The ESC-EHRA Atrial Fibrillation Ablation Long-Term registry is a prospective, multinational study that aims at providing an accurate picture of contemporary real-world ablation for atrial ...fibrillation (AFib) and its outcome.
A total of 104 centres in 27 European countries participated and were asked to enrol 20-50 consecutive patients scheduled for first and re-do AFib ablation. Pre-procedural, procedural and 1-year follow-up data were captured on a web-based electronic case record form. Overall, 3630 patients were included, of which 3593 underwent an AFib ablation (98.9%). Median age was 59 years and 32.4% patients had lone atrial fibrillation. Pulmonary vein isolation was attempted in 98.8% of patients and achieved in 95-97%. AFib-related symptoms were present in 97%. In-hospital complications occurred in 7.8% and one patient died due to an atrioesophageal fistula. One-year follow-up was performed in 3180 (88.6%) at a median of 12.4 months (11.9-13.4) after ablation: 52.8% by clinical visit, 44.2% by telephone contact and 3.0% by contact with the general practitioner. At 12-months, the success rate with or without antiarrhythmic drugs (AADs) was 73.6%. A significant portion (46%) was still on AADs. Late complications included 14 additional deaths (4 cardiac, 4 vascular, 6 other causes) and 333 (10.7%) other complications.
AFib ablation in clinical practice is mostly performed in symptomatic, relatively young and otherwise healthy patients. Overall success rate is satisfactory, but complication rate remains considerable and a significant portion of patients remain on AADs. Monitoring after ablation shows wide variations. Antithrombotic treatment after ablation shows insufficient guideline-adherence.
The present European Society of Cardiology (ESC) Guidelines is a European update to the 2006 European/American guidelines for the management of patients with ventricular arrhythmias (VA) and the ...prevention of sudden cardiac death (SCD). The update is timely considering new insights into the natural history of diseases predisposing to SCD especially for younger individuals and also with the completion of major trials that have impacted management strategies for heart failure (HF).
Background: Diagnosing arrhythmogenic right ventricular cardiomyopathy (ARVC) at an early stage can be challenging even after ECG recording and a combination of several imaging techniques. The ...purpose of this study was to explore if a body surface mapping (BSM) system with 252‐leads could identify repolarization abnormalities and thereby diagnose early stages of ARVC.
Methods: ARVC patients, gene carriers without signs of ARVC and controls underwent a 12‐lead resting ECG, signal‐averaged ECG, echocardiography, 24‐hours Holter monitoring, and BSM with electrocardiographic imaging (ECGI). All 252‐leads, divided into four quadrants of the vest, were analyzed regarding concordances between T wave polarity and QRS main vector.
Results: Of 40 patients included there were 12 ARVC patients, 20 gene carriers, and 8 controls. The ARVC patients had two different repolarization patterns, one with more pronounced negative T waves at the lower left panel and another with mixed changes that clearly differed from the controls, all of whom had a normal 12 lead ECGs and consistent repolarization patterns on their BSM recordings. The patterns observed in ARVC patients were also present in 5/20 (25%) gene carriers, three of whom had normal resting ECG. A novel repolarization index successfully detected all ARVC patients and 88% of gene carriers with pathologic repolarization pattern.
Conclusions: The finding that abnormal repolarization patterns could be unmasked by BSM in 25% of healthy gene carriers, suggests that it may potentially be a useful tool for identifying early manifestations of ARVC. Further and larger studies are warranted to assess its diagnostic accuracy.
Atrial fibrillation (AF) is a complex condition requiring holistic management with multiple treatment decisions about optimal thromboprophylaxis, symptom control (and prevention of AF progression), ...and identification and management of concomitant cardiovascular risk factors and comorbidity. Sometimes the information needed for treatment decisions is incomplete, as available classifications of AF mostly address a single domain of AF (or patient)-related characteristics. The most widely used classification of AF based on AF episode duration and temporal patterns (that is, the classification to first-diagnosed, paroxysmal, persistent/long-standing persistent, and permanent AF) has contributed to a better understanding of AF prevention and treatment but its limitations and the need for a multidimensional AF classification have been recognized as more complex treatment options became available. We propose a paradigm shift from classification toward a structured
of AF, addressing specific domains having treatment and prognostic implications to become a standard in clinical practice, thus aiming to streamline the assessment of AF patients at all health care levels facilitating communication among physicians, treatment decision-making, and optimal risk evaluation and management of AF patients. Specifically, we propose the 4S-AF structured pathophysiology-based
(rather than classification) scheme that includes four AF- and patient-related domains-Stroke risk, Symptoms, Severity of AF burden, and Substrate severity-and provide a hypothetical model for the use of 4S-AF characterization scheme to aid treatment decision making concerning the management of patients with AF in clinical practice.
The European Lead Extraction ConTRolled Registry (ELECTRa), is a prospective registry of consecutive transvenous lead extraction (TLE) procedures conducted by the European Heart Rhythm Association ...(EHRA) in order to identify the safety and efficacy of the current practice of TLE.
European centres performing TLE, invited by the organizing committee on behalf of EHRA, prospectively recruited all consecutive patients undergoing TLE at their institution. The primary endpoint was TLE safety defined by pre-discharge major procedure-related complications including death. Secondary endpoints included clinical and radiological success and overall complication rates. Outcomes were compared between Low Volume (LoV) vs. High Volume (HiV) centers (LoV < 30 and HiV ≥ 30 procedures/year). A total of 3555 consecutive patients (pts) of whom 3510 underwent TLE at 73 centres in 19 European countries were enrolled between November 2012 and May 2014. The primary endpoint of in-hospital procedure-related major complication rate was 1.7% 95% CI 1.3-2.1% (58/3510 pts) including a mortality of 0.5% 95% CI 0.3-0.8% (17/3510 pts). Approximately two-thirds (37/58) of these complications occurred during the procedure and one-third (21/58) in the post-operative period. The most common procedure related complications were those requiring pericardiocentesis or chest tube and/or surgical repair (1.4% 95% CI 1.0-1.8%). Complete clinical and radiological success rates were 96.7% 95% CI 96.1-97.3% and 95.7% 95% CI 95.2-96.2%, respectively. The all cause in-hospital major complications and deaths were significantly lower in HiV centres vs. LoV centres (2.4% 95% CI 1.9-3.0% vs. 4.1% 95% CI 2.7-6.0%, P = 0.0146; and 1.2% 95% CI 0.8-1.6% vs. 2.5% 95% CI 1.5-4.1% P = 0.0088), although those related to the procedure did not reach statistical significance. Radiological and clinical successes were more frequent in HiV vs. LoV centres.
The ELECTRa study is the largest prospective registry on TLE and confirmed the safety and efficacy of the current practice of TLE. Lead extraction was associated with a higher success rate with lower all cause complication and mortality rates in high volume compared with low volume centres.
Background
Early identification of individuals at risk of developing heart failure (HF) may improve poor prognosis. A dominant sympathetic activity is common in HF and associated with worse outcomes; ...however, less is known about the autonomic balance before HF.
Hypothesis
A low frequency/high frequency (L‐F/H‐F) ratio, index of heart rate variability, and marker of the autonomic balance predict the development of HF and may improve the performance of the HF prediction model when added to traditional cardiovascular (CV) risk factors.
Methods
Individuals in the PIVUS (Prospective Investigation of the Vasculature in Uppsala Seniors) study (n = 1016, all aged 70 years) were included. Exclusion criteria were prevalent HF, electrocardiographic QRS duration ≥130 millisecond, major arrhythmias, or conduction blocks at baseline. The association between the L‐F/H‐F ratio and incident HF was assessed using Cox proportional hazard analysis. The C‐statistic evaluated whether adding the L‐F/H‐F‐ratio to traditional CV risk factors improved the discrimination of incident HF.
Results
HF developed in 107/836 study participants during 15 years of follow‐up. A nonlinear, inverse association between the L‐F/H‐F ratio and incident HF was mainly driven by an L‐F/H‐F ratio of <30. The association curve was flat for higher values (hazard ratio, HR for the total curve = 0.78 95% confidence interval, CI: 0.69−0.88, p < .001; HR = 2 for L‐F/H‐F ratio = 10). The traditional prediction model improved by 3.3% (p < .03) when the L‐F/H‐F ratio was added.
Conclusions
An L‐F/H‐F ratio of <30 was related to incident HF and improved HF prediction when added to traditional CV risk factors.
Heart failure (HF) is characterized by autonomic dysfunction. Less is known about the autonomic balance before HF. This study tested the association between low frequency/high frequency (LF/HF) ratio and incident HF. The ratio <30 was related to incident HF and improved HF prediction when added to traditional risk factors.
Background
The diagnosis of ARVC remains complex requiring both imaging and electrocardiographic (ECG) techniques. The purpose was therefore to investigate whether QRS dispersion assessed by body ...surface mapping (BSM) could be used to detect early signs of ARVC, particularly in gene carriers.
Methods
ARVC patients, gene carriers without a history of arrhythmias or structural cardiac changes and healthy controls underwent 12‐lead resting ECG, signal‐averaged ECG, echocardiographic examination, 24‐hours Holter monitoring, and BSM with electrocardiographic imaging. All 252‐leads BSM recordings and 12‐leads ECG recordings were manually analyzed for QRS durations and QRS dispersion.
Results
Eight controls, 12 ARVC patients with definite ARVC and 20 healthy gene carriers were included. The ECG‐QRS dispersion was significantly greater in ARVC patients (42 vs. 25 ms, p < .05), but failed to fully differentiate them from controls. The BSM‐derived QRS dispersion was also significantly greater in ARVC patients versus controls (65 vs. 29 ms, p < .05) and distinguished 11/12 cases from controls using the cut‐off 40msec. The BSM derived QRS dispersion was abnormal (> 40 ms) in 4/20 healthy gene carriers without signs of ARVC, which may indicate early depolarization changes.
Conclusions
QRS dispersion, when assessed by BSM versus 12‐lead ECG, seem to better distinguish ARVC patients from controls, and could potentially be used to detect early ARVC in gene carriers. Further studies are required to confirm the value of BSM‐QRS dispersion in this respect.
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