Association between Epicardial Adipose Tissue and Atrial Fibrillation in Patients with Transfusion-Dependent ß-Thalassemia.

Background: Modern treatments for transfusion-dependent ß-thalassemia (TDßT) have allowed patients to reach high life expectancy with no iron overload. Despite survival improvement, atrial fibrillation (AF) has emerged as a relevant issue. AF pathophysiology and characteristics in TDßT are different than in the general population. Epicardial adipose tissue (EAT) may play a role but its relationship with AF in patients with TDßT has not been explored. Methods: A monocentric, cross-sectional study, enrolling consecutive patients with TDßT. Epicardial adipose tissue (EAT) was evaluated at magnetic resonance. Characteristics of patients with and without history of AF were investigated. Factors independently associated with AF prevalence were analyzed. Results: A total of 116 patients were enrolled. All patients were treated with regular chelation therapy. The prevalence of AF was 29.3% (34/116). Cardiac T2* and liver iron concentration were no different between patients with and without AF. EAT thickness was significantly higher in patients with AF at left atrium, right atrium and right ventricle (5.0 vs. 4.0 mm, p < 0.01, 4.4 vs. 4.0, p = 0.02 and 5.0 vs. 4.3, p = 0.04). Patients with AF presented with older age, (53 vs. 49 years, p < 0.01), more hypothyroidism (44.1 vs. 20.7%, p = 0.01), pulmonary hypertension (23.5 vs. 2.4% p < 0.01), splenectomy (88.2 vs. 64.6%, p = 0.01), higher right and left atrial volume (61 vs. 40 and 74 vs. 43 mL, both p < 0.01). At multivariable analysis, hypothyroidism, left atrial volume and left atrial EAT were independently associated with AF (odds ratio 9.95, 1.09 and 1.91, respectively). Conclusions: In a contemporary cohort of patients with TDßT, treated with regular chelation therapy, prevalence of AF was unrelated to iron overload. EAT was independently associated with AF.

Non-Vitamin K Antagonist Oral Anticoagulants in Patients with ß-Thalassemia.

Background. Patients with ß-thalassemia have a high incidence of atrial fibrillation (AF) and other supraventricular arrhythmias. The use of non-vitamin K antagonist oral anticoagulants (NOACs) for thromboembolic prophylaxis in patients with ß-thalassemia has not been systematically evaluated. Methods. We enrolled patients with transfusion-dependent ß-thalassemia, who were on treatment with NOACs for thromboembolic prophylaxis of supraventricular arrhythmias. Data on thromboembolic and bleeding events were collected. Results. Eighteen patients were enrolled. The patients had a history of AF (sixteen), typical atrial flutter (five), and atypical atrial flutter (four). The patients were treated with dabigatran (seven), apixaban (five), rivaroxaban (four) or edoxaban (two). The mean follow-up duration was 22 ± 15 months. No thromboembolic events were reported. No major bleedings were observed. Three patients had non-major bleeding events. Two patients reported dyspepsia during treatment with dabigatran and were shifted to a different NOAC. Conclusions. Our study suggests the efficacy and safety of NOACs in patients affected by transfusion-dependent ß-thalassemia.

[Heavy metal! A case of severe iron overload and supraventricular arrhythmias in a thalassemia major patient]. / Heavy metal! Un caso di severo accumulo di ferro e aritmie sopraventricolari in paziente con talassemia major.

Cardiovascular complications are among the main causes of mortality and morbidity in patients with thalassemia major. Iron-chelation therapy is essential to prevent the chronic iron overload linked to the need for transfusions and the consequent cardiac hemosiderosis. Despite the wide use of iron-chelation drugs, today it is still possible to find cases of severe iron accumulation. Furthermore, even regardless of iron overload and cardiac dysfunction, the thalassemic patient has a high arrhythmic burden, especially for supraventricular arrhythmias. There are still many doubts and open questions about the management of such patients, especially regarding the correct use of anticoagulant therapy and the best utilization of therapeutic strategies available for rhythm control. The case presented shows how the interventional approach with catheter ablation can be useful also in the acute phase when antiarrhythmic drugs are ineffective and it is not possible to wait for the iron-chelation therapy to take effect.

Risk Scores for Cardiac Implantable Electronic Device Infection: Which One to Believe In?

Infections are important complications of cardiac implantable electronic devices (CIED), with a high prognostic impact. Several risk factors for CIED infections are known. Different studies have been published proposing different risk scores, in order to preoperatively assess the individual likelihood of developing a CIED infection. Among the different scores, large heterogeneity exists and there is no consensus or convergence on a single score finding large applicability in global practice. The aim of this review is to comprehensively present and analyze all the available risk scores for CIED infection, with particular regard to the evidence of comparison studies.

Atrial Fibrillation in ß-Thalassemia: Overview of Mechanism, Significance and Clinical Management.

Thalassemia is an inherited blood disorder with worldwide distribution. Transfusion and chelation therapy have radically improved the prognosis of ß-thalassemic patients in the developed world, but this has led to the development of new chronic cardiac complications like atrial fibrillation (AF). Prevalence of AF in patients with ß-thalassemia is higher than in the general population, ranging from 2 to 33%. Studies are lacking, and the little evidence available comes from a small number of observational studies. The pathophysiology is not well understood but, while iron overload seems to be the principal mechanism, AF could develop even in the absence of iron deposition. Furthermore, the clinical presentation is mainly paroxysmal, and patients are highly symptomatic. The underlying disease, the pathophysiology, and the clinical presentation require a different management of AF in ß-thalassemia than in the general population. Rhythm control should be preferred over rate control, and the most important antiarrhythmic therapy is represented by chelation drugs. Thromboembolic risk is high, but the available risk scores are not validated in ß-thalassemia, and the choice of anticoagulation therapy should be considered early. The main purpose of this review is to summarize the actual knowledge about AF in ß-thalassemia, with a specific focus on the clinical management of these complex patients.

Ablation of Atrioventricular Nodal Re-Entrant Tachycardia Combining Irrigated Flexible-Tip Catheters and Three-Dimensional Electroanatomic Mapping: Long-Term Outcomes.

BACKGROUND: Transcatheter ablation is the standasrd treatment for atrioventricular nodal re-entrant tachycardia (AVNRT). However, different techniques are available. Data about the use of irrigated flexible-tip catheters and three-dimensional electroanatomical mapping (3D EAM) for AVNRT ablation are scant. The aim of this study was to evaluate in long-term follow-up efficacy and safety of a novel approach for AVNRT treatment. METHODS: This is a cohort single arm study with long-term follow-up. Patients with AVNRT were treated with catheter ablation by means of irrigated flexible-tip catheters combined with 3D EAM. RESULTS: One-hundred-and-fifty patients were enrolled and followed-up for a median of 38 months (minimum 12, maximum 74). Acute procedural success rate was 96.7% (145/150 patients). During follow-up, 11 patients had arrhythmia recurrences (7.3%). No patient developed atrioventricular conduction block with need for pacemaker implantation (0%). Fourteen patients died during follow-up (9.3%). CONCLUSIONS: Acute procedural success and long-term follow-up show that AVNRT could be safely and effectively treated with irrigated flexible-tip catheters and 3D EAM.