Radiation dose reduction in the setting of cryoballoon ablation for atrial fibrillation: the value of optimized fluoroscopy settings and intracardiac echocardiography.

Cryoballoon (CB) has proven to be very effective in the percutaneous treatment of atrial fibrillation (AF). CB ablation is still hampered by X-ray exposure and the doses applied are consistently higher if compared to radiofrequency ablation. All patients who underwent CB ablation between 2015 and 2020 were analysed. Intracardiac echography was consistently used for transeptal puncture. To demonstrate the differences in radiation exposure 3 groups of 50 consecutive patients were selected. In the first group (G1) 3D rotational angiography (3DRA) was used as an intraprocedural imaging method. In the second group (G2), traditional X-ray imaging was used and frame rates both for fluoro and cine modes of diascopy were lowered. In the third group (G3) only 2-3 frames per second were used, cine mode was abandoned and the grid was removed from the X-ray detector. A total of 150 patients were included (76% males, mean age 57.3 ± 11.5 years). A dramatic reduction of radiation dose was obtained from 9585 ± 5610 µGy/m2 in G1 to 2469 ± 2002 µGy/m2 in G2 and finally 227.1 ± 360 µGy/m2 in G3 (p < 0.0001). There was also a significant decrease of procedural and fluoroscopy times. No difference in major complications and midterm outcomes was found between the groups. By following a few relatively simple steps (omitting the pre-procedural imaging, removing grid from the X-ray detector and using very low frame rates) CB ablation could be performed with ultralow radiation exposure without compromising the safety of efficacy of the procedure.

Comparison of media and academic attention of recently published positive and neutral or negative randomized cardiovascular clinical trials.

BACKGROUND: Citations are used to assess the importance of authors, articles and journals in the scientific community, but do not examine how they affect general public journal readership. The Altmetric Attention Score (AAS) is a new metric for measuring media attention of the published paper. METHODS: We examined cardiovascular (CV) randomized clinical trials (RCTs), published in the 3 highest Web of Science Impact Factor journals (Journal Citation Reports 2019: category "Medicine, General & Internal") and in the 3 highest Web of Science Impact Factor CV journals (Journal Citation Reports 2019: category "Cardiac & Cardiovascular Systems"), through the calendar year of 2017, 2018 and 2019. The primary outcomes were the assessment of the difference between number of citations and AAS among positive and negative CV RCTs. RESULTS: Among the included 262 RCTs, more positive CV RCTs were published (p = 0.002). There was no significant statistical difference between the positive and negative trials, considering the number of citations (p = 0.61). Interestingly, positive trials had a tendency towards a higher AAS (p = 0.058). The correlation between the AAS and the number of citations was moderate positively correlated (ρ = 0.47, p < 0.001). CONCLUSION: We did not find any differences between CV RCTs with positive vs CV RCTs with negative results considering the number of their citations. A tendency towards a higher AAS among positive CV RCTs could indicate higher activity on social media regarding CV trials with positive results. A higher number of published positive CV RCTs among all published CV RCTs could indicate the presence of publication bias but further investigation of unpublished RCTs in trial registries (e.g., clinicaltrials.gov) is needed.

Intra-procedural three-dimensional rotational angiography in cryoballoon ablation for atrial fibrillation.

Cryoballoon (CB) is an established technology for atrial fibrillation (AF) ablation and is usually performed using solely fluoroscopy. We aimed to study the feasibility of three-dimensional rotational angiography (3DRA) as intra-procedural imaging in CB ablation. Analyzed data were retrospectively collected from patients that underwent second generation CB ablation from February 2015 to August 2017. We studied 68 consecutive patients that received 3DRA (3DRA group). Sixty-six patients who received conventional X-ray imaging served as a control group. 3DRA was performed via an introducer placed in the left atrium. Angiographic images were segmented and fused with live fluoroscopy to guide the ablation. We have analyzed 134 CB patients (73.8% male, 56.9 ± 11.4 years). Paroxysmal AF was present in 77.6% of patients. 3DRA was successfully performed in all 3DRA group patients. The mean procedure time was significantly shorter in the control group (82.4 ± 26.3 min) than in the 3DRA group (121.1 ± 21.4 min) (p < 0.0001). Total radiation dose (419.3 ± 317.9 vs 998.3 ± 673 mGy, p < 0.0001) and contrast administration (83.2 ± 22.3 mL vs 191.6 ± 33.4 mL, p < 0.0001) were significantly lower in control group. There was no significant difference in 2-year success rate, 35.2% of patients had AF recurrence in the 3DRA group and 30.3% in the control group (p = 0.584). Major complications occurred in 2.9% and 1.5% of patients in 3DRA group and control group, respectively (p = 1.000). 3DRA is a feasible method of intra-procedural imaging to guide CB ablation. However, it prolongs procedure time, increases radiation dose and contrast administration with no significant effect on procedure outcomes and complication rates.

Use of figure of eight suture for groin closure with no heparin reversal in patients undergoing cryoballoon ablation for atrial fibrillation.

PURPOSE: We aimed to demonstrate the feasibility of figure of eight (FoE) suture for groin access closure in cryoballoon (CB) ablation and its impact on the lab workflow. METHODS: We retrospectively analyzed all patients who underwent CB ablation in our institution from June 2018. From June 2019, we have been consistently using FoE suture for hemostasis (FoE+ group), and before that conventional manual compression was utilized (FoE- group). Ablations were performed under uninterrupted oral anticoagulant strategy. Both femoral veins were punctured, and a single introducer was placed in each vein. In the FoE- group, after ablation, protamine was administered, and manual compression was applied. In the FoE+ group, the suture was placed in both groins without protamine administration and manual compression. All patients were in decubitus position until the next morning. RESULTS: A total of 190 consecutive patients (73.2% male, 59.7 ± 11.0 years old) were evaluated, 90 being in the FoE+ group. There was no difference in the mean procedure duration between two groups (72.7 ± 23.1 min vs 73.7 ± 27.1 min, p = 0.784). However, the total lab time was significantly longer in FoE- group (132.9 ± 35.3 min vs 109.9 ± 32.6 min, p < 0.0001). There was no difference in complication rates. No major vascular complications were found in our cohort. CONCLUSIONS: Utilization of FoE sutures for hemostasis seems to be a safe and effective after cryoballoon ablation. It abolishes the need for protamine administration which can cause serious adverse events. As manual compression is unrequired, EP lab workflow improves due to significantly shortened total lab time per patient.

Improved real-time recordings using the fourth-generation cryoballoon technology-detection of dual fascicle electrograms.

BACKGROUND: We aimed to analyze the rate of visualization of real-time (RT) recordings and dual fascicle electrograms in our first series of patients treated with the fourth-generation cryoballoon (CB) device. METHODS: All consecutive patients who underwent CB ablation using the fourth-generation technology were included in the analysis. In all procedures, we used a 28-mm CB placed via a single transseptal puncture guided by intracardiac ultrasound. A 20-mm octapolar intraluminal circular catheter was used for intracardiac recordings. A single 180-s freeze strategy was employed. RESULTS: A total of 129 patients (72.9% male, mean age 60.1 ± 10.9 years) were enrolled in the study. RT recordings were detected in 445 (86.2%) pulmonary veins (PVs). Specifically, RT recordings were visualized in 115 left superior PVs (89.2%), 107 left inferior PVs (82.9%), 118 right superior PVs (91.4%), and 105 right inferior PVs (81.3%). Dual fascicle electrograms could be observed only in patients in sinus rhythm, in 23 of 396 PVs (5.8%). They were most commonly observed in the left superior PV (8.1%), somewhat less in both inferior veins (6.1%), while this phenomenon was least frequent in the right superior PV (3.0%). CONCLUSIONS: By using the fourth-generation CB, we report a specific pattern of isolation represented by a sequential isolation of two apparently distinct PV fascicles during a single CB freeze delivery. This phenomenon occurred in 5.8% of PV ablations. Of note, the rate of visualization of RT isolation with this novel CB was very high and could be documented in 86.2% of PVs.

Learning curves in atrial fibrillation ablation - A comparison between second generation cryoballoon and contact force sensing radiofrequency catheters.

OBJECTIVE: To examine the learning curves of atrial fibrillation (AF) ablation comparing the cryoballoon (CB) and radiofrequency (RF) catheters. METHODS: We performed a retrospective data analysis from the initiation of AF ablation program in our center. For CB ablation, a second generation 28 mm balloon was utilized and for RF ablation. RESULTS: A total of 100 consecutive patients (50 in each group) have been enrolled in the study (male 74%, mean age 58.9 ± 10 years, paroxysmal AF 85%). The mean procedure time was shorter for CB (116.6 ± 39.8 min) than RF group (191.8 ± 101.1 min) (p < 0.001). There was no difference in the mean fluoroscopy time, 24.2 ± 10.6 min in RF and 22.4 ± 11.7 min in CB group, (p = 0.422). Seven major complications occurred during the study; 5 in RF group (10%) and 2 in CB group (4%) (p = 0.436). After the mean follow up of 14.5 ± 2.4 months, 15 patients in RF group (30%) and 11 in CB group (26%) experienced AF recurrences (P = 0.300). CONCLUSION: When starting a new AF ablation program, our results suggest that CB significantly shortens procedure while fluoroscopy time and clinical outcomes are comparable to RF ablation.

TWARMI pilot trial: The value and optimal criteria of microvolt T-wave alternans in the diagnosis of reversible myocardial ischemia in patients without structural cardiac disease.

AIMS: Microvolt T-wave alternans (MTWA) testing is a beat-to-beat fluctuation in the amplitude of T wave. We investigated whether: (a) MTWA can be new non-invasive tool for detection of reversible ischemia in patients with suspected CAD without structural heart disease, (b) MTWA can detect ischemia earlier and with greater test accuracy compared with exercise ECG ST-segment testing, and (c) threshold value of MTWA and heart rate at which the alternans is estimated can be different compared to standard values. METHODS: A total of 101 patients with suspected stable coronary disease, but without structural heart disease, were included. Echocardiography, exercise ECG test, MTWA with classical and modified threshold alternans values, and coronary angiography were performed. RESULTS: About 33.3% patients had a false-positive result on exercise ECG test. The sensitivity of exercise ECG ST-segment test in the detection of coronary artery disease was 97.8%, and the specificity was 42.5% (DOR 33.89). In a group of angiographically positive patients, standard MTWA accurately identified 60% of patients, while 40% had a false-negative result. About 91.8% patients with negative angiography result were accurately identified with 8.2% false positives. The sensitivity of MTWA was 59.61% and specificity 91.83%. Best ratio of sensitivity and specificity (86.53% and 95.91%, DOR 151.06) had modified criteria for positive MTWA (MTWA >1.5 µV at heart rate 115-125/min). CONCLUSIONS: This study showed that MTWA can be the new non-invasive tool for the detection of reversible ischemia in patients with suspected CAD without structural heart disease. Also, MTWA can detect ischemia earlier and with greater accuracy compared with exercise ECG testing.

[ATRIAL FIBRILLATION AND HEMODINAMICALY UNSTABLE WIDE QRS COMPLEX TACHYCARDIA ­ A case report].

Tachycardia is an arrhythmia characterized by heart rate > 100 / minute. According to the width of the QRS complex it can be divided into narrow QRS (< 120 ms) and wide QRS tachycardia (> 120 ms). Narrow QRS tachycardia is always supraventricular which means that its source is proximal to the bundle of His, while wide QRS tachycardia can be ventricular (source is in the ventricle, distal to the bundle of His) or supraventricular. The strategies for treating these two conditions are different so the correct diagnosis is prerequisite for optimal therapy. We present this case because the differential diagnosis of wide QRS tachycardia and therefore the treatment planning was particularly difficult due to concurrently present atrial fibrillation with hemodynamic compromise and an acute threat to the life of the patient.

[The first case of radiofrequent ablation of ventricular tachycardia in a patient with ischemic cardiomyopathy in our country]. / Prvi slucaj radiofrekventne ablacije ventrikularne tahikardije kod bolesnika s ishemijskom kardiomiopatijom u nasoj zemlji.

Ablation of ventricular tachycardia in patients with ischemic cardiomyopathy is more complicated and more difficult than ablation of most supraventricular tachycardias. Arrhythmogenic substrate is complex and its localisation is often unclear. Because of the tachycardia characteristics, more precise mapping methods often can't be utilised. Also, patients are usually seriously ill with decreased systolic function, heart failure, ischemia and various comorbidities where tachycardia induction and ablation procedure may facilitate abrupt hemodynamic disturbance. Uninducibility of the clinical tachycardia can be achieved in 65-95% of patients, but tachycardia recurs in 20-44% of patients. Serious complications were noted in 8% of patients with lethal outcome in 2.7% of patients. Decision about therapeutic strategy should be made individually according to potential risk and procedure benefit. This paper presents the first case of the successful ablation of ventricular tachycardia in a patient with ischemic cardiomyopathy in our country.

Quality of life after cardiac surgery.

The aim of this study was to determine a health-related quality of life two or more years after a cardiac surgery using the MOS-36 item short-form health survey questionnaire. 330 members of "Croatian society of patients who underwent cardiac surgery" were asked and 196 responders, 122 men and 74 women, were included in survey, all of them more than two years after surgery and older than fifty years of age. The answers were collected by phone. Women gained better results for Physical Functioning (p < 0.003) and men estimated better scores for psychical health (p < 0.001). Our patients gained some different results in respect to the Croatian sample of healthy people of the same age. They declared better General Health (p < 0.001), less Bodily Pain (p < 0.001), but inferior Role-Emotion (p < 0.001) and Social Functioning (p < 0.001). The estimations of QOL improving were comparable with the results of numerous shorter follow-ups.

Behaviour after cardiosurgery.

Aim of this study was to estimate behavioral changes after cardiac surgery (CS). A questionnaire was sent by mail to 74 women and 122 men during May 2004 and the answers were collected by phone. For statistical analysis, the chi2-test was used. A common unhealthy habits before CS were inappropriate diet (80% of all responders), addictions to alcohol (62%) and nicotine (54%). Significantly fewer patients after CS continue with fatty diet (chi2 = 39.069; p < 0.001), smoking (chi2 = 90.286; p < 0.001) and alcohol drinking habits (chi2 = 60.667; p < 0.001). A significant worsening of sexual life (chi2 = 91.533; p < 0.001) and significantly less negative influence of weather changes (chi2 = 20.821; p < 0.001) was found after CS. Men drink more (chi2 = 16.299; p < 0.001) and smoke more (chi2 = 19.635; p < 0.001), have better sexual life (chi2 = 17.317; p < 0.001), fewer sleeping disorders (chi2 = 17.334; p < 0.001) and better oral health (chi2 = 38.632; p < 0.001) than women. These results can be useful for setting up preventive measures for CVD.

[Influence of electrical cardioversion on troponine I and brain natriuretic peptide (NT-proBNP) levels in patients with persistent atrial fibrillation/flutter]. / Utjecaj elektrokonverzije na vrijednosti troponina I i mozdanog natriuretskog peptida (NT-proBNP) u bolesnika s perzistentnom fibrilacijom/undulacijom atrija.

The goal of our research was to determine how electrical cardioversion influences troponine I and brain natriuretic peptide (NT-proBNP) levels in patients with persistent atrial fibrillation (AF), without heart failure. Reaserch was conducted on 20 patients with AF. Before and after cardioversion levels of troponine I, creatine-kinase (CK), lactate-dehydrogenase (LDH) and brain natriuretic peptide (NT-proBNP) were measured. Average total applied energy was 344,2 +/- 268,9 Joule. After cardioversion CK level was insignificantly higher (113,3:259,0). Levels of troponine I did not change significantly after cardioversion (0,185:0,202). By measuring levels of NT-proBNP significantly lower levels of NT-proBNP were found after cardioversion (1095:432). There was a strong correlation between the duration of arrhythmia and the NT-proBNP level. Electrical cardioversion with standard recommended energy does not cause significant myocardial lesion. CK level elevation is a consequence of skeletal muscle lesion. Possible elevation of troponine I should be interpreted by another etiology. Increased production of BNP is caused by increased pressure and volume overload of the atrium, in patients with AF, independent of global cardiac function, according to that we think that in patients with AF discriminatory values of BNP in heart failure diagnostics should be corrected to higher levels.