Cardiac Resynchronization Therapy for Patients with Mild to Moderately Reduced Ejection Fraction and Left Bundle Branch Block.

BACKGROUND: It is unknown if CRT would improve or halt the progression of heart failure (HF) in patients with mild-moderately reduced LVEF (HFmmrEF) and LBBB. OBJECTIVE: To investigate the outcomes of CRT in patients with HFmmrEF and LV conduction delay. METHODS: A prospective, randomized clinical trial sponsored by NHLBI included 76 patients who met the study inclusion criteria (LVEF 36-50% and LBBB). Patients received CRTP and were randomized to CRT-OFF (RV pacing 40bpm) or CRT-ON (BIV pacing 60-150bpm). At a 6-month follow-up, pacing programming was changed to the opposite settings. NYHA class, NT pro-BNP levels, and echocardiography were collected at baseline, 6-month, and 12-month. The primary study endpoint was the LV end-systolic volume (LVESV) change from baseline, and the primary randomized comparison was the comparison of 6-month to 12-month changes between randomized groups. RESULTS: The mean patient age was 68.4±9.8 years (male 71%). Baseline characteristics were similar between 2 randomized groups (all P>0.05). In patients randomized to CRT-OFF first, then ON, LVESV was reduced from baseline only after CRT-ON (baseline 116.1±36.5 mL, CRT-ON 87.6±26.0 mL, P<0.0001). The randomized analysis of LVEF showed a significantly better change from 6 to 12 months in the "OFF-ON" group, P=0.003. LVEF was improved by CRT (baseline 41.3±4.7%, CRT-ON 46.0±8.0%, P=0.002). In patients randomized to CRT-ON first, then OFF, LVESV was reduced both after CRT-ON and CRT-OFF (baseline 109.8±23.5 mL, CRT-ON 91.7±30.5 mL, P<0.0001; CRT-OFF 99.3±28.9 mL, P=0.012). However, the LVESV reduction effect became smaller between CRT-ON and OFF (P=0.027). LVEF improved both after CRT-ON and CRT-OFF (baseline 42.7±4.3%, CRT-ON 48.5±8.6%, P<0.001; CRT-OFF 45.9±7.7%, P=0.025). CONCLUSION: CRT for patients with HFmmrEF significantly improves LVEF and ventricular remodeling after 6 months of CRT. The study provides novel evidence that early CRT benefits patients with HFmmrEF with LBBB.

Use of three-dimensional electroanatomic mapping for epicardial access: needle tracking, electrographic characteristics, and clinical application.

AIMS: Pericardiocentesis is usually completed under fluoroscopy. The electroanatomic mapping (EAM) system allows visualizing puncture needle tip (NT) while displaying the electrogram recorded from NT, making it possible to obtain epicardial access (EA) independent of fluoroscopy. This study was designed to establish and validate a technique by which EA is obtained under guidance of three-dimensional (3D) EAM combined with NT electrogram. METHODS AND RESULTS: 3D shell of the heart was generated, and the NT was made trackable in the EAM system. Unipolar NT electrogram was continuously monitored. Penetration into pericardial sac was determined by an increase in NT potential amplitude and an injury current. A long guidewire of which the tip was also visible in the EAM system was advanced to confirm EA. Epicardial access was successfully obtained without complication in 13 pigs and 22 patients. In the animals, NT potential amplitude was 3.2 ± 1.0 mV when it was located in mediastinum, 5.2 ± 1.6 mV when in contact with fibrous pericardium, and 9.8 ± 2.8 mV after penetrating into pericardial sac (all P ≤ 0.001). In human subjects, it measured 1.54 ± 0.40 mV, 3.61 ± 1.08 mV, and 7.15 ± 2.88 mV, respectively (all P < 0.001). Fluoroscopy time decreased in every 4-5 cases (64 ± 15, 23 ± 17, and 0 s for animals 1-4, 5-8, 9-13, respectively, P = 0.01; 44 ± 23, 31 ± 18, 4±7 s for patients 1-7, 8-14, 15-22, respectively, P < 0.001). In five pigs and seven patients, EA was obtained without X-ray exposure. CONCLUSION: By tracking NT in the 3D EAM system and continuously monitoring the NT electrogram, it is feasible and safe to obtain EA with minimum or no fluoroscopic guidance.

3-D transesophageal echocardiography aids in assessment of embolic stroke due to aortic atherosclerotic plaque: A case series.

Atherosclerosis is the most common cause of heart disease and stroke. Plaque thickness ≥4 mm in the ascending aorta or aortic arch is strongly correlated with cerebral embolic events and ischemic stroke. However, despite imaging workup, the cause of embolic stroke remains unidentified in many patients. Transesophageal echocardiography (TEE) is the preferred echocardiographic method for the evaluation of cardiac source of emboli. 2D TEE imaging evaluates aortic root and aortic arch in a single plane or two planes with biplane imaging. However, 2D TEE often fails to detect mobile or complex components in the ascending aorta and aortic arch plaques. The routine availability of 3D TEE in current ultrasound systems may significantly improve the assessment of aortic plaques as a potential embolic source. In this case series, we present four consecutive patients with stroke who underwent TEE by a single cardiologist for possible cardioembolic source. Some of these patients may have been labelled as "cryptogenic stroke" or "embolic stroke of undetermined source" (ESUS) due to the presence of insignificant or nonmobile ascending aortic or aortic arch plaques on 2D TEE imaging. In our four consecutive patients with ESUS who underwent TEE by a single operator, 3D TEE showed complex aortic arch plaques with ulceration with mobile components and established these plaques as the likely source of embolic stroke.

Catheter ablation of atrial fibrillation in patients with left bundle branch block.

BACKGROUND: Left bundle branch block (LBBB) and atrial fibrillation (AF) are commonly coexisting conditions. The impact of LBBB on catheter ablation of AF has not been well determined. This study aims to explore the long-term outcomes of patients with AF and LBBB after catheter ablation. METHODS: Forty-two patients with LBBB of 11,752 patients who underwent catheter ablation of AF from 2011 to 2020 were enrolled as LBBB group. After propensity score matching in a 1:4 ratio, 168 AF patients without LBBB were enrolled as non-LBBB group. Late recurrence and a composite endpoint of stroke, all-cause mortality, and cardiovascular hospitalization were compared between the two groups. RESULTS: Late recurrence rate was significantly higher in the LBBB group than that in the non-LBBB group (54.8% vs. 31.5%, p = .034). Multivariate analysis showed that LBBB was an independent risk factor for late recurrence after catheter ablation of AF (hazard ratio [HR] 2.19, 95% confidence interval [CI] 1.09-4.40, p = .031). LBBB group was also associated with a significantly higher incidence of the composite endpoint (21.4% vs. 6.5%, HR 3.98, 95% CI 1.64-9.64, p = .002). CONCLUSIONS: LBBB was associated with a higher risk for late recurrence and a higher incidence of composite endpoint in the patients underwent catheter ablation.

Hand-Held Echocardiography by Advanced Practice Providers in Patients with Congestive Heart Failure.

OBJECTIVES: The performed hand-held echocardiography (HHE) was evaluated and interpreted by trained advanced practice providers (APPs) on hospitalized CHF patients for image quality and interpretation by comparing with expert echocardiographer and SE findings. BACKGROUND: Congestive heart failure (CHF) is associated with increased hospital admissions and mortality. While a standard echocardiogram (SE) is the gold standard for cardiac assessment, it is not readily available. Hospitalized CHF patients require rapid assessment for expedited treatment. METHODS: Over 6 months, five trained APPs performed HHE on hospitalized CHF patients and interpreted: (a) left ventricular (LV) size, (b) LV ejection fraction (LVEF), and (c) right atrial pressure (RAP). The study echocardiographer reviewed and blindly interpreted the HHE images and compared them with APPs and SE findings. Kappa statistics determined the degree of agreement between APPs and the study echocardiographer's interpretation of the HHE images and SE. RESULTS: A total of 80 CHF patients (age 73 ± 14 years, 58% males; LVEF (by SE) 45 ± 19%; 36.3% body mass indexes ≥ 30 kg/m2) were enrolled. HHE interpretation by APPs had a good agreement for LVEF (kappa 0.79) with the study echocardiographer and SE (kappa 0.74) and a good agreement for RAP (kappa 0.67) with the study echocardiographer. The correlation between the absolute LVEF interpretation by the study echocardiographer on HHE and SE was r = 0.88 (p < 0.0001). CONCLUSIONS: Trained APPs obtained diagnostic-quality HHE images and interpreted the LV function and RAP in CHF patients in good agreement with the study echocardiographer. LVEF by HHE correlated with LVEF by SE. Our study suggests trained APPs can use HHE to evaluate LVEF and RAP in CHF patients, leading to expedited and optimized treatment.

Reconsideration of the definition of blanking period and significance of early recurrences after catheter ablation of atrial fibrillation.

PURPOSE OF REVIEW: Early recurrence of atrial tachyarrhythmia (ERAT) during blanking period (BP) is not uncommon after catheter ablation of AF. Current guidelines and consensus statements recommend conservative treatment of ERAT. This review summarized recent studies, underlying mechanism and clinical managements of ERAT, and proposed a reconsideration of the definition and clinical significance of BP. RECENT FINDINGS: Recent studies have shown that the entity of ERAT in the very early phase of BP (i.e., first 4 weeks of the 3-month period) is different from those ERATs occurring late which is strongly associated with the late recurrence of atrial tachyarrhythmia. The optimal BP duration suggested by clinical observation ranges from 21 to 58 days. Using antiarrhythmic drugs and early electrical cardioversion are the effective management for ERAT, whereas re-ablation is a reasonable strategy although remains controversial. SUMMARY: The definition of BP with a shorter duration, that is, 1 month instead of 3 months post AF ablation, is supported by the observations of latest clinical studies. Recurrent atrial tachyarrhythmia beyond the 1-month time frame is associated with higher risk of late recurrence and may warrant repeat ablation. A revisit to the guideline recommendation on management of ERAT is needed to change clinical practice.

Expression of m6A Regulator Genes can Facilitate the Diagnosis of Chronic Heart Failure.

BACKGROUND: RNA N6-methyladenosine (m6A) is the most common type of modification in eukaryotic mRNA. The relationship between m6A modification and disease has been studied extensively, but there have been few studies on chronic heart failure (CHF). This study investigated a possible role for m6A in the diagnosis of CHF. METHODS: Seven candidate m6A regulators (writers: WTAP and ZC3H13; readers: YTHDF3, FMR1, IGFBP1, and ELAVL1; eraser: FTO) were identified using a random forest (RF) model and the GSE5406 dataset from the Gene Expression Omnibus database. A nomogram model was developed to predict the risk of CHF, while consensus clustering methodology assigned CHF samples into two m6A patterns (cluster A and cluster B) according to the 7 candidate m6A regulators. Principal component analysis was used to calculate an m6A score for each sample and to quantify m6A patterns. RESULTS: Decision curve analysis and the nomogram model were used to obtain predictions that may be of clinical use. Patients in cluster B had higher m6A scores than patients in cluster A. Cluster B patients also had higher expression levels (ELs) of IL-4, IL-5, IL-10 and IL-13 than patients in cluster A, whereas cluster A patients had a higher EL for IL-33. The m6A cluster B pattern likely represents the ischemic heart failure (HF) disease group. CONCLUSION: m6A regulators are important in the pathogenesis of CHF associated with ischemic and idiopathic dilated cardiomyopathy, and may prove useful for the diagnosis and treatment of CHF.

Point-of-Care Ultrasound in Detection, Severity and Mechanism of Significant Valvular Heart Disease and Clinical Management.

BACKGROUND: Early diagnosis of significant valvular heart disease (VHD) enables appropriate implementation of the best therapeutic strategy and follow-up. Cardiac auscultation remains suboptimal in early detection of VHD. The aim of this study was to evaluate the utility of point-of-care ultrasound (POCUS) for early detection of VHD and its severity. METHODS: All consecutive patients with VHD who did not have a standard echocardiogram prior to first outpatient cardiology consultation underwent history and physical examination followed by POCUS study by an experienced physician in a general cardiology clinic from June 2017 to August 2022 at our institution. Subsequent standard transthoracic echocardiography (sTTE) was performed as the gold standard. Comparison was performed between POCUS and sTTE for the presence and severity of VHD. sTTE was performed by registered cardiac sonographers and interpreted by another cardiologist blinded to the POCUS results. RESULTS: A total of 77 patients were studied (ge 72 ± 11 years, 58.4% males). A total of 89 significant valvular abnormalities were diagnosed. There were 39 (43.8%) cases of regurgitant VHD, 16 (18.0%) of stenotic VHD and 34 (38.2%) had evaluation for prosthetic valve function. The sensitivity (90.9%; 82.4%; 83.3%; 100%) and specificity (100%; 96.7%; 100%; 100%) were high for detecting ≥ moderate aortic regurgitation (AR), mitral regurgitation (MR), aortic stenosis (AS) and prosthetic valvular abnormality, respectively. The weighted κ coefficient between POCUS and sTTE for the assessment of ≥ moderate MR, AR and AS was 0.81 (95% CI, 0.65-0.97), 0.94 (95% CI, 0.84-1.00) and 0.88 (95% CI, 0.76-1.0), respectively, indicating excellent agreement. CONCLUSIONS: POCUS can identify patients with significant VHD and may serve as a powerful screening tool for early detection of significant VHD in the outpatient clinical practice with downstream impact on clinical management of significant VHD.

Association of shift work and dietary inflammatory potential with all-cause death among us hypertensive population: national health and nutrition examination study, 2005-2010.

BACKGROUND & AIMS: The individual effect of working schedule on survival in the hypertensive population has not been adequately studied. Shiftworkers are also prone to unhealthy lifestyles like pro-inflammatory diet. Therefore, we assessed the effect of shift work and its joint association with dietary inflammatory potential on mortality risk among the large US nationally representative sample of adult hypertensive population. METHODS: Data were from a nationally representative prospective cohort among US hypertensive population (n = 3680; weighted population, 54,192,988). The participants were linked to the 2019 public-access linked mortality archives. The working schedule were self-reported using the Occupation Questionnaire Section. Dietary inflammatory index (DII) scores were equally calculated using the 24-hour dietary recall (24 h) interviews. Multivariable Cox proportional hazards regression models were used to estimate hazard ratio and 95% confidence intervals (95%CI) for survival of hypertension individuals by work schedule and dietary inflammatory potential. The joint effect of work schedule and dietary inflammatory potential was then examined. RESULTS: Among the 3680 hypertension individuals (39.89% female [n = 1479] and 71.42% white [n = 1707]; weighted mean [SE] age, 47.35 [0.32] years), 592 individuals reported shift work status. 474 (10.76%) reported shift work status with pro-inflammatory dietary pattern (DII scores > 0). 118 (3.06%) reported shift work status with anti-inflammatory dietary pattern (DII scores < 0). 646 (19.64%) reported a non-shift working schedule with anti-inflammatory dietary pattern, while 2442 (66.54%) reported non-shift working schedule with pro-inflammatory dietary pattern. After a median follow-up of 11.67 years (140 months), 317 deaths (cardiovascular diseases (CVD), 65; cancer, 104) were registered. Cox regression analysis showed that shift work was associated with higher risk of all-cause mortality (hazard ratio [HR], 1.48; 95% CI, 1.07-2.06) compared with non-shift workers. In the joint analysis, shift work status combined with pro-inflammatory dietary pattern was associated with the highest all-cause mortality risk. Moreover, adopting the anti-inflammatory diet significantly attenuates the deleterious effect of shift work on mortality risk. CONCLUSIONS: In this large representative sample of adults with hypertension in the U.S., the combination of shift work status with pro-inflammatory dietary pattern was highly prevalent and was associated with the highest risks of death from all causes.

Risk Factors for Left Ventricular Thrombus Formation in Patients with Dilated Cardiomyopathy.

BACKGROUND: Left ventricular thrombus (LVT) is a common complication of dilated cardiomyopathy (DCM), causing morbidity and mortality. METHODS: This study retrospectively analyzed patients with DCM from January 2002 to August 2020 in Beijing Anzhen Hospital. Clinical characteristics were compared between the LVT group and the age and sex 1:4 matched with the LVT absent group. The receiver operator characteristic (ROC) curve was plotted to evaluate the diagnostic value of D-dimer predicting LVT occurrence in DCM. RESULTS: A total of 3,134 patients were screened, and LVT was detected in 72 (2.3%) patients on echocardiography. The patients with LVT had higher D-dimer, fibrinogen, and lower systolic blood pressure than those without LVT. The ejection fraction (EF) was lower and left ventricular end-systolic diameter was larger in the LVT group. Severe mitral regurgitation (MR) was more common in the LVT absent groups. The prevalence of atrial fibrillation was lower in the LVT group. The ROC curve analysis yielded an optimal cut-off value of 444 ng/mL DDU (D-dimer units) for D-dimer to predict the presence of LVT. Multivariable binary logistic regression analysis revealed that EF (OR = 0.90, 95% CI = 0.86-0.95), severe MR (OR = 0.19, 95% CI = 0.08-0.48), and D-dimer level (OR = 15.4, 95% CI = 7.58-31.4) were independently associated with LVT formation. CONCLUSION: This study suggested that elevated D-dimer levels (>444 ng/mL DDU) and reduced EF were independently associated with increased risk of LVT formation. Severe MR could decrease the incidence of LVT.

The Role of Mitochondrial Quality Control in Anthracycline-Induced Cardiotoxicity: From Bench to Bedside.

Cardiotoxicity is the major side effect of anthracyclines (doxorubicin, daunorubicin, epirubicin, and idarubicin), though being the most commonly used chemotherapy drugs and the mainstay of therapy in solid and hematological neoplasms. Advances in the field of cardio-oncology have expanded our understanding of the molecular mechanisms underlying anthracycline-induced cardiotoxicity (AIC). AIC has a complex pathogenesis that includes a variety of aspects such as oxidative stress, autophagy, and inflammation. Emerging evidence has strongly suggested that the loss of mitochondrial quality control (MQC) plays an important role in the progression of AIC. Mitochondria are vital organelles in the cardiomyocytes that serve as the key regulators of reactive oxygen species (ROS) production, energy metabolism, cell death, and calcium buffering. However, as mitochondria are susceptible to damage, the MQC system, including mitochondrial dynamics (fusion/fission), mitophagy, mitochondrial biogenesis, and mitochondrial protein quality control, appears to be crucial in maintaining mitochondrial homeostasis. In this review, we summarize current evidence on the role of MQC in the pathogenesis of AIC and highlight the therapeutic potential of restoring the cardiomyocyte MQC system in the prevention and intervention of AIC.

Right Ventricular Enlargement and Dysfunction Are Associated With Increased All-Cause Mortality in Hypertrophic Cardiomyopathy.

OBJECTIVE: To assess whether right ventricular enlargement (RVE) and right ventricular dysfunction (RVD) adversely affect prognosis in hypertrophic cardiomyopathy (HCM). PATIENTS AND METHODS: Data were retrieved from Mayo Clinic's prospectively collected HCM registry between January 1, 2000, and September 30, 2012. Right ventricle (RV) size and function were semiquantitatively categorized via echocardiography as normal (RV-Norm) versus abnormal (RV-Abn) (RVE or RVD). All-cause mortality was the primary endpoint. RESULTS: Of 1878 HCM patients studied (mean age 53±15 years; 41.6% female), only 71 (3.8%) had RV-Abn (24 RVE, 28 RVD, 19 combined RVE and RVD). Compared with HCM patients with RV-Norm, RV-Abn patients were older (57±14 vs 53±15 years, P=.02), more symptomatic (New York Heart Association functional class III-IV in 62.0% vs 48.6%, P=.03), had more atrial fibrillation (53.5% vs 17.3%, P<.001), and more prior implantable cardioverter-defibrillator implantation (23.9% vs 11.3%, P=.02). Median follow-up was 9.4 years with 311 deaths. Patients who were RV-Abn had higher all-cause mortality compared with RV-Norm (log-rank P<.001); 24.1% (95% CI, 15.5% to 35.3%) vs 6.1% (95% CI, 5.1% to 7.3%) at 5 years. In multivariable Cox modeling, RV-Abn (hazard ratio, 1.89; 95% CI, 1.18 to 3.03; P=.008) was associated independently with all-cause mortality after adjusting for age, female sex, New York Heart Association functional class, atrial fibrillation, hypertension, coronary artery disease, implantable cardioverter-defibrillator implantation, beta blocker use, prior septal reduction therapy, resting LV outflow tract gradient, maximal LV wall thickness, and moderate or greater tricuspid regurgitation. CONCLUSION: Although perturbations in RV size and function were observed in fewer than 5% of patients with HCM, they were associated with nearly two-fold higher all-cause mortality at long-term follow-up.

Association of Postprocedural Left Atrial Volume and Reservoir Function with Outcomes in Patients with Atrial Fibrillation Undergoing Catheter Ablation.

BACKGROUND: The value of left atrial (LA) volume and reservoir function (ResF) after ablation for atrial fibrillation for predicting overall outcomes needs further investigation, particularly in large cohorts. The aim of this study was to test the hypothesis that abnormal LA volume and ResF after ablation are associated with adverse outcomes. METHODS: Patients who underwent primary atrial fibrillation ablation between 2007 and 2016 and had available measurements of maximum LA volume index (LAVImax) and minimum LA volume index (LAVImin) and LA ResF (LA emptying fraction and LA expansion index) at 3-month echocardiographic examination after ablation were included in this analysis. The primary endpoint was the composite of cardiac hospitalization for heart failure or acute ischemic events, stroke or transient ischemic attack, and all-cause death; secondary endpoints were cardiac hospitalization and all-cause death. RESULTS: A total of 792 patients were studied (mean age, 60 ± 10 years). Over a median of 7.5 years (interquartile range, 3.0-9.7 years) of follow-up, 96 patients experienced adverse events. After adjustment for several parameters, including age, comorbidities, and left ventricular structure and function, increased LA volumes and impaired ResF were each independently associated with the primary endpoint (LAVImax > 34 mL/m2: adjusted hazard ratio [HR], 2.37 [95% CI, 1.49-3.76; P = .0003]; LAVImin ≥ 20.5 mL/m2: adjusted HR, 3.21 [95% CI, 1.97-5.24; P < .0001]; LA emptying fraction < 40%: adjusted HR, 2.00 [95% CI, 1.29-3.10; P = .002]; LA expansion index < 66%: adjusted HR, 1.91 [95% CI, 1.22-2.98; P = .005]) as well as with the secondary endpoints of cardiac hospitalization (P < .05 for adjusted HR for all LA parameters) and all-cause death (P < .05 for adjusted HR for LAVImin, LA emptying fraction and LA expansion index). ResF measures were incremental to LAVImax (P < .05 for all), but not to LAVImin. In patients with normal LA (LAVImax ≤ 34 mL/m2; n = 403), those with higher LAVImin (≥17 mL/m2) were at 4 times higher risk for primary endpoint events (age-adjusted HR, 4.32; 95% CI, 1.90-9.81; P = .0005). All these findings were independent of atrial tachyarrhythmia recurrence. CONCLUSIONS: Enlarged left atrium and impaired ResF at 3 months after ablation for atrial fibrillation are strongly associated with long-term outcomes, independent of left ventricular function or cardiac rhythm at follow-up. LAVImin showed the strongest associations and even identified a high-risk subgroup among patients with nondilated left atria.

Impact of Heart Rate and Rhythm on Corrected QT Interval During Paroxysmal Atrial Fibrillation.

Current knowledge on the dynamic changes of corrected QT (QTc) before, during, and after an atrial fibrillation (AF) episode is limited. It remains controversial which of the presently available formulas performs the best in calculating QTc during AF. This study was designed to explore whether an AF attack would affect QTc and to determine the performance of 6 available formulas in correcting QT before, during, and after AF. A total of 101 patients with Holter-documented paroxysmal AF were enrolled. QT interval before, during, and after AF was measured and corrected to heart rate (HR) by using Bazett, Fridericia, Framingham, Hodges, Dmitrienko, and RTHa formulas. In 40 patients, QTc under AF was compared with under sinus rhythm (SR) with identical HR. Although QT was significantly longer before AF and after AF compared with during AF; there was no difference in QTc between SR and AF with identical HR regardless of the formulas used. QTc calculated by the Framingham formula showed excellent homogeneity with a mean delta difference of -0.2 ± 41.6 ms (before AF vs AF) and -6.6 ± 35.4 ms (after AF vs AF), respectively. QTc corrected by the Bazett formula (before AF vs AF -38.7 ± 52.3 ms; after AF vs AF -42.6 ± 46.9 ms) yielded significant heterogeneity among the 3 time points. In conclusion, AF does not influence QTc. The Framingham formula accurately corrects QT without being affected by the AF episode. The Bazett formula significantly overestimated QTc during AF.

Arrhythmia Recurrence After Atrial Fibrillation Ablation: Impact of Warfarin vs. Non-Vitamin K Antagonist Oral Anticoagulants.

PURPOSE: Both warfarin and non-vitamin K antagonist oral anticoagulants (NOACs) have pleiotropic effects including anti-inflammatory and anti-fibrotic properties. This study aims to explore whether arrhythmia recurrence after AF ablation is influenced by the choice of oral anticoagulant. METHODS: We retrospectively studied all patients who underwent primary AF ablation between 2011 and 2017 and divided them into two groups according to the anticoagulant used: Warfarin vs. NOACs. The primary endpoint was atrial tachyarrhythmia recurrence after ablation. RESULTS: Of the 1106 patients who underwent AF ablation in the study period (median age 62.5 years; 71.5% males, 48.2% persistent AF), 697 (63%) received warfarin and 409 (37%) received NOACs. After a median of 26.4 months follow-up, arrhythmia recurrence was noted in 368 patients in warfarin group and 173 patients in NOACs group, with a 1-year recurrence probability of 35% vs. 36% (log rank P = 0.81) and 5-year recurrence probability of 62% vs. 63% (Log rank P = 0.32). However, NOACs use was associated with a higher probability of recurrence (46% for 1 year, 68% for 5 years) in patients with persistent AF compared with those taking warfarin (34% for 1 year, 63% for 5 years; log rank P = 0.01 and P = 0.02 respectively). Multivariate analysis indicated that in patients with persistent AF, use of NOACs was an independent risk factor of atrial tachyarrhythmia recurrence after ablation (HR 1.39, 95% CI 1.07-1.81, P = 0.013). CONCLUSION: In this large contemporary cohort, overall AF recurrence after ablation was similar with NOACs or warfarin use. However, in patients with persistent AF, NOACs use was associated with a higher probability of arrhythmia recurrence and was an independent risk factor of recurrence at long-term follow-up.

Comparison of prognosis and outcomes of catheter ablation versus drug therapy in patients with atrial fibrillation and stable coronary artery disease: A prospective propensity-score matched cohort study.

BACKGROUND: Atrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist. HYPOTHESIS: To investigate the prognosis of catheter ablation versus drug therapy in patients with AF and SCAD. METHODS: In total, 25 512 patients with AF in the Chinese AF Registry between 2011 and 2019 were screened for SCAD. 815 patients with AF and SCAD underwent catheter ablation therapy were matched with patients by drug therapy in a 1:1 ratio. Primary end point was composite of thromboembolism, coronary events, major bleeding, and all-cause death. The secondary endpoints were each component of the primary endpoint and AF recurrence. RESULTS: Over a median follow-up of 45 ± 23 months, the patients in the catheter ablation group had a higher AF recurrence-free rate (53.50% vs. 18.41%, p < .01). In multivariate analysis, there was no significant difference between the strategy of catheter ablation and drug therapy in primary composite end point (adjusted HR 074, 95%CI 0.54-1.002, p = .0519). However, catheter ablation was associated with fewer all-cause death independently (adjusted HR 0.36, 95%CI 0.22-0.59, p < .01). In subgroup analysis, catheter ablation was an independent risk factor for all-cause death in the high-stroke risk group (adjusted HR 0.39, 95%CI 0.23-0.64, p < .01), not in the low-medium risk group (adjusted HR 0.17, 95%CI 0.01-2.04, p = .17). CONCLUSIONS: In the patients with AF and SCAD, catheter ablation was not independently associated with the primary composite endpoint compared with drug therapy. However, catheter ablation was an independent protective factor of all-cause death.

Post Procedural Peak Left Atrial Contraction Strain Predicts Recurrence of Arrhythmia after Catheter Ablation of Atrial Fibrillation.

BACKGROUND: Left atrial (LA) function can be impaired by the atrial fibrillation (AF) ablation and might be associated with the risk of recurrence. We sought to determine whether the post-procedural changes in LA function impact the risk of recurrence following AF ablation. METHODS: We retrospectively reviewed patients who underwent AF ablation between 2009 and 2011 and underwent transthoracic echocardiography before ablation, 1-day and 3-month after ablation. Peak left atrial contraction strain (PACS) and left atrial emptying fraction (LAEF) were evaluated during sinus rhythm and compared across the three time points. The primary endpoint was atrial tachyarrhythmia recurrence after ablation. RESULTS: A total of 144 patients were enrolled (mean age 61 ± 11 years, 77% male, 46% persistent AF). PACS and LAEF initially decreased 1-day following ablation but partially recovered within 3 months in PAF patients, with a similar trend in the PerAF patients. After median 24 months follow-up, 68 (47%) patients had recurrence. Patients with recurrence had higher PACS1-day than that in non-recurrence subjects (-10.9 ± 5.0% vs. -13.4 ± 4.7%, p = 0.003). PACS1-day -12% distinguished recurrence cases with a sensitivity of 67.7% and specificity of 60.5%. The Kaplan-Meier curves showed significant difference in 5-year cumulative probability of recurrence between those with PACS ≥ -12% and PACS < -12% (log rank p < 0.0001). Multivariate regression showed that PACS1-day was an independent risk factor of arrhythmia recurrence. CONCLUSIONS: Left atrial function deteriorates immediately following AF ablation and partially recovers in 3 months but remains abnormal in the majority of patients. PACS1-day post procedure predicts arrhythmia recurrence at long-term follow-up.

Modifications of the Langendorff Method for Simultaneous Isolation of Atrial and Ventricular Myocytes from Adult Mice.

A single cardiomyocyte is a vital tool in the cellular and subcellular level studies of cardiac biology and diseases as a fundamental unit of contraction and electrical activity. Hence, isolating viable, high-quality cardiomyocytes from the heart is the initial and most crucial experimental step. Comparing the various protocols for isolating the cardiomyocytes of adult mice, the Langendorff retrograde perfusion is the most successful and reproducible method reported in the literature, especially for isolating ventricular myocytes. However, isolating quality atrial myocytes from the perfused heart remains challenging, and few successful isolation reports are available. Solving this complicated problem is extremely important because apart from ventricular disease, atrial disease accounts for a large part of heart diseases. Therefore, further investigations on the cellular level to reveal the mechanisms are warranted. In this paper, a protocol based on the Langendorff retrograde perfusion method is introduced and some modifications in the depth of aorta cannulation and the steps that may affect the digestion process to isolate atrial and ventricular myocytes were simultaneously made. Moreover, the isolated cardiomyocytes are confirmed to be amenable to patch clamp investigation.

Ethanol infusion into the vein of Marshall for recurrent perimitral atrial tachycardia after catheter ablation for persistent atrial fibrillation.

BACKGROUND: Catheter ablation of perimitral atrial tachycardia (PMAT) is challenging. Epicardial conduction of the Marshall bundle (MB) across the mitral isthmus (MI) remains an important cause of recurrent tachycardia. The role of ethanol infusion into the vein of Marshall (EI-VOM) for PMAT has not been fully elucidated. METHODS: The study enrolled 28 consecutive patients with recurrent PMAT after atrial fibrillation (AF) ablation. Conventional PMAT (group 1, n = 15) and MB-related PMAT (group 2, n = 13) were diagnosed by detailed activation mapping and entrainment mapping. VOM venography and EI-VOM were first performed, and additional ablation was performed if necessary. RESULTS: The VOM was accessible in 24 (85.7%) patients (12 [80%] in group 1 and 12 [92.3%] in group 2). Patients with MB-related PMAT were more responsive to EI-VOM (as shown by PMAT termination or tachycardia cycle length prolongation) (92.4% vs 53.3%, P = .038). In the 16 patients requiring additional ablation after EI-VOM, all residual MI conduction gaps were located on the annular side of the MI. At the end of the procedure, MI bidirectional block was achieved in 14 (93.3%) patients in group 1 and in 12 (92.3%) patients in group 2 (P = 1.000). After a mean follow-up of 7.5 ± 3.1 months, three (10.7%) patients had recurrent AT. CONCLUSIONS: EI-VOM is feasible and effective in the treatment of PMAT after AF ablation, especially in patients with MB-related PMAT.

New-Onset Atrial Fibrillation and Adverse In-Hospital Outcome in Patients with Acute Pulmonary Embolism.

Atrial fibrillation (AF) can be secondary to acute pulmonary embolism (PE). This study aimed to investigate the prognostic impact of new-onset AF on patients with acute PE. In this study, 4,288 consecutive patients who were diagnosed with acute PE were retrospectively screened. In total, 77 patients with acute PE and new-onset AF were analyzed. Another 154 acute PE patients without AF were selected as the age- and sex-matched control group. Adverse in-hospital outcome comprised one of the following conditions: all-cause death, endotracheal intubation, cardiopulmonary resuscitation, and intravenous catecholamine therapy. The patients with new-onset AF had higher prevalence of congestive heart failure, higher simplified PE severity index (sPESI), higher creatinine, and larger left atrium diameter. The incidences of adverse in-hospital outcomes were 10.4 and 2.6% in patients with new-onset AF and no AF, respectively (p = 0.02). Patients with sPESI ≥ 1 had higher incidence of adverse in-hospital outcomes than those with sPESI = 0 (9.4 vs. 0.9%, p < 0.01). The area under the receiver operating characteristic curve of sPESI and sPESI + AF (adding 1 point for new-onset AF) scores in assessing the adverse in-hospital outcome were 0.80 (95% confidence interval [CI]: 0.68-0.93) and 0.84 (95% CI: 0.72-0.96), respectively. In multivariable analysis, sPESI ≥ 1 (odds ratio, 8.88; 95% CI: 1.10-72.07; p = 0.04) was an independent predictor of adverse in-hospital outcome. However, new-onset AF was not an independent predictor. In the population studied, sPESI is an independent predictor of adverse in-hospital outcomes, whereas new-onset AF following acute PE is not, but it may add predictive value to sPESI.