Alcohol Abstinence in Drinkers with Atrial Fibrillation Voskoboinik, Aleksandr; Kalman, Jonathan M; De Silva, Anurika ...
New England journal of medicine/The New England journal of medicine,
01/2020, Volume:
382, Issue:
1
Journal Article
Peer reviewed
Open access
Excessive alcohol consumption is associated with atrial fibrillation. Patients with paroxysmal or persistent atrial fibrillation who were in sinus rhythm and who were consuming 10 or more standard ...drinks per week were randomly assigned to either abstinence from alcohol or continued drinking for 6 months. Recurrence of atrial fibrillation was less common in the abstinence group.
Atrial fibrillation (AF) and left ventricular systolic dysfunction (LVSD) frequently co-exist despite adequate rate control. Existing randomized studies of AF and LVSD of varying etiologies have ...reported modest benefits with a rhythm control strategy.
The goal of this study was to determine whether catheter ablation (CA) for AF could improve LVSD compared with medical rate control (MRC) where the etiology of the LVSD was unexplained, apart from the presence of AF.
This multicenter, randomized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy (left ventricular ejection fraction LVEF ≤45%). After optimization of rate control, patients underwent cardiac magnetic resonance (CMR) to assess LVEF and late gadolinium enhancement, indicative of ventricular fibrosis, before randomization to either CA or ongoing MRC. CA included pulmonary vein isolation and posterior wall isolation. AF burden post-CA was assessed by using an implanted loop recorder, and adequacy of MRC was assessed by using serial Holter monitoring. The primary endpoint was change in LVEF on repeat CMR at 6 months.
A total of 301 patients were screened; 68 patients were enrolled between November 2013 and October 2016 and randomized with 33 in each arm (accounting for 2 dropouts). The average AF burden post-CA was 1.6 ± 5.0% at 6 months. In the intention-to-treat analysis, absolute LVEF improved by 18 ± 13% in the CA group compared with 4.4 ± 13% in the MRC group (p < 0.0001) and normalized (LVEF ≥50%) in 58% versus 9% (p = 0.0002). In those undergoing CA, the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF (10.7%; p = 0.0069) and normalization at 6 months (73% vs. 29%; p = 0.0093).
AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control. The restoration of sinus rhythm with CA results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on CMR. This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD. (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction CAMERA-MRI; ACTRN12613000880741).
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Enduring isolation of the pulmonary veins (PV) is becoming increasingly common in patients undergoing repeat catheter ablation for atrial fibrillation. We describe our approach to ablation strategy ...in a patient with enduring isolation of PV and briefly discuss the role of non‐PV triggers.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Effect of Dietary Factors on Cardiac Rhythm Voskoboinik, Aleksandr; Prabhu, Sandeep; Sugumar, Hariharan ...
The American journal of cardiology,
10/2018, Volume:
122, Issue:
7
Journal Article
Peer reviewed
The interaction between arrhythmias and certain lifestyle factors such as obesity and alcohol consumption is well-established. There is significant public and professional interest in the role of ...various diets, vitamins, and minerals in cardiovascular health. However, many widely held beliefs are not supported by the literature. There is limited evidence for routine magnesium and omega-3 poly-unsaturated fatty acids supplementation, while coffee, tea, nuts, antioxidant vitamins, and even chocolate may have some antiarrhythmic properties. Saturated fat, added salt, and excessive energy drink consumption appear to be harmful for patients with rhythm disorders. However most recommendations are based on observation studies, and this remains a fertile area for further research.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background
Pneumothorax is a well‐recognized complication of cardiac implantable electronic device (CIED) insertion. While AP fluoroscopy alone is the most commonly imaging technique for subclavian ...or axillary access, caudal fluoroscopy (angle 40°) is routinely used at our institution. The caudal view provides additional separation of the first rib and clavicle and may reduce the risk of pneumothorax. We assessed outcomes at our institution of AP and caudal fluoroscopic guided pacing lead insertion.
Methods
Retrospective cohort study of consecutive patients undergoing transvenous lead insertion for pacemakers, defibrillators, and cardiac resynchronization therapy devices between 2011 and 2023. Both de novo and lead replacement/upgrade procedures were included. Data were extracted from operative, radiology, and discharge reports. All patients underwent postprocedure chest radiography.
Results
Three thousand two hundred fifty‐two patients underwent insertion of pacing leads between February 2011 and March 2023. Mean age was 71.1 years (range 16–102) and 66.7% were male. Most (n = 2536; 78.0%) procedures used caudal guidance to obtain venous access, while 716 (22.0%) procedures used AP guidance alone. Pneumothoraxes occurred in five (0.2%) patients in the caudal group and five (0.7%) patients in the AP group (p = .03). Subclavian contrast venography was performed less frequently in the caudal group (26.2% vs. 42.7%, p < .01).
Conclusion
Caudal fluoroscopy for axillary/subclavian access is associated with a lower rate of pneumothorax and contrast venography compared with an AP approach.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Aims
The impact of atrial fibrillation (AF) ablation in early heart failure with preserved ejection fraction (HFpEF) is unknown. Our aim was to determine the impact of AF ablation on symptoms and ...exercise haemodynamic parameters of early HFpEF.
Methods and results
Symptomatic AF patients referred for index AF ablation with ejection fraction ≥50% underwent baseline quality of life questionnaires, echocardiography, cardiac magnetic resonance imaging, exercise right heart catheterisation (exRHC), and brain natriuretic peptide (BNP) testing. HFpEF was defined by resting pulmonary capillary wedge pressure (PCWP) ≥15 mmHg or peak exercise PCWP ≥25 mmHg. Patients with HFpEF were offered AF ablation and follow‐up exRHC ≥6 months post‐ablation. Of 54 patients undergoing baseline evaluation, 35 (65%) had HFpEF identified by exRHC. HFpEF patients were older (64 ± 10 vs. 54 ± 13 years, P < 0.01), and more frequently female (54% vs. 16%, P < 0.01), hypertensive (63% vs. 16%, P < 0.001), and suffering persistent AF (66% vs. 11%, P < 0.001), compared to those without HFpEF. Twenty HFpEF patients underwent AF ablation and follow‐up exRHC 12 ± 6 months post‐ablation. Nine (45%) patients no longer fulfilled exRHC criteria for HFpEF at follow‐up. Patients remaining arrhythmia free (n = 9, 45%) showed significant improvements in peak exercise PCWP (29 ± 4 to 23 ± 2 mmHg, P < 0.01) and Minnesota Living with Heart Failure (MLHF) score (55 ± 30 to 22 ± 30, P < 0.01) while the remainder did not (PCWP 31 ± 5 to 30.0 ± 4 mmHg, P = NS; MLHF score 55 ± 23 to 25 ± 20, P = NS).
Conclusion
Heart failure with preserved ejection fraction frequently coexists in patients with symptomatic AF and preserved ejection fraction. Restoration and maintenance of sinus rhythm in patients with comorbid AF and HFpEF improves haemodynamic parameters, BNP and symptoms associated with HFpEF.
Overview of the study illustrating the proportion of patients referred for consideration of atrial fibrillation (AF) ablation who met the criteria for heart failure with preserved ejection fraction (HFpEF) in panel A. Three‐dimensional reconstruction of the left atrium with radiofrequency lesions used to achieved pulmonary vein electrical isolation at the time of AF ablation in panel B and results of the follow‐up exercise right heart catheterisation at ≥6 months following AF ablation based on arrhythmia recurrence status in panel C. Panel D illustrates the potential interaction between AF and HFpEF. BNP, brain natriuretic peptide; LA, left atrial; LAPW, left atrial posterior wall; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; PCWP, pulmonary capillary wedge pressure; QoL, quality of life; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.
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BFBNIB, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
The success of pulmonary vein isolation (PVI) is reduced in persistent AF (PsAF) compared to paroxysmal AF. Adjunctive ablation strategies have failed to show consistent incremental benefit over PVI ...alone in randomized studies. The left atrial posterior wall is a potential source of non-PV triggers and atrial substrate which may promote the initiation and maintenance of PsAF. Adding posterior wall isolation (PWI) to PVI had shown conflicting outcomes, with earlier studies confounded by methodological limitations.
To determine whether combining PWI with PVI significantly improves freedom from AF recurrence, compared to PVI alone, in patients with PsAF.
This is a multi-center, prospective, international randomized clinical trial. 338 patients with symptomatic PsAF refractory to anti-arrhythmic therapy (AAD) will be randomized to either PVI alone or PVI with PWI in a 1:1 ratio. PVI involves wide antral circumferential pulmonary vein (PV) isolation, utilizing contact force sensing ablation catheters. PWI involves the creation of a floor line connecting the inferior aspect of the PVs, and a roof line connecting the superior aspect of the PVs. Follow up is for a minimum of 12 months with rhythm monitoring via implantable cardiac device and/or loop monitor, or frequent intermittent monitoring with an ECG device. The primary outcome is freedom from any documented atrial arrhythmia of > 30 seconds off AAD at 12 months, after a single ablation procedure.
This randomized study aims to determine the success and safety of adjunctive PWI to PVI in patients with persistent AF.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Aims
Obesity is associated with higher electrical cardioversion (ECV) failure in persistent atrial fibrillation (PeAF). For ease‐of‐use, many centers prefer patches over paddles. We assessed the ...optimum modality and shock vector, as well as the safety and efficacy of the Manual Pressure Augmentation (MPA) technique.
Methods
Patients with obesity (BMI ≥ 30) and PeAF undergoing ECV using a biphasic defibrillator were randomized into one of four arms by modality (adhesive patches or handheld paddles) and shock vector (anteroposterior AP or anteroapical AA). If the first two shocks (100 and 200 J) failed, then patients received a 200‐J shock using the alternative modality (patch or paddle). Shock vector remained unchanged. In an observational substudy, 20 patients with BMI of 35 or more, and who failed ECV at 200 J using both patches/paddles underwent a trial of MPA.
Results
In total, 125 patients were randomized between July 2016 and March 2018. First or second shock success was 43 of 63 (68.2%) for patches and 56 of 62 (90.3%) for paddles (P = 0.002). There were 20 crossovers from patches to paddles (12 of 20 third shock success with paddles) and six crossovers from paddles to patches (three of six third shock success with patches). Paddles successfully cardioverted 68 of 82 patients compared with 46 of 69 using patches (82.9% vs 66.7%;
P = 0.02). Shock vector did not influence first or second shock success rates (82.0% AP vs 76.6% AA;
P = 0.46). MPA was successful in 16 of 20 (80%) who failed in both (patches/paddles), with 360 J required in six of seven cases.
Conclusion
Routine use of adhesive patches at 200 J is inadequate in obesity. Strategies that improve success include the use of paddles, MPA, and escalation to 360 J.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Abstract
Introduction
The absence of ventricular scar in patients with atrial fibrillation (AF) and systolic heart failure (HF) predicts left ventricular (LV) recovery following AF ablation. It is ...unknown whether age impacts the degree of LV recovery, reverse remodeling, or AF recurrence following catheter ablation (CA) among this population.
Objectives
To evaluate the impact of age on LV recovery and AF recurrence in a population with AF and systolic HF without fibrosis (termed AF‐mediated cardiomyopathy) following CA.
Methods
Consecutive patients undergoing CA between 2013 and 2021 with LV ejection fraction (LVEF) < 45% and absence of cardiac magnetic resonance imaging (CMR) detected LV myocardial fibrosis were stratified by age (<65 vs. ≥65 years). Following CA, participants underwent remote rhythm monitoring for 12 months with repeat CMR for HF surveillance.
Results
The study population consisted of 70 patients (10% female, mean LVEF 33 ± 9%), stratified into younger (age < 65 years, 63%) and older (age ≥ 65 years, 37%) cohorts. Baseline comorbidities, LVEF (34 ± 9 vs. 33 ± 8 ≥65 years,
p
= .686), atrial and ventricular dimensions (left atrial volume index: 55 ± 21 vs. 56 ± 14 mL/m
2
age ≥ 65,
p
= .834; indexed left ventricular end‐diastolic volume: 108 ± 40 vs. 104 ± 28 mL/m
2
age ≥ 65,
p
= .681), pharmacotherapy and ablation strategy (pulmonary vein isolation in all; posterior wall isolation in 27% vs. 19% age ≥ 65,
p
= .448; cavotricuspid isthmus in 9% vs. 11.5% age ≥ 65) were comparable (all
p
> .05) albeit a higher CHADS
2
VASc score in the older cohort (2.7 ± 0.9 vs. 1.6 ± 0.6 age < 65,
p
< .001). Freedom from AF was comparable (hazard ratio: 0.65, 95% confidence interval: 0.38–1.48, LogRank
p
= .283) as was AF burden 0% (interquartile range, IQR: 0.0–2.1) vs. age ≥ 65: 0% (IQR 0.0–1.7),
p
= .516, irrespective of age. There was a significant improvement in LV systolic function in both groups (ΔLVEF + 21 ± 14% vs. +21 ± 12% age ≥ 65,
p
= .913), with LV recovery in the vast majority (73% vs. 69%, respectively,
p
= .759) at 13 (IQR: 12–16) months. This was accompanied by comparable improvements in functional status (New York Heart Association class
p
= .851; 6‐min walk distance 50 ± 61 vs. 93 ± 134 m in age ≥ 65,
p
= .066), biomarkers (ΔN‐terminal‐pro brain natriuretic peptide −139 ± 246 vs. −168 ± 181 age ≥ 65,
p
= .629) and HF symptoms (Short Form‐36 survey Δphysical component summary
p
= .483/Δmental component summary,
p
= .841).
Conclusion
In patients undergoing CA for AF with systolic HF in the absence of ventricular scar, comparable improvements in ventricular function, symptoms, and freedom from AF are achieved irrespective of age.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Catheter ablation has become standard of care in patients with symptomatic atrial fibrillation (AF). Although there have been significant advances in our understanding and technology, a substantial ...proportion of patients have ongoing AF requiring repeat procedures. Pulmonary vein isolation (PVI) is the cornerstone of AF ablation; however, it is less effective in patients with persistent as opposed to paroxysmal atrial fibrillation. Left atrial posterior wall isolation (PWI) is commonly performed as an adjunct to PVI in patients with persistent AF with nonrandomized studies showing improved outcomes. Anatomical considerations and detailed outline of the various approaches and techniques to performing PWI are detailed, and advantages and pitfalls to assist the clinical electrophysiologist successfully and safely complete PWI are described.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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