 2021. Esophageal temperature was monitored throughout the procedure using a temperature probe and patients underwent EGD the following day. Small ulcers, nonbleeding erosions, erythema, and/or esophagitis were considered positive EGD findings. RESULTS: Mean age was 64.9 years; 46.5% of the patients were female. Eleven patients had positive EGD findings (group 1) and 32 patients had normal EGD (group 2). There was no statistical difference in mean esophageal peak temperature between group 1 and group 2 (43.9°C ± 2.9°C and 42.5°C ± 2.3°C, respectively, P = .17). There was no association between positive EGD results and esophageal temperature during PVI. Mean baseline esophageal temperature was similar in both groups (36.1°C, P = .78). Average contact force (P = .53), ablation time (P = .67), age (P = .3096), sex (P = .4), body mass index (P = .14), and other comorbidities did not correlate with positive endoscopy results. We found positive correlation between the distance of the left atrium (LA) to esophagus and positive EGD (P = .0001). CONCLUSION: EI during HPSD PVI does not correlate to esophageal temperature changes during ablation. However, esophageal injury does correlate to a shorter proximity of the esophagus to the LA.

Acute Lesion Imaging in Predicting Chronic Tissue Injury in the Ventricles.

BACKGROUND: Chronic lesion formation after cardiac tissue ablation is an important indicator for procedural outcome. Moreover, there is a lack of knowledge regarding the features that predict chronic lesion formation. OBJECTIVE: The aim of this study is to determine whether acute lesion visualization using late gadolinium enhanced magnetic resonance imaging (LGE-MRI) can reliably predict chronic lesion size. METHODS: Focal lesions were created in left and right ventricles of canine models using either radiofrequency (RF) ablation or cryofocal ablation. Multiple ablation parameters were used. The first LGE-MRI was acquired within 1-5 h post-ablation and the second LGE-MRI was obtained 47-82 days later. Corview software was used to perform lesion segmentations and size calculations. RESULTS: Fifty-Five lesions were created in different locations in the ventricles. Chronic volume size decreased by a mean of 62.5 % (95% CI 58.83-67.97, p < 0.0005). Similar regression of lesion volume was observed regardless of ablation location (p = 0.32), ablation technique (p = 0.94), duration (p = 0.37), power (p = 0.55) and whether lesions were connected or not (p = 0.35). There was no significant difference in lesion volume reduction assessed at 47-54 days and 72-82 days after ablation (p = 0.31). Chronic lesion volume was equal to 0.32 of the acute lesion volumes (R2 = 0.75). CONCLUSION: Chronic tissue injury related to catheter ablation can be reliably modeled as a linear function of the acute lesion volume as assessed by LGE-MRI, regardless of the ablation parameters.

Transradial approach for diagnostic cerebral angiograms in the elderly: a comparative observational study.

BACKGROUND: The transradial approach (TRA) reduces mortality, morbidity, access site complications, hospital cost, and length of stay while maximizing patient satisfaction. We aimed to assess the technical success and safety of TRA for elderly patients (aged ≥75 years). METHODS: A retrospective chart review and comparative analysis was performed for elderly patients undergoing a diagnostic cerebral angiogram performed via TRA versus transfemoral approach (TFA). Also, a second comparative analysis was performed among the TRA cohort between elderly patients and their younger counterparts. RESULTS: Comparative analysis in the elderly (TRA vs TFA) showed no significant differences for contrast dose per vessel (43.7 vs 34.6 mL, P=0.106), fluoroscopy time per vessel (5.7 vs 5.2 min, P=0.849), procedure duration (59.8 vs 65.2 min, P=0.057), conversion rate (5.8% vs 2.9%, P=0.650), and access site complications (2.3% vs 2.9%, P=1.00). Radiation exposure per vessel (18.9 vs 51.9 Gy cm2, P=0.001) was significantly lower in the elderly TRA group.The second comparison (TRA in elderly vs TRA in the young) showed no significant differences for contrast dose per vessel (43.7 vs 37.8 mL, P=0.185), radiation exposure per vessel (18.9 vs 16.5 Gy cm2, P=0.507), procedure duration (59.8 vs 58.3 min, P=0.788), access site complication (2.3% vs 1.7%, P=0.55), and conversation rate (5.8% vs 1.8%, P=0.092). A trend for prolonged fluoroscopy time per vessel (5.7 vs 4.7 min, P=0.050) was observed in the elderly TRA group. CONCLUSIONS: TRA is a technically feasible and safe option for diagnostic neurointerventional procedures in the elderly. Our small elderly cohort was not powered enough to show a significant difference in terms of access site complications between TRA and TFA.