Epicardial adipose tissue volume assessed by cardiac CT as a predictor of atrial fibrillation recurrence following catheter ablation.

INTRODUCTION: In patients with atrial fibrillation (AF), up to one third have recurrence after a first catheter ablation (CA). Epicardial adipose tissue (EAT) has been considered to be closely related to AF, with a potential role in its recurrence. We aimed to evaluate the association between the volume of EAT measured by cardiac computed tomography (CT) and AF recurrence after CA. METHODS: Consecutive AF patients underwent a standardized cardiac CT protocol for quantification of EAT, thoracic adipose volume (TAV) and left atrium (LA) volume before CA. An appropriate cut-off of EAT was determined and risk recurrence was estimated. RESULTS: 305 patients (63.6 % male, mean age 57.5 years, 28.2 % persistent AF) were followed for 24 months; 23 % had AF recurrence at 2-year mark, which was associated with higher EAT (p = 0.037) and LAV (p < 0.001). Persistent AF was associated with higher EAT volumes (p = 0.010), TAV (p = 0.003) and LA volumes (p < 0.001). EAT was predictive of AF recurrence (p = 0.044). After determining a cut-off of 92 cm3, survival analysis revealed that EAT volumes > 92 cm3 showed higher recurrence rates at earlier time points after the index ablation procedure (p = 0.006), with a HR of 1.95 (p = 0.008) of AF recurrence at 2-year. After multivariate adjustment, EAT > 92 cm3 remained predictive of AF recurrence (p = 0.028). CONCLUSION: The volume of EAT measured by cardiac CT can predict recurrence of AF after ablation, with a volume above 92 cm3 yielding almost twice the risk of arrhythmia recurrence in the first two years following CA. Higher EAT and TAV are also associated with persistent AF.

Evaluation of left atrial strain imaging and integrated backscatter as predictors of recurrence in patients with paroxysmal, persistent, and long-standing persistent atrial fibrillation undergoing catheter ablation.

BACKGROUND: Impaired left atrial (LA) strain predicts atrial fibrillation (AF) recurrence after catheter ablation (CA), but currently there is no cut-off to guide patient selection for CA. Integrated backscatter (IBS) is a promising tool for noninvasive quantification of myocardial fibrosis. The aim of this study was to compare LA strain and IBS between paroxysmal, persistent, and long-standing persistent AF and evaluate their association with AF recurrence after CA. METHODS: Analysis of consecutive patients with symptomatic paroxysmal and persistent AF who underwent CA. LA phasic strain, strain rate and IBS were assessed by two-dimensional speckle-tracking at baseline. RESULTS: We analyzed 78 patients, 31% with persistent AF (46% long-standing AF), 65% male, mean age 59 ± 14 years, who underwent CA and were followed-up for 12 months. AF recurrence occurred in 22 (28%) patients. LA phasic strain parameters were significantly impaired in patients with AF recurrence and were independent predictors of AF recurrence in a multivariable analysis. LA reservoir strain (LASr) < 18% predicted AF recurrence with 86% sensitivity and 71% specificity, with a higher predictive power compared to LA volume index (LAVI). LASr < 22% in paroxysmal AF and LASr < 12% in persistent AF correlated with AF recurrence. Increased IBS was a predictor of AF recurrence in patients with paroxysmal AF. CONCLUSION: LA phasic strain parameters were predictors of AF recurrence after CA, independently of LAVI and AF subtype. LASr < 18% showed a higher predictive power compared to LAVI. Further studies are needed to investigate the role of IBS as a predictor of AF recurrence.

A simplified single transseptal puncture approach using high-density 3D voltage mapping for atrial fibrillation ablation: acute complications and long-term results.

Background: An ablation catheter and a circular mapping catheter requiring a double transeptal puncture (TSP) for left atrial access have been conventionally used for atrial fibrillation (AF) ablation. Recently, different operators have combined a single transseptal puncture technique with 3D high-density mapping catheters for pulmonary vein isolation (PVI). Objective: This study aims to compare two strategies, single vs. double TSP, regarding the duration of the procedure, radiation time, complication rates, and outcomes. Methods: Retrospective analysis of a large cohort of consecutive patients that underwent first PVI with radiofrequency energy (RF), using a point-by-point strategy, with a 3D mapping system, either with single or double TSP, according to the operator's choice. Results: 285 patients with a mean age of 59.5 ± 11.6 years (36.5% female, 67.7% paroxysmal AF) underwent a point-by-point catheter ablation with RF between July 2015 and March 2020. The mean CHA2DS2-VASc score was 1.7 ± 1.3. Single TSP was performed in 115 (40.3%) patients and double TSP in 170 (59.6%). The operator's experience (≥5 years of AF ablation procedures) was equally distributed among the two groups. The average procedure time (133 ± 31.7 min vs. 123 ± 35.5 min, for single and double TSP, respectively) did reach a statistical difference between both groups (p = 0.008), but there was a substantial advantage regarding fluoroscopy time (13 ± 6.3 min vs. 19 ± 9.1 min, for single and double TSP, respectively; p < 0.001). Acute major complications present similar rates in both groups (2.6% vs. 2.3%, p = 0.799). At the 2-year follow-up, both groups had a similar sinus rhythm maintenance rate (76.5% vs. 78.8%, p = 0.646). Conclusion: A simplified single-TSP technique using high-density multi-electrode 3D mapping is a safe and highly successful option for AF ablation. This approach yields a substantial reduction in fluoroscopy time, with the potential to avoid acute complications, compared to a conventional double-TSP strategy.

Case report: Mutation in NPPA gene as a cause of fibrotic atrial myopathy.

Early-onset atrial fibrillation (AF) can be the manifestation of a genetic atrial myopathy. However, specific genetic identification of a mutation causing atrial fibrosis is rare. We report a case of a young patient with an asymptomatic AF, diagnosed during a routine examination. The cardiac MRI revealed extensive atrial fibrosis and the electrophysiology study showed extensive areas of low voltage. The genetic investigation identified a homozygous pathogenic variant in the NPPA gene in the index case and the presence of the variant in heterozygosity in both parents.

Quadripolar left ventricle only single lead pacing in a patient with a tricuspid mechanical valve: A less invasive approach.

In the presence of prosthetic tricuspid valve, the inaccessibility to the right ventricle makes permanent pacing challenging. The placement of a left ventricle (LV) single lead in the coronary sinus (CS) is a well-accepted alternative, with some limitations regarding sensing and threshold. We describe a clinical case of a patient who had a previous LV only lead in the CS due to the presence of a prosthetic tricuspid valve and, after a surgical valvular intervention, presented with recurrent syncope episodes due to lead malfunction with lack of pacing capture and significant ventricular pauses. A quadripolar lead was chosen to be placed in the CS connected to a cardiac resynchronization therapy pacemaker device, programmed at biventricular VVI and using a specific manufacturer T-wave protection algorithm to prevent pacemaker-induced arrhythmias and to use the patient's own rhythm. This approach prevented a fourth surgical intervention to place an epicardial lead and resulted in reasonable LV sensing and pacing threshold. Learning objectives: This paper reports an alternative and atypical approach that could solve some of the limitations associated with ventricular pacing in patients with tricuspid prosthetic valves and multiple previous surgeries.

Electrical storm in hypertrophic cardiomyopathy: Cardiac magnetic resonance and sudden cardiac death risk stratification: a case report.

Background: Risk stratification for sudden cardiac death (SCD) is a key factor in the management of patients with hypertrophic cardiomyopathy (HCM). Cardiac magnetic resonance (CMR) has a unique role in the evaluation of HCM and offers superior diagnostic and prognostic information to assess the indication for a prophylactic implantable cardioverter-defibrillator (ICD). Case summary: A 39-year-old patient with non-obstructive HCM with a low ESC HCM Risk-SCD score underwent a CMR revealing a left ventricular apical aneurysm and extensive late gadolinium enhancement; a prophylactic ICD was thus implanted. A month later, the patient was admitted in refractory electrical storm with over 50 appropriate ICD shocks due to sustained ventricular tachycardia. Despite anti-arrhythmic therapy and mechanical ventilation, the evolution was unfavourable with haemodynamic instability; veno-arterial extracorporeal membrane oxygenation was implanted. The patient was submitted to CMR-guided epicardial VT catheter ablation with complications of LV thrombus and severe pericardial effusion. Discussion: This case details the complex risk stratification for SCD in patients with HCM, highlighting the important role of CMR in the integrated approach to risk stratification.

The Atrium in Atrial Fibrillation - A Clinical Review on How to Manage Atrial Fibrotic Substrates.

Atrial fibrillation (AF) is the most common sustained arrhythmia in the population and is associated with a significant clinical and economic burden. Rigorous assessment of the presence and degree of an atrial arrhythmic substrate is essential for determining treatment options, predicting long-term success after catheter ablation, and as a substrate critical in the pathophysiology of atrial thrombogenesis. Catheter ablation of AF has developed into an essential rhythm-control strategy. Nowadays is one of the most common cardiac ablation procedures performed worldwide, with its success inversely related to the extent of atrial structural disease. Although atrial substrate evaluation remains complex, several diagnostic resources allow for a more comprehensive assessment and quantification of the extent of left atrial structural remodeling and the presence of atrial fibrosis. In this review, we summarize the current knowledge on the pathophysiology, etiology, and electrophysiological aspects of atrial substrates promoting the development of AF. We also describe the risk factors for its development and how to diagnose its presence using imaging, electrocardiograms, and electroanatomic voltage mapping. Finally, we discuss recent data regarding fibrosis biomarkers that could help diagnose atrial fibrotic substrates.

Non-Vitamin K Oral Anticoagulants Assessment in High Risk of Bleeding Patients with Non-Valvular Atrial Fibrillation.

Atrial fibrillation (AF) is commonly associated with advanced age and the presence of multiple, concomitant acute and chronic health conditions, placing this population at high risk for serious therapeutic side effects. Nonvitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation. The purpose of this study was to investigate the effectiveness and safety of NOAC in a group at high risk of bleeding complications, in a real-world setting. We conducted a retrospective analysis of a high-risk cohort of 418 patients (pts) followed-up in our anticoagulation unit; data on patient characteristics, anticoagulation treatment, and bleeding and thrombotic complications were evaluated. The population had a median age of 77.8 ± 10.3 years and the mean CHA2DS2-VASc score was 3.85 (SD ± 1.4). Overall, 289 (69.1%) were ≥75 years old. During a mean follow-up time of 51.2 ± 35.7 months, we observed a rate of any bleeding of 7, a clinically relevant non-major bleeding rate of 4.8, a major bleeding rate of 2.2, a stroke rate of 1.6, and a rate of thrombotic events of 0.28 per 100 patient-years. There were 59 hospitalizations due to any cause (14.1%) and 36 (8.6%) deaths (one due to ischemic stroke). A structured follow-up, with judicious prescribing and drug compliance, may contribute to preventing potential complications.

Lockdown measures for COVID-19 outbreak and variation in physical activity in patients with heart failure and cardiac implantable devices.

AIMS: The present study analysed the patterns of physical activity pre-, during and post-lockdown measures for COVID-19 pandemic in patients with chronic heart failure (CHF) and cardiac implantable electronic devices (CIED) under remote monitoring (RM), and assessed the physical activity patterns during these periods. METHODS: The raw data from 95 patients with CHF (age 67,7 ± 15,1 years, 71,5% male) corresponding to 2238 RM transmissions of the Medtronic Carelink™ network platform was obtained. The physical exercise profiles and the impact of the lockdown measures on the physical behaviour during and after the measures were analysed. According to the level of activity duration in the pre-lockdown, lockdown and post-lockdown periods, the patterns of behaviour were identified (non-recoverees, incomplete recoverees, recoverees and full-recoverees). CONCLUSION: RM of CHF patients with CIED using the Carelink™ network is useful for close follow-up and identification of heart failure risk status variations. After relieving the confinement measures there were two groups of patients that did not recover the previous physical activity levels. Physical inactivity in patients with CHF can have a significant impact on outcomes.

His-bundle pacing as an alternative to CRT in a patient with left bundle branch block, left ventricular dysfunction, and TAVI-induced complete AV block.

Our clinical case supports the effectiveness of distal His-Bundle pacing in obtaining ventricular resynchronization in patients with LBBB and left ventricular dysfunction, particularly in the context of post-TAVI conduction disturbances.

Response and outcomes of cardiac resynchronization therapy in patients with renal dysfunction.

PURPOSE: Renal dysfunction is often associated with chronic heart failure, leading to increased morbi-mortality. However, data regarding these patients after cardiac resynchronization therapy (CRT) is sparse. We sought to evaluate response and long-term mortality in patients with heart failure and renal dysfunction and assess renal improvement after CRT. METHODS: We analyzed 178 consecutive patients who underwent successful CRT device implantation (age 64 ± 11 years; 69% male; 92% in New York Heart Association (NYHA) functional class ≥ III; 34% with ischemic cardiomyopathy). Echocardiographic response was defined as ≥ 15% reduction in left ventricular end-systolic diameter and clinical response as a sustained improvement of at least one NYHA functional class. Renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m2. RESULTS: Renal dysfunction was present in 34.7%. Renal dysfunction was not an independent predictor of echocardiographic response (OR 1.109, 95% CI 0.713-1.725, p 0.646) nor clinical response (OR 1.003; 95% CI 0.997-1.010; p 0.324). During follow-up (mean 55.2 ± 32 months), patients with eGFR < 60mL/min/1.73 m2 had higher overall mortality (HR 4.902, 95% CI 1.118-21.482, p 0.035). However, clinical response in patients with renal dysfunction was independently associated with better long-term survival (HR 0.236, 95% CI 0.073-0.767, p 0.016). Renal function was significantly improved in patients who respond to CRT (ΔeGFR + 5.5 mL/min/1.73 m2 at baseline vs. follow-up, p 0.049), while this was not evident in nonresponders. Improvements in eGFR of at least 10 mL/min/1.73 m2 were associated with improved survival in renal dysfunction patients (log-rank p 0.036). CONCLUSION: Renal dysfunction was associated with higher long-term mortality in CRT patients, though, it did not influence echocardiographic nor functional response. Despite worse overall prognosis, renal dysfunction patients who are responders showed long-term survival benefit and improvement in renal function following CRT.

What happens to non-responders in cardiac resynchronization therapy?

INTRODUCTION AND OBJECTIVES: Left ventricular reverse remodeling (LVRR) is strongly related to the long-term prognosis of patients undergoing cardiac resynchronization therapy (CRT). The aim of this study was to assess the long-term clinical outcome of patients without LVRR at six months after CRT implantation and to determine the prognostic impact of clinical response in this population. METHODS: We analyzed 178 consecutive patients who underwent successful CRT device implantation (age 64±11 years; 69% male; 89% in New York Heart Association [NYHA] functional class III; 35% with ischemic cardiomyopathy). Clinical status and echocardiographic parameters were determined before and six months after CRT implantation. We identified those without criteria for LVRR (≥10% increase in left ventricular ejection fraction with ≥15% reduction in left ventricular end-systolic diameter compared to baseline). Clinical responders were defined by a sustained improvement of at least one NYHA functional class. RESULTS: At six-month assessment after CRT, 109 (61%) patients showed LVRR. During a mean follow-up of 56±21 months, 47 (26%) patients died, with higher mortality in the group without LVRR (36% vs. 20%, p=0.023). Clinical response was greater in patients with LVRR (88% vs. 55%, p<0.001). In patients without LVRR, clinical response to CRT was the strongest independent predictor of survival (hazard ratio: 0.120; 95% confidence interval: 0.039-0.366; p<0.001). CONCLUSION: Although patients without LVRR six months after CRT implantation had a worse prognosis, with higher all-cause mortality, clinical response can be an independent predictor of survival in this population.

Improved outcomes with European Society of Cardiology guideline-adherent antithrombotic treatment in high-risk patients with atrial fibrillation: a report from the EORP-AF General Pilot Registry.

AIMS: Guideline-adherent therapy for stroke prevention in atrial fibrillation has been associated with better outcomes, in terms of thromboembolism (TE) and bleeding. METHODS AND RESULTS: In this report from the EuroObservational Research Programme-Atrial Fibrillation (EORP-AF) Pilot General Registry, we describe the associated baseline features of 'high risk' AF patients in relation to guideline-adherent antithrombotic treatment, i.e. whether they were adherent, over-treated, or under-treated based on the 2012 European Society of Cardiology (ESC) guidelines. Secondly, we assessed the predictors of guideline-adherent antithrombotic treatment. Thirdly, we evaluated outcomes for all-cause mortality, TE, bleeding, and the composite endpoint of 'any TE, cardiovascular death or bleeding' in relation to whether they were ESC guideline-adherent treatment. From the EORP-AF cohort, the follow-up dataset of 2634 subjects was used to assess the impact of guideline adherence or non-adherence. Of these, 1602 (60.6%) were guideline adherent, whilst 458 (17.3%) were under-treated, and 574 (21.7%) were over-treated. Non-guideline-adherent treatment can be related to region of Europe as well as associated clinical features, but not age, AF type, symptoms, or echocardiography indices. Over-treatment per se was associated with symptoms, using the EHRA score, as well as other comorbidities. Guideline-adherent antithrombotic management based on the ESC guidelines is associated with significantly better outcomes. Specifically, the endpoint of 'all cause death and any TE' is increased by >60% by undertreatment [hazard ratio (HR) 1.679 (95% confidence interval (CI) 1.202-2.347)] or over-treatment [HR 1.622 (95% CI 1.173-2.23)]. For the composite endpoint of 'cardiovascular death, any TE or bleeding', over-treatment increased risk by >70% [HR 1.722 (95% CI 1.200-2.470)]. CONCLUSION: Even in this cohort with high overall rates of oral anticoagulation use, ESC guideline-adherent antithrombotic management is associated with significantly better outcomes, including those related to mortality and TE, as well as the composite endpoint of 'cardiovascular death, any TE or bleeding'. These contemporary observations emphasize the importance of guideline implementation, and adherence to the 2012 ESC guidelines for stroke prevention in AF.

Regional differences in presentation and treatment of patients with atrial fibrillation in Europe: a report from the EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry.

AIMS: Country differences in management practices are evident, and the publication of management guidelines by the European Society of Cardiology (ESC) and other learned societies has tried to recommend a uniform evidence-based approach to management. Despite the availability of guidelines and efforts to improve implementation, differences in guideline adherence are evident, and differences between countries and regions within Europe are therefore likely. METHODS AND RESULTS: In this analysis from the baseline dataset of the EORP-AF Pilot survey, we examined regional differences in presentation and treatment of contemporary patients with atrial fibrillation (AF) in Europe, as managed by European cardiologists. We focused on a subgroup of 902 hospital admitted patients in whom no rhythm control was performed or planned. Chronic heart failure was more common in East countries (P < 0.0001) while hypertension and peripheral artery disease were more common in South countries (both P < 0.0001). Previous bleeding and chronic kidney disease were more common in South countries (both P < 0.0001). A CHA2DS2-VASc score of ≥2 was highest in East and South countries (93.0 and 95.3%, respectively) compared with 80.8% in West countries (P < 0.0001). A HAS-BLED score of ≥3 was also highest in East and South countries (18.0 and 29.2% respectively) compared with 4.8% in West countries (P < 0.0001). Oral anticoagulation (OAC) use (either as OAC or OAC plus antiplatelet therapy) in West, East, and South countries was 72.0, 74.7, and 76.2%, respectively. Only antiplatelet therapy was used in 13.6, 15.4, and 12.4%, respectively. An initial rate control strategy only was most common in South countries (77.8%) (P < 0.0001). CONCLUSION: From the systematic collection of contemporary data regarding the management and treatment of AF in nine participating member ESC countries, we provide hypothesis-generating insights into regional management practices in Europe with regard to patient characteristics and treatment options.

A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry.

AIMS: Given the advances in atrial fibrillation (AF) management and the availability of new European Society of Cardiology (ESC) guidelines, there is a need for the systematic collection of contemporary data regarding the management and treatment of AF in ESC member countries. METHODS AND RESULTS: We conducted a registry of consecutive in- and outpatients with AF presenting to cardiologists in nine participating ESC countries. All patients with an ECG-documented diagnosis of AF confirmed in the year prior to enrolment were eligible. We enroled a total of 3119 patients from February 2012 to March 2013, with full data on clinical subtype available for 3049 patients (40.4% female; mean age 68.8 years). Common comorbidities were hypertension, coronary disease, and heart failure. Lone AF was present in only 3.9% (122 patients). Asymptomatic AF was common, particularly among those with permanent AF. Amiodarone was the most common antiarrhythmic agent used (∼20%), while beta-blockers and digoxin were the most used rate control drugs. Oral anticoagulants (OACs) were used in 80% overall, most often vitamin K antagonists (71.6%), with novel OACs being used in 8.4%. Other antithrombotics (mostly antiplatelet therapy, especially aspirin) were still used in one-third of the patients, and no antithrombotic treatment in only 4.8%. Oral anticoagulants were used in 56.4% of CHA2DS2-VASc = 0, with 26.3% having no antithrombotic therapy. A high HAS-BLED score was not used to exclude OAC use, but there was a trend towards more aspirin use in the presence of a high HAS-BLED score. CONCLUSION: The EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot Registry has provided systematic collection of contemporary data regarding the management and treatment of AF by cardiologists in ESC member countries. Oral anticoagulant use has increased, but novel OAC use was still low. Compliance with the treatment guidelines for patients with the lowest and higher stroke risk scores remains suboptimal.