Detection of atrial fibrillation in persons aged 65 years and above using a mobile electrocardiogram device.

BACKGROUND: Untreated atrial fibrillation (AF) often results in increased morbidity and mortality. Opportunistic AF screening in persons aged ≥ 65 years is recommended to identify patients with AF in order to prevent AF-related complications. OBJECTIVE: The aim of this study was to assess the feasibility of screening persons for AF with the Kardia mobile electrocardiogram device (MED) and to determine the percentage of newly detected AF cases by selective population screening in the Netherlands. METHODS: Persons aged ≥ 65 years, without a medical history of AF, in nursing homes, at public events or visiting the general practitioner (GP) were approached to participate. A Kardia MED smartphone ECG (sECG) was recorded and the CHA2DS2-VASc score was calculated. An automated AF algorithm classified the sECGs as 'sinus rhythm', 'AF' or 'unclassified'. In the case of AF, participants were referred to their GP. All sECGs were assessed by blinded experts. RESULTS: A total of 2168 participants were screened for AF. According to the expert's interpretation, 2.5% had newly detected AF, of whom 76.4% never experienced palpitations and 89.1% had a CHA2DS2-VASc score ≥ 2. The algorithm result was unclassified in 12.2% of cases, of which 95.5% were interpretable by experts. With expert opinion as the gold standard and excluding unclassified sECGs, the Kardia MED's negative and positive predictive value for detecting AF was 99.8% and 60.0%, respectively. CONCLUSION: Screening for AF using the Kardia MED is feasible and results in 2.5% newly detected AF cases. Expert interpretation of algorithm outcomes AF and unclassified is recommended.

Concomitant arrhythmia surgery in patients with congenital heart disease.

OBJECTIVES: Atrial tachyarrhythmia, including atrial fibrillation (AF), atrial flutter (AFL) and intra-atrial reentrant tachycardia (IART), occur frequently in patients with congenital heart disease (CHD), who may undergo multiple surgical procedures throughout life. However, data on the effectiveness of concomitant arrhythmia surgery in CHD patients are scarce. METHODS: Outcome of concomitant arrhythmia surgery for AF or AFL/IART was examined in 66 successive patients [31 men (47%); age at surgery: 56 ± 14 (24-78) years] with various CHD. RESULTS: Concomitant arrhythmia surgery was performed in patients with a history of only AF (n = 46, 70%), only AFL/IART (n = 6, 9%) or a combination of AF and AFL/IART (n = 14, 21%). Median follow-up after arrhythmia surgery was 2 (1-4) years. AF reoccurred in 40 patients (67%), of whom 13 (22%) only had early recurrences; none of the patients with only AFL or IART prior to arrhythmia surgery developed AF after arrhythmia surgery. Recurrence-free survival of late AF was 4.6 years and differed according to the type of AF prior to surgery. Late recurrence-free survival at 3-year follow-up was 71% for paroxysmal AF, 45% for persistent AF and 20% for long-standing persistent AF (P = 0.047). Age at arrhythmia surgery was an independent predictor for late AF recurrence (odds ratio 1.05, P = 0.006). AFL/IART occurred in 17 patients (26%) after arrhythmia surgery, which was de novo in 11 patients (17%). CONCLUSIONS: Arrhythmia surgery in CHD patients results in freedom from late AF recurrence for a small majority of patients after median follow-up of 2 years. (Long-standing) persistent AF and older age at arrhythmia surgery are related to higher recurrence rates.

Progression of late postoperative atrial fibrillation in patients with tetralogy of Fallot.

INTRODUCTION: ToF patients are at risk for ventricular deterioration at a relatively young age, which can be aggravated by AF development. Therefore, knowledge on AF development and its timespan of progression is essential to guide treatment strategies for AF. OBJECTIVE: We examined late postoperative AF onset and progression in ToF patients during long-term follow-up after ToF correction. In addition, coexistence of AF with regular supraventricular tachyarrhythmias (SVT) and ventricular tachyarrhythmias (VTA) was analyzed. METHODS AND RESULTS: ToF patients (N  =  29) with AF after ToF correction referred to the electrophysiology department between 2000 and 2015 were included. All available rhythm registrations were reviewed for AF, regular SVT, and VTA. AF progression was defined as transition from paroxysmal AF to (longstanding) persistent/permanent AF or from (longstanding) persistent AF to permanent AF. At the age of 44 ± 12 years, ToF patients presented with paroxysmal (N  =  14, 48%), persistent (N  =  13, 45%) or permanent AF (N  =  2, 7%). Age of AF development was similar among patients who either underwent initial shunt creation (N  =  15, 45 ± 11 [25-57] years) or primary total ToF correction (N  =  14, 43 ± 13 [26-66] years) (P  =  0.785). AF coexisted with regular SVT (N  =  18, 62%) and VTA (N  =  13, 45%). Progression of AF occurred in 11 patients (38%) within 5 ± 5 years after AF onset despite antiarrhythmic drug class II (AAD, P  =  0.052) or III (P  =  0.587) usage. CONCLUSIONS: AF in our ToF population developed at a young age and showed rapid progression. Rhythm control by pharmacological therapy was ineffective in preventing AF progression.

Intraoperative arrhythmias in children with congenital heart disease: transient, innocent events?

Aims: The significance and incidences of intraoperative arrhythmias occurring in the operating room (OR) in children with congenital heart disease (CHD) are unknown. Aims of this study were to determine incidences of intraoperative arrhythmias in children with CHD and to examine whether they are associated with persistent arrhythmias during follow-up. Methods and results: Continuous ECG recordings obtained from 134 consecutive paediatric CHD patients were manually examined from the moment the aortic cross-clamp (ACC) was removed [use of ACC and cardiopulmonary bypass (CPB)], when CPB was stopped (use of only CPB) or when the sternum was closed (no use of ACC and CPB) until departure from the OR. In the OR, 2nd (60%) and 3rd (34%) degree atrioventricular conduction block (AVB), ectopic atrial rhythm (30%), and junctional rhythm (32%) were most often observed in patients who underwent surgery with both ACC and CPB. Incidences of these arrhythmias decreased after cessation of CPB (P < 0.01). (Supra)ventricular premature beats were mostly observed between end of ACC time and sternum closure (64-84%), but decreased before departure from the OR (6-16%, P < 0.01). During a median follow-up of 37 months, 17 patients (13%) had new onset, late post-operative arrhythmias. Of these patients, 88% had intraoperative arrhythmias compared with 85% of patients without late post-operative arrhythmias (P = 1). Conclusion: Intraoperative arrhythmias, mainly 2nd degree AVB and (supra)ventricular premature beats, were frequently observed in children with CHD undergoing cardiac surgery with use of CPB and ACC. Most arrhythmias were short-lasting and transient and appeared not to be related to late post-operative arrhythmias.

Usefulness of Fragmented QRS Complexes in Patients With Congenital Heart Disease to Predict Ventricular Tachyarrhythmias.

Fragmented QRS complexes (fQRS) on 12-lead electrocardiogram are known predictors of ventricular tachyarrhythmia (VTA) in patients with coronary artery disease. There is limited knowledge of the clinical implications of fQRS in patients with congenital heart defects (CHD). Aims of this study were to examine (1) the occurrence of fQRS in patients with various types of CHD and (2) whether fQRS is associated with development of VTA. This study was designed as retrospective case-control study. Patients with CHD with VTA were included and matched with control patients of the same age, gender, and CHD type. Clinical data and fQRS were analyzed and compared. The initial VTA episode developed in 139 patients with CHD at a mean age of 39 ± 14 years. Compared with controls (n = 219, age 38 ± 13 years), QRS duration was longer in patients with VTA (110 vs 100 ms; p <0.01). Furthermore, fQRS was more frequently observed in patients with VTA in the last electrocardiogram before VTA (n = 73 [53%] vs n = 67 [31%]; p <0.001), especially in patients with sustained VTA (64%). Multiple conditional logistic regression demonstrated more fQRS (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.5 to 5.8; p = 0.002), nonsystemic ventricular dysfunction (OR 5.1, 95% CI 2.1 to 12.4; p <0.001), and more prolonged QRS complexes (OR 2.8, 95% CI 1.3 to 6.2; p = 0.011) in patients with VTA. Therefore, the presence of fQRS on electrocardiogram may be a useful tool in daily clinical practice to identify patients at risk for developing VTA in patients with CHD, in addition to known predictors of VTA.

Non-sustained ventricular tachycardia in patients with congenital heart disease: An important sign?

BACKGROUND: Sustained ventricular tachycardia (susVT) and ventricular fibrillation (VF) are observed in adult patients with congenital heart disease (CHD). These dysrhythmias may be preceded by non-sustained ventricular tachycardia (NSVT). The aims of this study are to examine the 1] time course of ventricular tachyarrhythmia (VTA) in a large cohort of patients with various CHDs and 2] the development of susVT/VF after NSVT. METHODS: In this retrospective study, patients with VTA on ECG, 24-hour Holter or ICD-printout or an out-of-hospital-cardiac arrest due to VF were included. In patients with an ICD, the number of shocks was studied. RESULTS: Patients (N=145 patients, 59% male) initially presented with NSVT (N=103), susVT (N=25) or VF (N=17) at a mean age of 40 ± 14 years. Prior to VTA, 58 patients had intraventricular conduction delay, 14 an impaired ventricular dysfunction and 3 had coronary artery disease. susVT/VF rarely occurred in patients with NSVT (N=5). Fifty-two (36%) patients received an ICD; appropriate and inappropriate shocks, mainly due to supraventricular tachycardia (SVT), occurred in respectively 15 (29%) (NSVT: N=1, susVT: N=9, VF: N=5) and 12 (23%) (NSVT: N=4, susVT: N=5, VF: N=3) patients. CONCLUSIONS: VTA in patients with CHD appear on average at the age of 40 years. susVT/VF rarely developed in patients with only NSVT, whereas recurrent episodes of susVT/VF frequently developed in patients initially presenting with susVT/VF. Hence, a wait-and-see treatment strategy in patients with NSVT and aggressive therapy of both episodes of VTA and SVT in patients with susVT/VF seems justified.

Time Course of Atrial Fibrillation in Patients With Congenital Heart Defects.

BACKGROUND: The incidence of atrial fibrillation (AF) is rising in the aging patients with congenital heart defects (CHD). However, studies reporting on AF in patients with CHD are scarce. The aim of this multicenter study was to examine in a large cohort of patients with a variety of CHD: (1) the age of onset and initial treatment of AF, coexistence of atrial tachyarrhythmia and (2) progression of paroxysmal to (long-standing) persistent/permanent AF during long-term follow-up. METHODS AND RESULTS: Patients (n=199) with 15 different CHD and documented AF episodes were studied. AF developed at 49±17 years. Regular atrial tachycardia (AT) coexisting with AF occurred in 65 (33%) patients; 65% initially presented with regular AT. At the end of a follow-up period of 5 (0-24) years, the ECG showed AF in 81 patients (41%). In a subgroup of 114 patients, deterioration from paroxysm of AF to (long-standing) persistent/permanent AF was observed in 29 patients (26%) after only 3 (0-18) years of the first AF episode. Cerebrovascular accidents/transient ischemic attacks occurred in 26 patients (13%), although a substantial number (n=16) occurred before the first documented AF episode. CONCLUSIONS: Age at development of AF in patients with CHD is relatively young compared with the patients without CHD. Coexistence of episodes of AF and regular AT occurred in a considerable number of patients; most of them initially presented with regular AT. The fast and frequent progression from paroxysmal to (long-standing) persistent or permanent AF episodes justifies close follow-up and early, aggressive therapy of both AT and AF.

Management of atrial fibrillation in patients with congenital heart defects.

Due to improved surgical technologies and post-operative care, long-term survival has improved in patients with congenital heart disease. Atrial fibrillation (AF) is increasingly observed in this aging population and is associated with morbidity and mortality; however, reports about the pathophysiology and the outcome of different treatment modalities of AF are still scarce in patients with congenital heart disease. In this review, the authors describe the epidemiology, pathophysiology and outcome of the different therapies of AF in this specific patient population.

Right versus left atrial pacing in patients with sick sinus syndrome and paroxysmal atrial fibrillation (Riverleft study): study protocol for randomized controlled trial.

BACKGROUND: The incidence of sick sinus syndrome will increase due to population ageing. Consequently, this will result in an increase in the number of pacemaker implantations. The atrial lead is usually implanted in the right atrial appendage, but this position may be ineffective for prevention of atrial fibrillation. It has been suggested that pacing distally in the coronary sinus might be more successful in preventing atrial fibrillation episodes. The aim of this trial is to study the efficacy of distal coronary sinus versus right atrial appendage pacing in preventing atrial fibrillation episodes in patients with sick sinus syndrome. METHODS/DESIGN: This study is designed as a multicenter, randomized controlled trial. Patients with sick sinus syndrome and at least one atrial fibrillation episode of 30 seconds or more in the six months before recruitment will be eligible for participation in this study.All participants will be randomized between pacing distally in the coronary sinus and right atrial appendage. Randomization is stratified for all participating centers. Conventional dual-chamber pacemakers with advanced home monitoring functionality will be implanted. The ventricular lead will be implanted in the right ventricular apex. The first three months of the 36-month follow-up period are considered as run-in time. During the pre-randomization visit and follow-up, an interview, electrocardiogram and pacemaker assessment will be performed, prescribed antiarrhythmic medication will be reviewed and patients will be asked to complete an SF-36 questionnaire. An echocardiographic examination will be conducted in the pre-randomization phase and at the end of each follow-up year. Home monitoring will be used to send daily reports in case of atrial fibrillation episodes. DISCUSSION: This randomized controlled trial is the first in which home monitoring will be used to compare atrial fibrillation recurrences between pacing in the distal coronary sinus or right atrial appendage. Home monitoring gives the opportunity to accurately detect atrial fibrillation episodes and to study characteristics of atrial fibrillation episodes. Should distal coronary sinus pacing significantly diminish atrial fibrillation recurrences, this study will redefine the preferential location of an atrial lead for preventive pacing. TRIAL REGISTRATION: Current Controlled Trials ISRCTN65911661, registered on 8 July 2013.