Echocardiographically measured epicardial fat predicts new-onset atrial fibrillation after cardiac surgery

Abstract Objective: The current study aims to investigate the role of echocardiographically measured epicardial adipose tissue (EAT) thickness in the prediction of new-onset atrial fibrillation (AF) following coronary artery bypass grafting (CABG) surgery. Methods: One hundred and twenty-four patients scheduled to undergo isolated on-pump CABG due to coronary artery disease were enrolled to the current study. Patient characteristics, medical history and perioperative variables were prospectively collected. EAT thickness was measured using transthoracic echocardiography (TTE). Any documented episode of new-onset postoperative AF (POAF) until discharge was defined as the study endpoint. Fortyfour participants with POAF served as AF group and 80 patients without AF served as Non-AF group. Results: Two groups were similar in terms of baseline echocardiographic and laboratory findings. In laboratory findings, the groups were similar in terms of the studied parameters, except N-terminal pro-brain natriuretic peptide (NT Pro-BNP), which was higher in AF group than in Non-AF group (P=0.035). The number of left internal mammary artery (LIMA) grafts was not different in both groups. AF group had higher cross-clamp (CC) and cardiopulmonary bypass (CPB) times than Non-AF group (P=0.01 and P<0.001). In multivariate logistic regression analysis, EAT was found an independent predictor for the development of POAF (OR 4.47, 95% CI 3.07-5.87, P=0.001). Conclusion: We have shown that EAT thickness is associated with increased risk of AF development and can be used as a prognostic marker for this purpose.

Preventive effect of preoperative vitamin d supplementation on postoperative atrial fibrillation

Abstract Objective: To assess the relationship between preoperative vitamin D (vitD) supplementation and the development of postoperative atrial fibrillation (POAF). Methods: The study group consisted of 328 consecutive patients. The ınfluence of preoperative vitD supplementation on POAF was reviewed in 136 patients who underwent coronary artery bypass graft surgery with vitD insufficiency (n=80) and vitD deficiency (n=56). Patients were assigned to receive either oral vitD (50.000 U) (treatment group, n=68) or not (control group, n=68) 48 hours before surgery. Patients were followed up during hospitalisation process with respect to POAF. Results: There was no significant difference between treatment and control groups with regards to age, gender, diabetes mellitus, smoking history, chronic obstructive pulmonary disease, left atrial diameter, and biochemical parameters. Also, there was no significant difference between these groups with regards to mean vitD level on both insufficiency and deficiency patients (24.6±3.7 vs. 24.9±3.9 ng/ml P=0.837, 11.4±4.9 vs. 10.9±5.2 ng/ml P=0.681, respectively). Although the occurrence of POAF was not significantly different among treatment and control groups in patients with vitD insufficiency (31% vs. 33% P=0.538), there was a significant difference between the two groups regarding to POAF in patients with vitD deficiency (18% vs. 29% P=0.02). Conclusion: Although preoperative vitD supplementation was not found to be associated with prevention of POAF in patients with vitD insufficiency, it was found to be strongly associated with prevention of POAF in those with vitD deficiency.

Pulmonary Vein Anatomy is Associated with Cryo Kinetics during Cryoballoon Ablation for Atrial Fibrillation / A Anatomia da Veia Pulmonar está Associada à Criocinética durante a Ablação por Criobalão da Fibrilação Atrial

Abstract Background: The influence of pulmonary vein (PV) anatomy on cryo kinetics during cryoballoon (CB) ablation is unclear. Objective: To investigate the relationship between PV anatomy and cryo kinetics during CB ablation for atrial fibrillation (AF). Methods: Sixty consecutive patients were enrolled. PV anatomy, including ostial diameters (long, short and corrected), ratio between short and long diameters, ostium shape (round, oval, triangular, and narrow), and drainage pattern (typical, with common trunk, common antrum, ostial branch and supernumerary PV) were evaluated on multi-detector computed tomography (MDCT) images pre-procedure. Cryo kinetics parameters [balloon freeze time from 0 to -30ºC (BFT), balloon nadir temperature (BNT) and balloon warming time from -30 to +15ºC (BWT)] were recorded during procedure. All p values are two-sided, with values of p < 0.05 considered to be statistically significant. Results: 606 times of freezing cycle were accomplished. Moderate negative correlation was documented between BNT and corrected PV diameter (r = -0.51, p < 0.001) when using 23-mm CBs, and mild negative correlation (r = - 0.32, p = 0.001) was found when using 28-mm CBs. Multivariate logistic regression analysis revealed that PV corrected ostial diameter (OR, 1.4; p = 0.004) predicted a BNT < -51ºC when using 23-mm CBs, while PV ostium oval shape (OR, 0.3; p = 0.033) and PV locations (left inferior PV: OR, 0.04; p = 0.005; right superior PV: OR, 4.3; p = 0.025) predicted BNT < -51ºC when using 28-mm CBs. Conclusions: MDCT can provide PV anatomy accurate evaluation prior CB ablation. PV anatomy is associated with cryo kinetics during ablation.

Resumo Fundamentos: A influência da anatomia da veia pulmonar (VP) na criocinética durante a ablação por criobalão (CB) não está clara. Objetivo: Investigar a relação entre a anatomia da VP e a criocinética durante a ablação com CB para fibrilação atrial (FA). Métodos: sessenta pacientes consecutivos foram matriculados. Foram avaliados em imagens de tomografia computadorizada multidetectora (TCMD) pré-procedimento a anatomia da VP, incluindo diâmetros dos óstios (longo, curto e corrigido), relação entre diâmetros curtos e longos, forma do óstio (redondo, oval, triangular e estreito) e padrão de drenagem (típico, com tronco comum, antro comum, ramo ostial e VP supranumerária). Os parâmetros criocinéticos [tempo de congelamento de balão de 0 a -30ºC (TCB), temperatura do nadir do balão (TNB) e tempo de aquecimento do balão de -30 a + 15ºC (TAB)] foram registrados durante o procedimento. Todos os valores de p são bicaudais, com valores de p < 0,05 considerados estatisticamente significativos. Resultados: o ciclo de congelamento foi realizado 606 vezes. Correlação negativa moderada foi documentada entre o TNB e o diâmetro VP corrigido (r = - 0,51, p < 0,001) ao usar CBs de 23 mm e correlação negativa leve (r = - 0,32, p = 0,001) foi encontrada ao usar 28- mm CBs. A análise de regressão logística multivariada revelou que o diâmetro corrigido do óstio da VP (OR, 1,4; p = 0,004) previu um TNB < -51ºC ao usar CB de 23 mm, enquanto a forma oval do óstio VP (OR, 0,3; p = 0,033) e as localizações da VP (VP inferior: OR, 0,04; p = 0,005; VP superior direito: OR, 4,3; p = 0,025) previram TNB < -51ºC ao usar CBs de 28 mm. Conclusões: A TCMD pode fornecer uma avaliação precisa da anatomia da VP antes da ablação por CB. A anatomia da VP está associada à criocinética durante a ablação.

Fibrilación auricular en pacientes con ictus isquémico en Hospital Universitario Comandante Faustino Pérez. 2017 / Atrial fibrillation in patients with ischemic stroke in the University Hospital Comandante Faustino Pérez. 2017

Introducción: se realizó un estudio observacional transversal en pacientes con fibrilación auricular ingresados con ictus isquémico en la sala de neurología en el Hospital Universitario Comandante Faustino Pérez el año 2017. Objetivo: caracterizar la fibrilación auricular en estos pacientes en relación con edad y sexo, factores de riesgo, tipo de fibrilación y factores de riesgo de embolismo. Materiales y métodos: el universo del estudio fue de 40 pacientes con fibrilación auricular e ictus isquémico. Durante el ingreso a los pacientes y/o sus familiares se les aplicó una encuesta para la obtención de la información. Resultados: predominó el grupo de edades de 75-84 años y el sexo masculino con el 50 % y 70 % respectivamente. Los factores de riesgo más frecuentes en los pacientes con fibrilación auricular e ictus isquémico fueron la hipertensión arterial y edad mayor de 75 años con 85 % y la insuficiencia cardiaca con 70 %. La fibrilación auricular más frecuente fue la diagnosticada por primera vez con 55 %. Según la respuesta ventricular predominó la fibrilación auricular con respuesta ventricular rápida con 75 %. Los factores de riesgo de embolismo predominantes fueron la hipertensión arterial y la edad ≥ 75 años con 85 % seguida de la insuficiencia cardiaca con 70 %. Conclusiones: la fibrilación auricular en los pacientes con ictus isquémico predominó en hombres mayores de 75 años, hipertensos con insuficiencia cardiaca y en la mayoría de los pacientes se realizó el diagnóstico de la fibrilación auricular durante el ingreso con ictus isquémico (AU).

Introduction: it was carried out a transversal observational study in the in-patients with atrial fibrillation and ischemic stroke in the neurology ward of the Faustino Pérez Hospital in 2017. Objective: to characterize the atrial fibrillation in these patients taking into account age, sex, risk factors, fibrillation type and embolic risk. Materials and methods: the universe of the study was 40 patients with atrial fibrillation and ischemic stroke. During the hospitalization, a survey was applied to patients and/or their relatives for collecting the information. Results: The 75-84 age group predominated and male patients predominated. With 50 % and 70 % respectively. The most frequent risk factors in patients with atrial fibrillation and ischemic stroke were arterial hypertension and being more than 75 years old with 85 % and heart failure with 70 %. The most frequent atrial fibrillation was the one diagnosed for the first time with 55 %. According to the ventricular answer, atrial fibrillation with fast ventricular answer predominated, with 75 %. The predominant embolic risk factors were arterial hypertension and patients aged ≥ 75 years with 85 %, followed by heart failure with 70 %. Conclusions: atrial fibrillation in in-patients with ischemic stroke was predominant in male hypertensive patients aged 75 years and more with cardiac failure; in most of the patients the atrial fibrillation was made during the hospitalization with ischemic stroke (AU).

Mid-Term Results of Surgical Treatment of Atrial Fibrillation in Valvular Heart Disease Assesed by Speckle Tracking Echocardiography / Resultados em Médio Prazo do Tratamento da Fibrilação Atrial na Doença Valvular Cardíaca Avaliados por Ecocardiografia com Speckle Tracking

Abstract Background: Atrial fibrillation frequently affects patients with valvular heart disease. Ablation of atrial fibrillation during valvular surgery is an alternative for restoring sinus rhythm. Objectives: This study aimed to evaluate mid-term results of successful atrial fibrillation surgical ablation during valvular heart disease surgery, to explore left atrium post-ablation mechanics and to identify predictors of recurrence. Methods: Fifty-three consecutive candidates were included. Eligibility criteria for ablation included persistent atrial fibrillation <10 years and left atrium diameter < 6.0 cm. Three months after surgery, echocardiogram, 24-hour Holter monitoring and electrocardiograms were performed in all candidates who maintained sinus rhythm (44 patients). Echo-study included left atrial deformation parameters (strain and strain rate), using 2-dimensional speckle-tracking echocardiography. Simultaneously, 30 healthy individuals (controls) were analyzed with the same protocol for left atrial performance. Significance was considered with a P value of < 0.05. Results: After a mean follow up of 17 ± 2 months, 13 new post-operative cases of recurrent atrial fibrillation were identified. A total of 1,245 left atrial segments were analysed. Left atrium was severely dilated in the post-surgery group and, mechanical properties of left atrium did not recover after surgery when compared with normal values. Left atrial volume (≥ 64 mL/m2) was the only independent predictor of atrial fibrillation recurrence (p = 0.03). Conclusions: Left atrial volume was larger in patients with atrial fibrillation recurrence and emerges as the main predictor of recurrences, thereby improving the selection of candidates for this therapy; however, no differences were found regarding myocardial deformation parameters. Despite electrical maintenance of sinus rhythm, left atrium mechanics did not recover after atrial fibrillation ablation performed during valvular heart disease surgery.

Resumo Fundamento: A fibrilação atrial frequentemente afeta pacientes com doenças das valvas cardíacas. A ablação da fibrilação atrial durante a cirurgia das válvulas é uma alternativa para restaurar o ritmo sinusal. Objetivos: Este estudo teve como objetivos avaliar resultados em médio prazo da ablação cirúrgica bem sucedida da FA durante cirurgia para doença valvar, para explorar a mecânica do AE após a ablação e identificar preditores de recorrência. Métodos: Foram incluídos 53 candidatos consecutivos. Os critérios de elegibilidade para ablação foram fibrilação atrial persistente <10 anos e diâmetro do átrio esquerdo < 6 cm. Três meses após a cirurgia, foram realizados ecocardiografia, Holter por 24 horas, e eletrocardiografias em todos os candidatos que mantiveram o ritmo sinusal (44 pacientes). O estudo eco incluiu parâmetros de deformação ao átrio esquerdo (strain e taxa de strain) usando ecocardiografia bidimensional com speckle tracking. Simultaneamente, 30 indivíduos sadios (controles) foram analisados com o mesmo protocolo para o desempenho do átrio esquerdo. Um valor de P < 0,05 foi considerado significativo. Resultados: Após um período médio de acompanhamento de 17 ± 2 meses, 13 novos casos de fibrilação atrial no pós-operatório foram identificados. Um total de 1245 segmentos do átrio esquerdo foi analisado. O grupo pós-cirúrgico apresentou dilatação grave do átrio esquerdo, e as propriedades mecânicas do átrio esquerdo não se recuperaram após a cirurgia quando comparadas com valores normais. O volume do átrio esquerdo (≥ 64 mL/m2) foi o único preditor independente de recorrência de fibrilação atrial (p = 0,03). Conclusões: O volume do átrio esquerdo foi maior nos pacientes com fibrilação atrial recorrente, e desponta como o principal preditor de recorrência, melhorando, assim, a seleção de candidatos para essa terapia. No entanto, não foram encontradas diferenças em relação aos parâmetros de deformação do miocárdio. Apesar da manutenção elétrica do ritmo sinusal, a função mecânica do átrio esquerdo não se recuperou após a ablação da fibrilação atrial realizada durante a cirurgia para doença da valva cardíaca.

First results of the Brazilian Registry of Percutaneous Left Atrial Appendage Closure / Primeiros Resultados do Registro Brasileiro de Oclusão Percutânea do Apêndice Atrial Esquerdo

Abstract Background: Left atrial appendage closure (LAAC) is an effective alternative to oral anticoagulation (OA) for the prevention of stroke in patients with non-valvular atrial fibrillation (NVAF). Objective: To present the immediate results and late outcomes of patients submitted to LAAC and included in the Brazilian Registry of Percutaneous Left Atrial Appendage Closure. Methods: 91 patients with NVAF, high stroke risk (CHA2DS2VASc score = 4.5 ± 1.5) and restrictions to OAC (HAS-BLED score = 3.6 ± 1.0) underwent 92 LAAC procedures using either the Amplatzer cardiac plug or the Watchman device in 11 centers in Brazil, between late 2010 and mid 2016. Results: Ninety-six devices were used (1.04 device/procedure, including an additional non-dedicated device), with a procedural success rate of 97.8%. Associated procedures were performed in 8.7% of the patients. Complete LAAC was obtained in 93.3% of the successful cases. In cases of incomplete closure, no residual leak was larger than 2.5 mm. One patient needed simultaneous implantation of 2 devices. There were 7 periprocedural major (5 pericardial effusions requiring pericardiocentesis, 1 non-dedicated device embolization and 1 coronary air embolism without sequelae) and 4 minor complications. After 128.6 patient-years of follow-up there were 3 deaths unrelated to the procedure, 2 major bleedings (one of them in a patient with an unsuccessful LAAC), thrombus formation over the device in 2 cases (both resolved after resuming OAC for 3 months) and 2 strokes (2.2%). Conclusions: In this multicenter, real world registry, that included patients with NVAF and high thromboembolic and bleeding risks, LAAC effectively prevented stroke and bleeding when compared to the expected rates based on CHA2DS2VASc and HASBLED scores for this population. Complications rate of the procedure was acceptable considering the beginning of the learning curve of most of the involved operators.

Resumo Fundamento: A oclusão percutânea do apêndice atrial esquerdo (OAAE) é uma alternativa eficaz à anticoagulação oral (ACO) para a prevenção de acidente vascular cerebral (AVC) em pacientes com fibrilação atrial não-valvular (FANV). Objetivo: Apresentar os resultados imediatos e o seguimento tardio de pacientes submetidos a OAAE e incluídos no Registro Brasileiro de Oclusão Percutânea do Apêndice Atrial Esquerdo. Métodos: 91 pacientes com FANV, alto risco de AVC (escore CHA2DS2VASc = 4,5 ± 1,5) e restrição à AO (escore HAS-BLED = 3,6 ± 1,0) foram submetidos a 92 procedimentos de OAAE com as próteses Amplatzer Cardiac Plug e Watchman em 11 centros do Brasil, entre o final de 2010 e a metade de 2016. Resultados: Utilizaram-se 96 próteses no total (1,04 próteses/procedimento, incluindo-se o uso de 1 prótese não-dedicada adicional em um dos casos), obtendo-se sucesso em 97,8% dos procedimentos. Realizaram-se procedimentos associados à OAAE em 8,7% dos pacientes. Observou-se oclusão total do AAE em 93,3% dos casos com sucesso, e nos casos de oclusão incompleta, nenhum leak foi > 2,5 mm. Um paciente necessitou do implante simultâneo de 2 próteses. Houve 7 complicações maiores periprocedimento (5 derrames pericárdicos necessitando pericardiocentese, 1 embolização da prótese não-dedicada e 1 embolia aérea coronariana sem sequelas) e 4 menores. No seguimento de 128,6 pacientes-ano, houve 3 óbitos não relacionados ao procedimento, 2 sangramentos maiores (um deles em um dos casos de insucesso da OAAE), formação de trombo sobre a prótese em 2 casos (tratados com sucesso com reinstituição da ACO por 3 meses), e 2 AVCs (2,2%). Conclusões: Neste registro multicêntrico de mundo real, que incluiu pacientes com FANV e alto risco de sangramento e de eventos tromboembólicos, a OAAE foi eficaz na prevenção de AVC e sangramento quando comparada às taxas de AVC previstas pelos escores CHA2DS2VASc e HASBLED para esta população. O índice de complicações do procedimento foi aceitável, considerando se tratar do início da curva de aprendizado da maioria dos operadores envolvidos.