Background Postoperative atrial fibrillation (POAF) is common after cardiac surgery, but little is known about its incidence and natural course after noncardiac surgery. We evaluated the natural ...course and clinical impact of POAF and the long-term impact of anticoagulation therapy in patients without a history of atrial fibrillation (AF) undergoing noncardiac surgery. Methods and Results We retrospectively analyzed the database of Asan Medical Center (Seoul, Korea) to identify patients who developed new-onset POAF after undergoing noncardiac surgery between January 2006 and January 2016. The main outcomes were AF recurrence, thromboembolic event, and major bleeding during follow-up. Of 322 688 patients who underwent noncardiac surgery, 315 patients (mean age, 66.4 years; 64.4% male) had new-onset POAF with regular rhythm monitoring after discharge. AF recurred in 53 (16.8%) during 2 years of follow-up. Hypertension (hazard ratio, 2.12;
=0.02), moderate-to-severe left atrial enlargement (hazard ratio, 2.33;
=0.007) were independently associated with recurrence. Patients with recurrent AF had higher risks of thromboembolic events (11.2% versus 0.8%;
<0.001) and major bleeding (26.9% versus 4.1%;
<0.001) than those without recurrence. Patients with recurrent AF and without anticoagulation were especially predisposed to thromboembolic events (
<0.001). Overall, anticoagulation therapy was not significantly associated with thromboembolic events (1.4% versus 2.5%,
=0.95). Conclusions AF recurred in 16.8% of patients with POAF after noncardiac surgery. AF recurrence was associated with higher risks of adverse clinical outcomes. Considering the high risk of anticoagulation-related bleeding, the benefits of routine anticoagulation should be carefully weighed in this population. Active surveillance for AF recurrence is warranted.
The authors developed and validated a diagnostic algorithm using the optimal upper and lower cut‐off values of office and home BP at which ambulatory BP measurements need to be applied. Patients ...presenting with high BP (≥140/90 mm Hg) at the outpatient clinic were referred to measure office, home, and ambulatory BP. Office and home BP were divided into hypertension, intermediate (requiring diagnosis using ambulatory BP), and normotension zones. The upper and lower BP cut‐off levels of intermediate zone were determined corresponding to a level of 95% specificity and 95% sensitivity for detecting daytime ambulatory hypertension by using the receiver operator characteristic curve. A diagnostic algorithm using three methods, OBP‐ABP: office BP measurement and subsequent ambulatory BP measurements if office BP is intermediate zone; OBP‐HBP‐ABP: office BP, subsequent home BP measurement if office BP is within intermediate zone and subsequent ambulatory BP measurement if home BP is within intermediate zone; and HBP‐ABP: home BP measurement and subsequent ambulatory BP measurements if home BP is within intermediate zone, were developed and validated. In the development population (n = 256), the developed algorithm yielded better diagnostic accuracies than 75.8% (95%CI 70.1–80.9) for office BP alone and 76.2% (95%CI 70.5–81.3) for home BP alone as follows: 96.5% (95%CI: 93.4–98.4) for OBP‐ABP, 93.4% (95%CI: 89.6–96.1) for OBP‐HBP‐ABP, and 94.9% (95%CI: 91.5–97.3%) for HBP‐ABP. In the validation population (n = 399), the developed algorithm showed similarly improved diagnostic accuracy. The developed algorithm applying ambulatory BP measurement to the intermediate zone of office and home BP improves the diagnostic accuracy for hypertension.
Background Severe conduction delay and inter/intra-atrial dissociation may occur in patients who undergo an extensive catheter ablation or a maze procedure for atrial tachyarrhythmia. We report a ...series of patients with inter/intra-atrial dissociation that mimicked complete atrioventricular block or ventricular tachycardia. Methods and Results We retrospectively reviewed the medical records of 7 patients who were referred for the evaluation of atrioventricular block (patients 1-6) or ventricular tachycardia (patient 7) that occurred after biatrial maze procedure and valvular surgery. During the electrophysiologic study, slow atrial or junctional escape rhythm dissociated from isolated atrial activity mimicked complete atrioventricular blocks. Intra-atrial dissociation of the right atrium or left atrium was observed. Atrioventricular nodal conduction from the nondissociated atrium to the ventricle was preserved in all patients, while the conduction from the dissociated atrium was blocked. In patient 7, the pacing of the ventricle by tracking of atrial tachycardia from the nondissociated left atrium/coronary sinus mimicked ventricular tachycardia during pacemaker interrogation. A total of 5 patients received new permanent pacemaker implantations during the index hospitalization for the surgery (n=2) or as a deferred procedure (n=3) according to the treatment for sick sinus syndrome. Conclusions Pseudo-atrioventricular block or pseudo-ventricular tachycardia may occur because of inter/intra-atrial dissociation after a maze procedure. The selection of patients for permanent pacemaker implantation should be determined based on the patient's symptoms and the status of the escape pacemaker and not on the apparent atrioventricular block. Proper diagnosis is important to avoid unnecessary implantation of a pacemaker or a defibrillator.
Abstract
Background
The efficacy and safety of high-power, short-duration (HPSD) radiofrequency catheter ablation for atrial fibrillation (AF) have been demonstrated in several studies. We aimed to ...evaluate and compare the effects of the conventional method and the HPSD method for AF ablation on the sinus and AV node function in patients with paroxysmal AF.
Methods
The medical records of patients with paroxysmal AF who underwent pulmonary vein isolation (PVI) were retrieved from a prospectively collected AF ablation registry at a large-sized tertiary center. The HPSD group (
n
= 41) was distinguished from the conventional ablation group (
n
= 198) in terms of the power (50 W vs. 20–40 W) and duration (6–10 s vs. 20–30 s) of radiofrequency energy delivery during PVI. Peri-procedural changes in cardiac autonomy were assessed in terms of the changes in sinus cycle length (SCL), block cycle length (BCL), and effective refractory period (ERP) of the atrioventricular node (AVN).
Results
The SCL, BCL, and ERP of the AVN at baseline and post-ablation were not significantly different between the conventional ablation group and the HPSD group. Shortening of the SCL, BCL, and ERP of the AVN was observed immediately after AF ablation in both groups. One-year recurrence of AF/atrial flutter (35.1% vs. 20.3%;
P
= 0.011) and atrial flutter (13.8% vs. 4.7%;
P
= 0.015) were higher in the HPSD group than in the conventional ablation group.
Conclusion
Both the HPSD and the conventional ablation method resulted in post-ablation vagal modification as evidenced by the shortening of SCL, BCL, and ERP of the AVN. One-year recurrence of atrial flutter and AF/atrial flutter was higher in patients who underwent the HPSD method.
We evaluated the association between cardiovascular risk factors and the magnitude of the difference in systolic blood pressure (SBP) between office and ambulatory measurements (masked effect) in ...untreated individuals without apparent hypertension-mediated organ damage (HMOD).
The inclusion criteria were 1) age ≥ 20 years, 2) blood pressure ≥ 140/90 mmHg at the outpatient clinic, and 3) not receiving antihypertensive medications. The difference between office and ambulatory SBP was calculated by subtracting the ambulatory daytime SBP from the office SBP. The association between the masked effect and SBP variability was analyzed in individuals without HMOD (no electrocardiographic left ventricular hypertrophy, spot urine albumin-to-creatinine ratio < 30 mg/g, and estimated glomerular filtration rate ≥ 60 mL/min/1.73 m
, n = 296).
Among the cardiovascular risk factors, ambulatory BP variability was significantly correlated with the SBP difference. The standard deviation (SD) and coefficient of variation (cv) of 24-h SBP exhibited a significant negative linear association with the SBP difference in univariate and multivariate analyses adjusted for age, sex, presence of diabetes, and 24-h ambulatory SBP. A significant association was observed in patients with ambulatory daytime hypertension. In the multivariate analysis, individuals with a negative SBP difference > -5 mmHg exhibited a higher SD and cv of 24-h SBP than those with a negative SBP difference ≤ -5 mmHg or a positive SBP difference.
The results of our study suggest that the magnitude of the negative difference in office and ambulatory SBP may be a potential risk factor, even in individuals without apparent HMOD.
This trial is registered with ClinicalTrials.gov ( NCT03855605 ).
Abstract
Background
An automated tagging module (VISITAG™; Biosense Webster, Irvine, CA) allows objective demonstration of energy delivery. However, the effect of VISITAG™ on clinical outcomes ...remains unclear. This study evaluated (1) clinical outcome after AF ablation using VISITAG™ and (2) the prevalence of gaps in the ablation line.
Methods
This retrospective analysis included 157 consecutive patients (mean age, 56.7 years; 73.2% men) with paroxysmal atrial fibrillation who underwent successful PVI between 2013 and 2016. Outcomes after the index procedure were compared between those using the VISITAG™ module (VISITAG group,
n
= 62) and those not using it (control group,
n
= 95). The primary outcome was recurrence of AF or atrial tachycardia after a blanking period of 3 months.
Results
The VISITAG group showed significantly shorter overall procedure time (172.2 ± 37.6 min vs. 286.9 ± 66.7 min,
P
< 0.001), ablation time (49.8 ± 9.7 min vs. 82.8 ± 28.2 min,
P
< 0.001), and fluoroscopy time (11.8 ± 5.3 min vs. 34.2 ± 30.1 min,
P
< 0.001) compared with controls. The 1-year recurrence-free survival rate was not statistically different between the groups (70.8% in the VISITAG group vs. 79.2% in the control group,
P
= 0.189). Gaps in the VISITAG line were common in the both carina and left side pulmonary veins. Patients without gaps (≥ 5 mm) by the criteria emphasizing catheter stability (> 15 s, < 4 mm range, > 60% force over time, > 6 g contact force) showed higher recurrence-free survival rate compared with those with gaps (borderline statistical significance, 91.7% vs. 66.0%,
P
= 0.094).
Conclusion
Use of the VISITAG™ module significantly reduced procedure, ablation, and fluoroscopic times with a similar AF/AT recurrence rate compared with the conventional ablation. Clinical implications of minimizing gaps along the ablation line should be evaluated further in the future prospective studies.
Abstract Background Both new dual antiplatelet therapy (DAT; aspirin and prasugrel) and triple antiplatelet therapy (TAT; aspirin, clopidogrel and cilostazol) are more potent than classic DAT ...(aspirin and clopidogrel). We compared the antiplatelet efficacy between new DAT and TAT in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary coronary percutaneous coronary intervention (PCI). Methods Forty patients who were eligible for primary PCI were prospectively randomized to DAT group (n = 20) or TAT group (n = 20) immediately after hospital arrival. The primary end point was P2Y12 reaction unit (PRU) determined with the VerifyNow P2Y12 point-of-care assay at the time of discharge. Results PRU value at discharge was significantly lower in patients receiving DAT compared with that of TAT (84.5 ± 44.7 vs. 128.4 ± 74.9, p = 0.032). Percent platelet inhibition was significantly higher for DAT compared with TAT at discharge (72.1 ± 12.2 vs. 57.5 ± 23.5, p = 0.020). Inter-patient variability of PRU values at discharge was significantly smaller in patient taking DAT compared with TAT (p = 0.026). Conclusion A new DAT is more potent antiplatelet therapy than TAT in patients with STEMI undergoing primary PCI.
Hypertension is an independent risk factor for thromboembolic events in patients with atrial fibrillation (AF). However, the association between blood pressure (BP) control and thromboembolic events ...remains under-evaluated in patients with AF. We aimed to identify the relation between BP control and the risk of ischemic stroke and systemic embolism in hypertensive patients with AF. Data on 13,712 consecutive patients with AF (9,505 with and 4,207 without hypertension) were retrospectively analyzed. The hypertensive group was divided into quartiles according to the initial BP, linearly interpolated mean BP, variability independent of the mean of the BP, and time in therapeutic range (<130 mm Hg for systolic BP SBP and <80 mm Hg for diastolic BP) during follow-up. The primary outcome was ischemic stroke and systemic embolism. The mean follow-up duration of the study population was median 2.7 years (interquartile range 1.1 to 4.9 years), and the median number of BP measurements was 14 (interquartile range 6 to 25) times. Strictly controlled initial and interpolated mean BP and low variability in controlled BP (variability independent of the mean) were associated with a lower risk of ischemic stroke and systemic embolism for both SBP and diastolic BP. A similar risk was observed in patients with strictly controlled SBP (time in therapeutic range under 130 mm Hg >94%) and those without hypertension. In conclusion, continuous and strict maintenance of SBP under 130 mm Hg with low variability at outpatient clinic follow-up reduces the risk of ischemic stroke and systemic embolism in patients with hypertension and AF.
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