Linear lesions for treating the recurrence of persistent atrial tachyarrhythmia after cryoballoon ablation of atrial fibrillation

Overall, 133 patients underwent 170 procedures for the treatment of persistent ATa following an index cryoballoon pulmonary vein isolation (n = 715). After all the procedures, > 90% of the patients had a roof line, a mitral isthmus and/or septal line, and a cavotricuspid isthmus line. Ninety-two patients (69.2%) were in sinus rhythm after a median of 36 months since the index cryoballoon PVI. ATa: atrial tachyarrhythmia; cryo: cryoballoon; CTI: cavotricuspid isthmus; LSPV: left superior pulmonary vein; LIPV: left inferior pulmonary vein; PVI: pulmonary vein isolation; RF: radiofrequency; RSPV: right superior pulmonary vein; RIPV: right inferior pulmonary vein.

     

The impact of malnutrition on atrial fibrillation recurrence post ablation

Background and aimsBoth malnutrition and atrial fibrillation (AF) are the major health problems in modern society. Only a few studies focused on the relationship between malnutrition and recurrence of atrial arrhythmias post AF ablation (AF recurrence), which used body mass index (BMI) as nutrition assessment tool. However, BMI can't credibly reflect body composition and has limitation in patients with water-sodium retention. In this study, we used controlling nutritional status score (CONUT score) and geriatric nutritional risk index (GNRI) to identify the malnutrition patients and explored the effect of malnutrition on AF recurrence.Methods and resultsThis retrospective study included 246 patients who underwent AF ablation. During a median 11-month follow-up, 77 patients (31.3%) experienced AF recurrence. The recurrence group had higher CONUT score (2.3 ± 1.5 vs. 0.9 ± 1.0, P < 0.001) and lower GNRI (99.9 ± 7.6 vs. 103.9 ± 5.6, P < 0.001). After balancing the traditional risk factors, both CONUT score (OR: 2.614, 95%CI: 1.831–3.731, P < 0.001) and GNRI (OR: 0.884, 95%CI: 0.828–0.944, P < 0.001) were the independent predictors for AF recurrence. Pre-ablation CONUT score ≥1 and GNRI≥95.66 are indicative of AF recurrence. Adding CONUT score or GNRI to the base prediction model for AF recurrence significantly improved the discrimination and calibration. However, adding BMI to the base prediction model did not improve the model performance.ConclusionsCONUT score and GNRI are ideal tools to evaluate the nutrition status of AF patients. Undernourished patients are more likely to suffer from AF recurrence. Improving nutrition status may be a potential target for reducing the postoperative recurrence rate.     

Low vitamin D levels predict left atrial thrombus in nonvalvular atrial fibrillation

Background and aimsWe determined the association between left atrial (LA) thrombus occurrence and a non-classic risk marker, plasma levels of vitamin D, in atrial fibrillation (AF) patients on continuous non-vitamin K antagonist oral anticoagulant (NOAC) therapy for ≥4 weeks. Low levels of plasma 25-hydroxy vitamin D (25-OHD) are predictive of fatal stroke. Vitamin D has anticoagulant effects on the coagulation cascade, which are indirectly targeted by NOAC therapy. The impact of plasma levels of vitamin D on the rate of LA thrombus detected by transesophageal echocardiography (TEE) in AF patients is unknown.Methods and resultsWe enrolled 201 (133 female) AF patients who were using continuous NOAC therapy for ≥4 weeks. All patients underwent transthoracic and TEE examination. Serum concentrations of 25-OHD, C-reactive protein (CRP) levels, CHA₂DS₂-VASc scores and parameters, LA size, and left ventricle ejection fraction (LVEF) were examined before the TEE procedure. LA thrombus occurrence was independently associated with serum levels of 25-OHD (OR: 0.884; 95% CI: 0.839–0.932; P < 0.001), LA diameter (OR: 1.120; 95% CI: 1.038–1.209; P = 0.003), and LVEF(OR: 0.944; 95% CI: 0.896–0.995; P = 0.032). Dense spontaneous echo contrast (SEC) presence was also inversely associated with 25-OHD concentrations.ConclusionsLow 25-OHD levels, as a non-classic risk factor, were independently and significantly associated with dense SEC and LA thrombus occurrence in AF patients under NOAC therapy, as well as LA enlargement and decreased LVEF. Further large-scale studies are needed to explain the role of vitamin D deficiency, or efficacy of replacement, on LA thrombus occurrence.     

Clinical validation of an artificial intelligence algorithm offering cross-platform detection of atrial fibrillation using smart device electrocardiograms

BackgroundSeveral smart devices are able to detect atrial fibrillation automatically by recording a single-lead electrocardiogram, and have created a work overload at the hospital level as a result of the need for over-reads by physicians.AimTo compare the atrial fibrillation detection performances of the manufacturers’ algorithms of five smart devices and a novel deep neural network-based algorithm.MethodsWe compared the rate of inconclusive tracings and the diagnostic accuracy for the detection of atrial fibrillation between the manufacturers’ algorithms and the deep neural network-based algorithm on five smart devices, using a physician-interpreted 12-lead electrocardiogram as the reference standard.ResultsOf the 117 patients (27% female, median age 65 years, atrial fibrillation present at time of recording in 30%) included in the final analysis (resulting in 585 analyzed single-lead electrocardiogram tracings), the deep neural network-based algorithm exhibited a higher conclusive rate relative to the manufacturer algorithm for all five models: 98% vs. 84% for Apple; 99% vs. 81% for Fitbit; 96% vs. 77% for AliveCor; 99% vs. 85% for Samsung; and 97% vs. 74% for Withings (P < 0.01, for each model). When applying our deep neural network-based algorithm, sensitivity and specificity to correctly identify atrial fibrillation were not significantly different for all assessed smart devices.ConclusionIn this clinical validation, the deep neural network-based algorithm significantly reduced the number of tracings labeled inconclusive, while demonstrating similarly high diagnostic accuracy for the detection of atrial fibrillation, thereby providing a possible solution to the data surge created by these smart devices.     

Comparative non-persistence in the first year of treatment with oral anticoagulants in patients with atrial fibrillation: A French comprehensive nationwide study

BackgroundDirect oral anticoagulants (DOACs) were developed as an alternative to vitamin K antagonists (VKAs) and are commonly used for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). Unlike VKAs, DOACs do not require Internal Normalized Ratio (INR) monitoring, but regular intake is as important for effective anticoagulation.ObjectivesThis study examined treatment persistence among patients receiving oral anticoagulants (OACs) for NVAF.MethodsWithin the French healthcare claims database (SNDS), we assessed and compared the rates of non-persistence (≥ 30-day treatment gap) among patients with NVAF initiating an OAC between January 2014 and December 2016. The time-to-event of non-persistence was computed and plotted using a cumulative incidence function accounting for the competing risk of mortality. After adjusting on confounding factors, the risk for non-persistence was compared between apixaban and each other OACs using a Cox proportional hazard model, or Fine and Gray models.ResultsIn a cohort of 321,501 OAC-naive patients with NVAF, the cumulative incidence of non-persistence at 12 months considering competing risk was 44.3%, 31.0%, 41.3% and 46.8% for VKAs, apixaban, rivaroxaban and dabigatran, respectively. Median therapy duration before non-persistence ranged between 70 and 121 days. Non-persistence was lower with apixaban compared with VKAs (HR = 0.63, 95%CI = [0.62–0.64]), rivaroxaban (HR = 0.71, 95%CI = [0.70–0.73]), and dabigatran (HR = 0.60, 95%CI = [0.59–0.62]).ConclusionsIn this nationwide observational study, non-persistence rates of oral anticoagulant treatment were high in patients treated for NVAF. Apixaban-treated patients seem to experience lowest discontinuation rates 12 months after treatment initiation compared to patients treated with any other OAC.     

Thromboembolic events in atrial fibrillation: Different level of risk and pattern between peripheral artery disease and coronary artery disease

A. Clinical outcomes (ischaemic stroke, ischaemic stroke/systemic thromboembolism and systemic thromboembolism) among patients with atrial fibrillation (AF) without coronary artery disease (CAD) or peripheral artery disease (PAD). B. Clinical outcomes among patients with AF and only CAD. C. Clinical outcomes among patients with AF and only PAD. D. Clinical outcomes among patients with AF and both CAD and PAD.

     

Impact of left atrial and diastolic ventricular dysfunction on mortality in patients with aortic stenosis

BackgroundDiastolic dysfunction (DD) is common in severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF ≥ 50%).AimTo determine the impact of American Society of Echocardiography/European Association of Cardiovascular Imaging-recommended DD grading and left atrial strain on mortality in a cohort of patients with severe AS and preserved LVEF.MethodsWe studied patients with severe AS (aortic valve area indexed < 0.6 cm²/m² and/or aortic valve area < 1 cm²), LVEF ≥ 50% and no or mild AS-related symptoms. The endpoint was all-cause mortality.ResultsA total of 387 patients (median age 76 years; 53% women) were studied. During a median follow-up of 57 (interquartile range 37; 83) months, 158 patients died. After adjustment for prognostic factors, patients with grade II or III DD had an increased mortality risk versus patients with grade I DD (adjusted hazard ratio (aHR) 1.62, 95% confidence interval (CI) 1.11–2.38; P = 0.013; aHR 4.73, 95% CI 2.49–8.99; P < 0.001; respectively). Adding peak atrial longitudinal strain (PALS) ≤ 14% to a multivariable model including DD grade improved predictive performance, with better global model fit, reclassification and discrimination. Patients with grade III DD or grade II DD + PALS ≤ 14% displayed an increased mortality risk versus patients with grade I DD + PALS > 14% (aHR 4.17, 95% CI 2.46–7.06; P < 0.0001). Those with grade I DD + PALS ≤ 14% or grade II DD + PALS > 14% were at intermediate risk (aHR 1.63, 95% CI 1.07–2.49; P = 0.024).ConclusionsOur results demonstrate the strong relationship between DD and mortality in patients with severe AS and preserved LVEF. Patients with grade III or grade II DD and impaired PALS are at very high risk. These data demonstrate the importance of a comprehensive assessment of diastolic function in patients with severe AS.     

No association between alcohol consumption and risk of atrial fibrillation: A two-sample Mendelian randomization study

Background and aimsAlthough many observational studies have suggested that alcohol intake was associated with incident atrial fibrillation (AF), controversy remains. This study aimed to examine the causal association of alcohol intake with the risk of AF.Methods and resultsTwo-sample Mendelian randomization (MR) analysis was performed to estimate the causal effects of alcohol consumption, alcohol dependence, or alcohol use disorder identification test (AUDIT) scores on AF. Summary data on single nucleotide polymorphisms (SNPs) associated with AF were obtained from a genome-wide association study (GWAS) with up to 1,030,836 participants. The fixed- and random-effect inverse-variance weighted (IVW) methods were used to calculate the overall causal effects. MR analysis revealed nonsignificant association of genetically predicted alcohol consumption with risk of AF using fixed- and random-effect IVW approaches (odds ratio (OR) [95% confidence interval (CI)] = 1.004 [0.796–1.266], P = 0.975; OR [95% CI] = 1.004 [0.766–1.315], P = 0.979). Genetically predicted alcohol dependence was also not causally associated with AF in the fixed- and random-effect IVW analyses (OR [95% CI] = 1.012 [0.978–1.048], P = 0.490; OR [95% CI] = 1.012 [0.991–1.034], P = 0.260). There was no significantly causal association between AUDIT and AF in the fixed- and random-effect IVW analyses (OR [95% CI] = 0.889 [0.433–1.822], P = 0.748; OR [95% CI] = 0.889 [0.309–2.555], P = 0.827). Sensitivity analyses indicated no evidence of pleiotropy and heterogeneity in statistical models.ConclusionsThis MR study did not find evidence of a causal association between alcohol intake and AF.     

Association of adipocytokines serum levels with left atrial thrombus formation in atrial fibrillation patients on oral anticoagulation (Alert) – A cross-sectional study

Background and aimsOral anticoagulation is effective for stroke prevention in atrial fibrillation (AF). However, strokes may still occur in high-risk individuals. We conducted a prospective trial to assess the association between adipocytokine serum levels and surrogate parameters for thromboembolic events.Methods and resultsIn this cross-sectional multicenter trial, we enrolled 189 patients with AF who were on oral anticoagulation. The primary endpoint was defined as either the presence of spontaneous echo contrast (SEC), a left atrial appendage (LAA), or a left atrial (LA) thrombus on transesophageal echocardiography. We investigated the association of adipocytokine serum levels with the combined endpoint using logistic regression analysis. Forty-eight individuals (25%) were assigned to group 1 (G1) due to the occurrence of at least one of the components of the combined endpoint (41 [21.7%] SEC, 3 [1.6%] LA thrombus, 13 [6.9%] LAA thrombus), whereas the remaining patients formed group 2 (G2). The BMI, logarithmized (log_e) leptin (G1: 2.0 ± 1.3 μg/ml, G2: 2.0 ± 1.1 μg/ml, p = 0.746) and visfatin serum levels (G1: 3.4 ± 0.3 ng/ml, G2: 3.4 ± 0.5 ng/ml, p = 0.900) did not significantly differ between the groups. Conversely, logarithmized adiponectin (G1: 3.3 ± 0.6 ng/ml, G2: 3.1 ± 0.7 ng/ml, p = 0.036) and resistin levels (G1: 1.8 ± 0.5 ng/ml, G2: 1.6 ± 0.5 ng/ml, p = 0.009) were higher in patients with the primary endpoint. Multivariate logistic regression analysis using a score that combined the individual adiponectin and resistin values in each patient corroborated this association.ConclusionsOur results suggest that adiponectin and resistin may act as potential biomarkers to identify individuals with AF who are at high thromboembolic risk.     

Oral antithrombotic therapy and one-year clinical outcomes among patients with atrial fibrillation in resource-limited settings

BackgroundAtrial fibrillation is associated with increased risk of morbidity and mortality. There's limited data on the outcomes of atrial fibrillation patients in Africa. We aimed at evaluating the clinical outcomes and their associated factors in patients with atrial fibrillation on antithrombotic therapy in Douala.MethodsThe Douala atrial fibrillation registry is a prospective, observational cohort study of patients with atrial fibrillation followed by cardiovascular specialists in 3 specialized care centres. From January to April 2018, all patients with electrocardiographic diagnosis of atrial fibrillation, aged 21 years or older, were included in the registry provided their consent. The composite endpoint of heart failure, stroke, major bleeding, hospitalisation and mortality as well as their individual occurrence were assessed at 12 months.ResultsOf 113 participants that were included, 6(5.3%) were lost to follow-up. The mean age was 70 ± 12 years, with a female predominance (68%). After a mean follow-up time of 12.2 ± 0.7 months, 51 patients (47.7%) had at least one outcome. Hospitalisation, all-cause mortality, heart failure, stroke and major bleeding rates were 33.3%, 16.8%, 15.2%, 4.8% and 2.9% respectively. There was no significant difference in the composite outcome and mortality according to the antithrombotic treatment. Previous heart failure [aHR = 3.07, 95% CI (1.48–6.36) p = 0.003], new onset atrial fibrillation [aHR= 4.00, 95% CI (0.96–8.19) p < 0.001] and paroxystic atrial fibrillation [aHR= 3.74, 95% CI (1.33–10.53) p = 0.013] were significant predictors of outcome.ConclusionHalf of patients with atrial fibrillation in this registry developed an outcome after one year of follow-up, with heart failure, new onset and paroxystic atrial fibrillation being the main predicting factors. Diagnosing and managing atrial fibrillation in patients with heart disease should therefore be considered as a key priority.