Abstract Classically, the 3 pillars of atrial fibrillation (AF) management have included anticoagulation for prevention of thromboembolism, rhythm control, and rate control. In both prevention and ...management of AF, a growing body of evidence supports an increased role for comprehensive cardiac risk factor modification (RFM), herein defined as management of traditional modifiable cardiac risk factors, weight loss, and exercise. In this narrative review, we summarize the evidence demonstrating the importance of each facet of RFM in AF prevention and therapy. Additionally, we review emerging data on the importance of weight loss and cardiovascular exercise in prevention and management of AF.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Objectives The aims of this study were to: 1) use a novel method of late gadolinium enhancement (LGE) quantification that uses normalized intensity measures to confirm the association ...between LGE extent and atrial fibrillation (AF) recurrence following ablation; and 2) examine the presence of interaction and effect modification between LGE and AF persistence. Background Recurrent AF after catheter ablation has been reported to associate with the baseline extent of left atrial LGE on cardiac magnetic resonance. Traditional methods for measurement of intensity lack an objective threshold for quantification and interpatient comparisons of LGE. Methods The cohort included 165 participants (mean age 60.0 ± 10.2 years, 77% men, 57% with persistent AF) who underwent initial AF ablation. The association of baseline LGE extent with AF recurrence was examined using multivariable Cox proportional hazards models. Multiplicative and additive interactions between AF type and LGE extent were examined. Results During 10.2 ± 5.7 months of follow-up, 63 patients (38.2%) experienced AF recurrence. Baseline LGE extent was independently associated with AF recurrence after adjusting for confounders (hazard ratio: 1.5 per 10% increased LGE; p < 0.001). The hazard ratio for AF recurrence progressively increased as a function of LGE. The magnitude of association between LGE >35% and AF recurrence was greater among patients with persistent AF (hazard ratio: 6.5 p = 0.001 vs. 3.6 p = 0.001); however, there was no evidence for statistical interaction. Conclusions Regardless of AF persistence at baseline, participants with LGE ≤35% have favorable outcomes, whereas those with LGE >35% have a higher rate of AF recurrence in the first year after ablation. These findings suggest a role for: 1) patient selection for AF ablation using LGE extent; and 2) substrate modification in addition to pulmonary vein isolation in patients with LGE extent exceeding 35% of left atrial myocardium.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Left atrial flutter (LAFL) occurs in patients after atrial fibrillation ablation. Identification of optimal ablation targets to terminate LAFL remains challenging.
The purpose of this study was to ...use patient-specific models to simulate LAFL and predict optimal ablation targets using a novel approach based on flow network theory.
Late gadolinium-enhanced cardiac magnetic resonance scans from 10 patients with LAFL were used to construct atrial models incorporating fibrosis by investigators blinded to procedural findings. Rapid pacing was applied in silico to induce LAFL. In each LAFL, we represented reentrant wave propagation as an electric flow network and identified the "minimum cut" (MC), which was the smallest amount of tissue that separated the flow into 2 discontinuous components. In silico ablation was applied at MCs, and targets were compared to those that terminated LAFL during catheter ablation.
Patient-specific atrial models were successfully generated from patient scans. LAFL was induced in 7 of 10 models. Ablation of MCs terminated LAFL in 4 models and produced new, slower LAFL morphologies in the other 3. For the latter cases, flow analysis was repeated to identify MCs of emergent LAFLs. Ablation of these MCs terminated emergent LAFLs. The MC-based ablation lesions in simulations were similar in length and location to ablation targets that terminated LAFL during catheter ablation for these 7 patients.
Personalized atrial simulations can predict ablation targets for LAFL. These simulations provide a powerful tool for planning ablation procedures and may reduce procedural times and complications.
The extent of left atrial (LA) late gadolinium enhancement (LGE), as a surrogate for fibrosis, has been associated with atrial fibrillation (AF) recurrence after catheter ablation. Furthermore, there ...is ex vivo evidence that islands of fibrosis may anchor fibrillatory rotors.
The purpose of this study was to examine the anatomical association of AF rotors with LA and right atrial (RA) LGE on cardiac magnetic resonance.
The cohort included 9 patients with persistent AF (mean age 61.1 ± 9.7 years) who underwent LGE cardiac magnetic resonance before AF ablation using the focal impulse and rotor modulation system. The extent of LA and RA LGE was quantified globally and in each of the 7 sectors: LA posterior/inferior wall, anterior wall, roof, left and right pulmonary vein antra, and RA lateral and septal regions. The multivariable association of rotor incidence with global and per sector LGE extent was examined using multivariable Bernoulli logistic regression estimated by generalized estimating equations.
The mean RA and LA volumes were 113.2 ± 37.31 and 143.03 ± 58.25 mL, respectively. The mean RA and LA LGE burden was 17.2% ± 11.0% and 17.4% ± 14.4%, respectively. A total of 18 LA rotors and 9 RA rotors were identified in all patients. No univariable or multivariable association was observed between global or per sector LGE extent and focal impulse and rotor modulation rotor incidence.
In this cohort of patients, there was no association between AF rotor incidence and the global or regional extent of RA and LA LGE.
Abstract Objectives This study assessed trends in transesophageal echocardiography (TEE) use, rate of left atrial appendage (LAA) thrombus detection, and incidence of periprocedural cerebrovascular ...accident (CVA) since transitioning to a strategy of uninterrupted warfarin or briefly interrupted novel oral anticoagulant therapy in 2010. Background TEE is routinely performed before ablation for atrial fibrillation (AF) to ensure absence of LAA thrombus. Methods Patients with AF ablation presenting between January 2010 and September 2015 at Johns Hopkins Hospital were enrolled in an AF ablation registry; TEE and ablation outcomes were retrospectively analyzed. Presence of LAA thrombus, dense spontaneous echo contrast (SEC), or patent foramen ovale (PFO) were recorded. CVA incidence from procedure onset to 30 days post-procedure was evaluated using electronic medical record review. Results Pre-procedure TEE was performed in 646 of 1,224 AF ablation cases (52.8%). There was a decline in pre-procedure TEE use from 86% in 2010 to 42% in 2015 (p < 0.001). CVA incidence was 4/1,224 (0.33%) cases, and did not change during the study period. TEE findings included LAA thrombus (n = 6; 0.93%), PFO (n = 23; 3.6%), and dense spontaneous echo contrast (n = 99; 15.3%). Both SEC and LAA thrombus were associated with persistent AF, higher CHA2 DS2 VASC score, increased LA size, reduced LAA flow velocity, and decreased left ventricular ejection fraction. PFO was not associated with prior AF ablation, and SEC was not associated with increased CVA incidence. Conclusions CVA is a rare complication of AF ablation in patients with minimally interrupted anticoagulation. Pre-ablation TEE may be reasonably avoided in patients without high-risk features.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Symptomatic left atrial (LA) flutter (LAFL) is common after atrial fibrillation (AF) ablation.
The purpose of this study was to examine the association of baseline LA function with incident LAFL ...after AF ablation.
The source cohort included 216 patients with cardiac magnetic resonance (CMR) before initial AF ablation between 2010 and 2013. Patients who underwent cryoballoon or laser ablation, patients with AF during CMR, and those with suboptimal CMR, or missing follow-up data were excluded. Baseline LA volume and function were assessed by feature-tracking CMR analysis.
The final cohort included 119 patients (mean age 58.9 ± 11 years; 76.5% men; 70.6% patients with paroxysmal AF). During a median follow-up of 421 days (interquartile range 235-751 days), 22 patients (18.5%) had incident LAFL. Baseline LA volume was similar between the 2 groups. In contrast, baseline reservoir, conduit, and contractile function of the LA were significantly impaired in patients with incident LAFL. Baseline global peak longitudinal atrial strain (PLAS) <22.65% predicted incident LAFL with 86% sensitivity and 68% specificity (C statistic 0.76). In a multivariable model adjusting for age, heart failure, and LA volume, PLAS (hazard ratio 0.9 per % increase in PLAS; P = .003) and LA linear lesions (hazard ratio 2.94; P = .020) were independently associated with incident LAFL. The coexistence of PLAS <22.65% and linear lesions was associated with 9-fold increased hazard of incident LAFL.
Baseline LA function and linear lesions were independently associated with incident LAFL after AF ablation. Linear lesions should be limited to selected cases, especially in patients with impaired LA function.
Objectives This study sought to examine the association between left ventricular hypertrophy (LVH), defined by cardiac magnetic resonance (CMR) and electrocardiography (ECG), with incident atrial ...fibrillation (AF). Background Previous studies of the association between AF and LVH were based primarily on echocardiographic measures of LVH. Methods The MESA (Multi-Ethnic Study of Atherosclerosis) enrolled 4,942 participants free of clinically recognized cardiovascular disease. Incident AF was based on MESA-ascertained hospital-discharge International Classification of Diseases codes and Centers for Medicare and Medicaid Services inpatient hospital claims. CMR-LVH was defined as left ventricular mass ≥95th percentile of the MESA population distribution. Eleven ECG-LVH criteria were assessed. The association of LVH with incident AF was evaluated using multivariable Cox proportional hazards models adjusted for CVD risk factors. Results During a median follow-up of 6.9 years, 214 incident AF events were documented. Participants with AF were more likely to be older, hypertensive, and overweight. The risk of AF was greater in participants with CMR-derived LVH (hazard ratio HR: 2.04, 95% confidence interval CI: 1.15 to 3.62). AF was associated with ECG-derived LVH measure of Sokolow-Lyon voltage product after adjusting for CMR-LVH (HR: 1.83, 95% CI: 1.06 to 3.14, p = 0.02). The associations with AF for CMR-LVH and Sokolow-Lyon voltage product were attenuated when adjusted for CMR left atrial volumes. Conclusions In a multiethnic cohort of participants without clinically detected cardiovascular disease, both CMR and ECG-derived LVH were associated with incident AF. ECG-LVH showed prognostic significance independent of CMR-LVH. The association was attenuated when adjusted for CMR left atrial volumes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
An estimated 1 million patients require cardiac implantable electronic devices (CIEDs) but go without annually. This disparity exists in low-to-middle-income nations largely owing to the cost of CIED ...hardware. Humanitarian reuse of CIEDs has been shown to be safe and feasible. However, recent publications have raised concern that promotion of CIED reuse may foster a CIED “black market,” to the dismay of manufacturers, regulators, and clinicians alike.
To determine if unregulated CIED sales for potential human use is a real issue by investigating unregulated public online CIED sale listings in the United States of America.
An observational study was undertaken over 6 months using multiple internet search engines from May 1 to November 1, 2019. We cataloged usable CIEDs (still in packaging, manufactured <7 years) and pricing. Manufacturers were contacted to determine status of sellers and unregulated CIEDs using model/serial numbers.
In total, 58 CIEDs—47 implantable cardioverter-defibrillators and 11 permanent pacemakers—from 4 manufacturers were listed for sale on 3 websites. During the study period, 8 of 11 pacemakers and 37 of 47 implantable cardioverter-defibrillators were sold (price range: $100–$1500 US dollars). No new listings were seen in the last 3 months of observation, possibly owing to concomitant industry investigation.
There does exist a public online market for unregulated CIED sales in the United States. This specific market seems to be small and unlikely to significantly expand with active monitoring by manufacturers and regulators.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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