Abstract
Aims
Despite recent advances in catheter ablation for atrial fibrillation (AF), pulmonary vein reconnection (PVR), and AF recurrence remain significantly high. Ablation index (AI) is a new ...method incorporating contact force, time, and power that should optimize procedural outcomes. We aimed to evaluate the efficacy and safety of AI-guided catheter ablation compared to a non-AI-guided approach.
Methods and results
A systematic search was performed on MEDLINE (via PubMED), EMBASE, COCHRANE, and European Society of Cardiology (ESC) databases (from inception to 1 July 2019). We included only studies that compared AI-guided with non-AI-guided catheter ablation of AF. Eleven studies reporting on 2306 patients were identified. Median follow-up period was 12 months. Ablation index-guided ablation had a significant shorter procedural time (141.0 vs. 152.8 min, P = 0.01; I2 = 90%), ablation time (21.8 vs. 32.0 min, P < 0.00001; I2 = 0%), achieved first-pass isolation more frequently odds ratio (OR) = 0.09, 95%CI 0.04–0.21; 93.4% vs. 62.9%, P < 0.001; I2 = 58% and was less frequently associated with acute PVR (OR = 0.37, 95%CI 0.18–0.75; 18.0% vs 35.0%; P = 0.006; I2 = 0%). Importantly, atrial arrhythmia relapse post-blanking was significantly lower in AI compared to non-AI catheter ablation (OR = 0.41, 95%CI 0.25–0.66; 11.8% vs. 24.9%, P = 0.0003; I2 = 35%). Finally, there was no difference in complication rate between AI and non-AI ablation, with the number of cardiac tamponade events in the AI group less being numerically lower (OR = 0.69, 95%CI 0.30–1.60, 1.6% vs. 2.5%, P = 0.39; I2 = 0%).
Conclusions
These data suggest that AI-guided catheter ablation is associated with increased efficacy of AF ablation, while preserving a comparable safety profile to non-AI catheter ablation.
Cardiac resynchronisation therapy (CRT) improves prognosis in patients with heart failure (HF) however the role of ABO blood groups and Rhesus factor are poorly understood. We hypothesise that blood ...groups may influence clinical and survival outcomes in HF patients undergoing CRT. A total of 499 patients with HF who fulfilled the criteria for CRT implantation were included. Primary outcome of all-cause mortality and/or heart transplant/left ventricular assist device was assessed over a median follow-up of 4.6 years (IQR 2.3-7.5). Online repositories were searched to provide biological context to the identified associations. Patients were divided into blood (O, A, B, and AB) and Rhesus factor (Rh-positive and Rh-negative) groups. Mean patient age was 66.4 ± 12.8 years with a left ventricular ejection fraction of 29 ± 11%. There were no baseline differences in age, gender, and cardioprotective medication. In a Cox proportional hazard multivariate model, only Rh-negative blood group was associated with a significant survival benefit (HR 0.68 0.47-0.98, p = 0.040). No association was observed for the ABO blood group (HR 0.97 0.76-1.23, p = 0.778). No significant interaction was observed with prevention, disease aetiology, and presence of defibrillator. Rhesus-related genes were associated with erythrocyte and platelet function, and cholesterol and glycated haemoglobin levels. Four drugs under development targeting RHD were identified (Rozrolimupab, Roledumab, Atorolimumab, and Morolimumab). Rhesus blood type was associated with better survival in HF patients with CRT. Further research into Rhesus-associated pathways and related drugs, namely whether there is a cardiac signal, is required.
We evaluated the effect of adenosine upon mechanisms sustaining persistent AF through analysis of contact electrograms and ECGI mapping.
Persistent AF patients undergoing catheter ablation were ...included. ECGI maps and cycle length (CL) measurements were recorded in the left and right atrial appendages and repeated following boluses of 18 mg of intravenous adenosine. Potential drivers (PDs) were defined as focal or rotational activations completing ≥ 1.5 revolutions. Distribution of PDs was assessed using an 18 segment biatrial model.
46 patients were enrolled. Mean age was 63.4 ± 9.8 years with 33 (72%) being male. There was no significant difference in the number of PDs recorded at baseline compared to adenosine (42.1 ± 15.2 vs 40.4 ± 13.0; p = 0.417), nor in the number of segments harbouring PDs, (13 (11-14) vs 12 (10-14); p = 0.169). There was a significantly higher percentage of PDs that were focal in the adenosine maps (36.2 ± 15.2 vs 32.2 ± 14.4; p < 0.001). There was a significant shortening of CL in the adenosine maps compared to baseline which was more marked in the right atrium than left atrium (176.7 ± 34.7 vs 149.9 ± 27.7 ms; p < 0.001 and 165.6 ± 31.7 vs 148.3 ± 28.4 ms; p = 0.003).
Adenosine led to a small but significant shortening of CL which was more marked in the right than left atrium and may relate to shortening of refractory periods rather than an increase in driver burden or distribution. Registered on Clinicaltrials.gov: NCT03394404.
Background Outcomes of catheter ablation of atrial fibrillation (AF) are variable and the predictors of success require further elucidation since the identification of correctable risk factors could ...help to optimize therapy. We aimed to assess the impact of body mass index (BMI) in the overall safety and efficacy of catheter ablation of AF, with emphasis on the use of cryoballoon ablation and novel oral anticoagulants. Methods and Results There were 2497 consecutive patients undergoing catheter ablation of AF in 7 European high volume centers were stratified according to BMI (normal weight <25 kg/m
, pre-obese 25-30 kg/m
, obesity 30-35 kg/m
, and morbid obesity ≥35 kg/m
) and comparisons of procedural outcomes evaluated. Pre-obese and obese patients presented more comorbidities (hypertension, diabetes mellitus, and sleep apnea), and had higher rates of non-paroxysmal AF ablation procedures. The rate of atrial 12-month arrhythmia relapse increased alongside with BMI (35.2%, 35.7%, 43.6%, and 48.0%
<0.001). During a median follow-up of 18.8 months (interquartile range 11-28), after adjusting for all baseline differences, BMI was an independent predictor of relapse (hazard ratio=1.01 per kg/m
; 95% CI 1.01-1.02;
=0.002), adding incremental predictive value to obstructive sleep apnea. BMI was not a predictor for any of the reported complications. Using novel oral anticoagulants and cryoballoon ablation was safe and efficacy was comparable with vitamin-K antagonists and radiofrequency ablation. Conclusions Obese patients present with a more adverse comorbidity profile, more advanced forms of AF, and have lower chances of being free from AF relapse after ablation. Use of novel oral anticoagulants and cryoballoon ablation may be an option in this patient group.
Purpose
A significant proportion of patients undergoing catheter ablation for atrial fibrillation (AF) experience arrhythmia recurrence. This is mostly due to pulmonary vein reconnection (PVR). ...Whether mapping using High-Density Wave (HDW) technology is superior to standard bipolar (SB) configuration at detecting PVR is unknown. We aimed to evaluate the efficacy of HDW technology compared to SB mapping in identifying PVR.
Methods
High-Density (HD) multipolar Grid catheters were used to create left atrial geometries and voltage maps in 36 patients undergoing catheter ablation for AF (either due to recurrence of an atrial arrhythmia from previous AF ablation or de novo AF ablation). Nineteen SB maps were also created and compared. Ablation was performed until pulmonary vein isolation was achieved.
Results
Median time of mapping with HDW was 22.3 IQR: 8.2 min. The number of points collected with HDW (13299.6±1362.8 vs 6952.8±841.9,
p
<0.001) and used (2337.3±158.0 vs 1727.5±163.8,
p
<0.001) was significantly higher compared to SB. Moreover, HDW was able to identify more sleeves (16 for right and 8 for left veins), where these were confirmed electrically silent by SB, with significantly increased PVR sleeve size as identified by HDW (
p
<0.001 for both right and left veins). Importantly, with the use of HDW, the ablation strategy changed in 23 patients (64% of targeted veins) with a significantly increased number of lesions required as compared to SB for right (
p
=0.005) and left veins (
p
=0.003).
Conclusion
HDW technology is superior to SB in detecting pulmonary vein reconnections. This could potentially result into a significant change in ablation strategy and possibly to increased success rate following pulmonary vein isolation.
Neutrophil to lymphocyte ratio (NLR) has been proposed as a marker of cardiovascular risk. The potential relation between NLR and periprocedural myocardial damage after percutaneous coronary ...intervention (PCI) is unclear. We enrolled 502 consecutive patients with stable coronary artery disease undergoing elective PCI. Blood samples were drawn in all patients at baseline, 6 hours, and 24 hours after PCI for complete blood cell count and cardiac biomarkers (creatine kinase-MB and troponin T Tn-T) assessment. NLR was calculated as the ratio between the absolute number of neutrophil over the absolute number of lymphocyte. Periprocedural myocardial infarction (PMI) was defined according to the 2012 universal definition of myocardial infarction. In the overall population, a significant postprocedural increase in NLR was observed (3.255 2.763 to 3.995 at baseline, 4.430 3.390 to 6.020 at 6 hours, 4.720 3.940 to 5.750 at 24 hours, p <0.0001). PMI occurred in 33 patients (6.6%). Baseline NLR was similar in patients with and without PMI (3.250 2.820 to 3.885 vs 3.260 2.750 to 4.000, p = 0.898); however, patients who developed PMI showed significantly higher NLR both at 6 hours (5.750 4.360 to 9.095 vs 4.370 3.370 to 5.950, p <0.001) and 24 hours (5.180 4.440 to 8.065 vs 4.670 3.920 to 5.710, p = 0.003). Among patients who developed PMI, periprocedural NLR increase showed a moderate positive correlation with both creatine kinase-MB (rho = 0.377, p = 0.031) and troponin T increase (rho = 0.506, p = 0.003). In conclusion, preprocedural NLR values do not impact on the occurrence of PMI during elective PCI; however, PCI procedures induce a significant increase in NLR that seems to be proportional to the magnitude of periprocedural myocardial damage.
Malnutrition among children population of less developed countries is a major health problem. Inadequate food intake and infectious diseases are combined to increase further the prevalence. ...Malnourishment brings to muscle cells loss with development of cardiac complications, like arrhythmias, cardiomyopathy and sudden death. In developed countries, malnutrition has generally a different etiology, like chronic diseases. The aim of our study was to investigate the correlation between malnutrition and left ventricular mass in an African children population.
313 children were studied, in the region of Antsiranana, Madagascar, with age ranging from 4 to 16 years old (mean 7,8 ± 3 years). A clinical and echocardiographic evaluation was performed with annotation of anthropometric and left ventricle parameters. Malnutrition was defined as a body mass index (BMI) value age- and sex-specific of 16, 17 and 18,5 at the age of 18, or under the 15th percentile. Left ventricle mass was indexed by height2.7 (LVMI).
We identified a very high prevalence of children malnutrition: 124 children, according to BMI values, and 100 children under the 15th percentile. LVMI values have shown to be increased in proportion to BMI percentiles ranging from 29,8 ± 10,8 g/m2.7 in the malnutrition group to 45 ± 15,1 g/m2.7 in >95th percentile group. LVMI values in children < 15th BMI percentile were significantly lower compared to normal nutritional status (29,8 ± 10,8 g/m2,7 vs. 32,9 ± 12,1 g/m2,7, p = 0.02). Also with BMI values evaluation, malnourished children showed statistically lower values of LVMI (29,3 ± 10,1 g/m2,7 vs. 33,6 ± 12,5 g/m2,7, p = 0.001).
In African children population, the malnourishment status is correlated with cardiac muscle mass decrease, which appears to be reduced in proportion to the decrease in body size.
Abstract Background In 1990 the American Heart Association (AHA) established a standard 0.05 to 150 Hz bandwidth for the routine recording of 12-lead electrocardiograms (ECGs). However, subsequent ...studies have indicated a very high prevalence of deviations from the recommended cutoffs. Objective This prospective observational study investigates the impact of 40 Hz compared to 150 Hz high-frequency cutoffs on ECG quality and clinical interpretation in a single-center surgical outpatient population. Methods 1582 consecutive adult patients underwent two standard 12-lead ECG tracings using different high-frequency cutoffs (40 Hz and 150 Hz). Two blinded cardiologists randomly reviewed and interpreted the recordings according to pre-defined parameters (PR and ST segment, Q and T wave abnormalities). An arbitrary score, ranging from 1 to 3, was established to evaluate the perceived quality of the recordings and the non-interpretable ECGs were noted. The tracings were then matched to compare interpretations between 40 and 150 Hz filters. Results A 40 Hz high-frequency cutoff resulted in an increased rate of optimal quality ECGs compared to the 150 Hz cutoff (93.4% vs 54.6%; p < 0.001) and a lower rate of non-interpretable traces (0.25% vs 4.80%; p < 0.001). Analyzing the morphologic parameters, no significant differences between the filter settings were found, except for a higher incidence of the J-point elevation in the 40 Hz high-frequency cutoff (p = 0.007) and a higher incidence of left ventricular hypertrophy in the 150 Hz high-frequency cutoff (7.4% vs 5.4%, p < 0.001). The latter was noted only in ECGs with borderline QRS amplitudes (between 3.3 and 3.7 mV; p < 0.001). Conclusion Despite current recommendations, the large deviation from standard high-frequency cutoff in clinical practice does not seem to significantly affect ECG clinical interpretation and a 40 Hz high-frequency cutoff of the band-pass filtering may be acceptable in a low risk population, allowing a better quality of tracings.
Outcomes of catheter ablation for non-paroxysmal atrial fibrillation (AF) remain suboptimal. Non-invasive stratification of patients based on the presence of atrial cardiomyopathy (ACM) could allow ...to identify the best responders to pulmonary vein isolation (PVI).
Observational multicentre retrospective study in patients undergoing cryoballoon-PVI for non-paroxysmal AF. The duration of amplified P-wave (APW) was measured from a digitally recorded 12-lead electrocardiogram during the procedure. If patients were in AF, direct-current cardioversion was performed to allow APW measurement in sinus rhythm. An APW cut-off of 150 ms was used to identify patients with significant ACM. We assessed freedom from arrhythmia recurrence at long-term follow-up in patients with APW ≥ 150 ms vs. APW < 150 ms.
We included 295 patients (mean age 62.3 ± 10.6), of whom 193 (65.4%) suffered from persistent AF and the remaining 102 (34.6%) from long-standing persistent AF. One-hundred-forty-two patients (50.2%) experienced arrhythmia recurrence during a mean follow-up of 793 ± 604 days. Patients with APW ≥ 150 ms had a significantly higher recurrence rate post ablation compared to those with APW < 150 ms (57.0% vs. 41.6%; log-rank
< 0.001). On a multivariable Cox-regression analysis, APW≥150 ms was the only independent predictor of arrhythmia recurrence post ablation (HR 2.03 CI
1.28-3.21;
= 0.002).
APW duration predicts arrhythmia recurrence post cryoballoon-PVI in persistent and long-standing persistent AF. An APW cut-off of 150 ms allows to identify patients with significant ACM who have worse outcomes post PVI. Analysis of APW represents an easy, non-invasive and highly reproducible diagnostic tool which allows to identify patients who are the most likely to benefit from PVI-only approach.
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