Relationship between efficacy of antiarrhythmic drug therapy and structural remodeling in patients with paroxysmal atrial fibrillation

OBJECTIVES: To evaluate whether the response to antiarrhythmic drug therapy in patients with paroxysmal atrial fibrillation affects the development of structural remodeling in the left atrium and ventricle. METHODS: This study included 230 patients (158 men and 72 women, mean age 67 +/- 11 years) in whom antiarrhythmic drug therapy was attempted for > or = 12 months to maintain sinus rhythm (mean follow-up period 45 +/- 27 months). The patients were divided into three groups according to the response to antiarrhythmic drug therapy: group A consisted of 78 patients without recurrence of atrial fibrillation, group B consisted of 87 patients with recurrence of atrial fibrillation and electrical and/or pharmacological cardioversion to restore sinus rhythm, and group C consisted of 65 patients with permanent conversion despite antiarrhythmic drug therapy. RESULTS: In group A, left atrial dimension (LAD), left ventricular end-diastolic dimension (LVDd), and left ventricular ejection fraction (LVEF) did not change after antiarrhythmic drug therapy. In group B, LAD increased significantly after antiarrhythmic drug therapy (from 32.6 +/- 6.4 to 36.0 +/- 6.5 mm, p < 0.01), Whereas either LVDd or LVEF did not change after antiarrhythmic drug therapy. In group C, LAD increased significantly after antiarrhythmic drug therapy (from 37.3 +/- 7.0 to 40.5 +/- 7.9 mm, p < 0.01) and LVEF was significantly reduced after antiarrhythmic drug therapy (from 69.4 +/- 6.2% to 66.5 +/- 8.9%, p < 0.05). LVDd did not change after antiarrhythmic drug therapy. The plasma concentration of human atrial natriuretic peptide during sinus rhythm at the initiation of antiarrhythmic drug therapy in group A (30.5 +/- 26.7 pg/ml) was significantly lower than those in group B (48.0 +/- 49.7 pg/ml) and group C (49.7 +/- 39.5 pg/ml). CONCLUSIONS: The development of structural remodeling in human myocardium can be prevented with antiarrhythmic drug therapy if sinus rhythm is maintained without recurrence of atrial fibrillation in patients with paroxysmal atrial fibrillation.     

Effect of the Implantable Atrial Defibrillator on the Natural History of Atrial Fibrillation

INTRODUCTION: The purpose of our study was to evaluate the effect of repeated cardioversion with an implantable atrial defibrillator on the clinical outcome of patients with atrial fibrillation. METHODS AND RESULTS: The effects of the implantable atrial defibrillator on the total duration of atrial fibrillation, number of atrial fibrillation recurrences, and left atrial size were evaluated prospectively in 16 patients with atrial fibrillation (13 men and 3 women; mean age 58 +/- 11 years). Seven patients had no cardiovascular disease, 5 patients had hypertension, 3 patients had coronary heart disease, and 1 patient had congenital heart disease. Eight patients had paroxysmal atrial fibrillation for a mean duration of 80 +/- 61 months, and eight patients had persistent atrial fibrillation for a mean duration of 68 +/- 119 months. Except for one patient who received digoxin throughout the study, all patients received the same Class I or III antiarrhythmic agent throughout the study. The implantable atrial defibrillator successfully converted 50 (93%) of 54 spontaneous episodes of atrial fibrillation in 12 patients. During the initial 3 months of clinical follow-up, the atrial defibrillator documented 261 +/- 270 hours of atrial fibrillation compared with 126 +/- 172 hours (P = 0.01) during the subsequent 3 months. The left atrial size decreased from 4.4 +/- 0.7 cm at the time of atrial defibrillator implantation to 4.1 +/- 0.6 cm (P = 0.02) 6 months later. The number of atrial fibrillation recurrences did not change. These findings were observed in the absence of changes in drug therapy. No complications were observed. CONCLUSION: Restoration and maintenance of sinus rhythm in patients with atrial fibrillation by repeated cardioversion with an implantable atrial defibrillator was associated with a reduction in the total arrhythmia duration and a reduction in left atrial size. These results suggest that maintenance of sinus rhythm with the atrial defibrillator may reverse the remodeling process associated with atrial fibrillation.     

Psychosocial aspects of patient-activated atrial defibrillation

Atrial Defibrillator. INTRODUCTION: The atrial defibrillator empowers patients to cardiovert themselves from atrial arrhythmias at a time that is socially and physically acceptable, thereby preventing hospitalization. The long-term psychosocial effects of repeated use of the patient-activated atrial defibrillator at home are unknown. METHODS AND RESULTS: Eighteen patients underwent placement of the Jewel AF atrial defibrillator for persistent atrial fibrillation only. All patients performed manually activated cardioversions at home under self-administered sedation. Automatic shock therapies were disabled. Hospital Anxiety and Depression Scale and Multidimensional Health Locus of Control questionnaires were obtained before implant. All patients completed questionnaires 1 year after device implant and at long-term follow-up. The spouse or partner of each patient was interviewed to identify positive and negative aspects of manual cardioversion at home. The baseline patient scores for both anxiety (5.7 +/- 2.7) and depression (3.4 +/- 2.3) fell within the predefined range of normality. At 1 year, there was no significant change in anxiety (4.9 +/- 3.7, P = 0.39) or depression (2.4 +/- 1.8, P = 0.06). At long-term follow-up (mean 28 months), a total of 377 patient-activated cardioversions were performed out of hospital (median 15 per patient). Scores for anxiety (6.0 +/- 4.0, P = 0.70) and depression (3.2 +/- 2.5, P = 0.68) remained unchanged. CONCLUSION: During long-term follow-up, patient-activated cardioversion using the atrial defibrillator was not associated with increased anxiety or depression. The procedure was well tolerated by patients and their partners, offering an acceptable treatment option for patients with recurrent persistent atrial fibrillation.     

Success of serial external electrical cardioversion of persistent atrial fibrillation in maintaining sinus rhythm; a randomized study.

AIMS: The aim of this prospective, randomized study was to determine the efficacy of a serial external electrical cardioversion strategy in maintaining sinus rhythm after 12 months in patients with recurrent persistent atrial fibrillation. METHODS AND RESULTS: Ninety patients with persistent atrial fibrillation lasting more than 72 h but less than 1 year were randomized in a one to one fashion to repetition of up to two electrical cardioversions in the event of relapse of atrial fibrillation detected within 1 month of the previous electrical cardioversion (Group AGG), or to non-treatment of atrial fibrillation relapse (Group CTL). ECGs were scheduled at 6 h, 7 days, and 1 month. Clinical examination and ECGs were repeated during the 6-month and 12-month follow-up examinations. Echocardiography was repeated during the 6-month follow-up examination. Clinical and echocardiographic characteristics were similar in the two groups. All patients were treated with antiarrhythmic drugs before electrical cardioversion and throughout follow-up. After 12 months, sinus rhythm was maintained in 53% of Group AGG patients and in 29% of Group CTL patients (P<0.03). After 6 months, left ventricular ejection fraction had recovered significantly only in Group AGG (56.8 +/- 9.0% at enrollment vs 60.4 +/- 9.4% at 6 months,P <0.001). CONCLUSION: These results demonstrate that an aggressive policy towards persistent atrial fibrillation by means of repetition of electrical cardioversion after early atrial fibrillation recurrence is useful in maintaining sinus rhythm after 12 months.     

Increase in radionuclide left ventricular ejection fraction after cardioversion of chronic atrial fibrillation in idiopathic dilated cardiomyopathy.

To assess the potential improvement in left ventricular ejection fraction after cardioversion of chronic atrial fibrillation to sinus rhythm in idiopathic dilated cardiomyopathy, we studied prospectively 17 patients, aged 58 +/- 6 years, by radionuclide angiocardiography at rest. Left ventricular ejection fraction was determined before treatment and at a mean delay of 4.7 months after cardioversion. Return to sinus rhythm was obtained in 12 patients, pharmacologically or by electrical cardioversion. Five patients remained in atrial fibrillation. No clinical, echocardiographic or haemodynamic finding could predict the success of cardioversion. In chronic atrial fibrillation, the ejection fraction did not change significantly: 30.0 +/- 9.1% (19 to 44%) at the first evaluation and 29.5 +/- 8.3% (22 to 41%) after 4.7 months. After successful cardioversion, left ventricular ejection fraction improved from 32.1 +/- 5.3% (24 to 41%) to 52.9 +/- 9.7% (37 to 71%) (P less than 0.001). The difference was 20.8 +/- 11.3% and left ventricular ejection fraction was normalized in 50% (6/12) of the patients. There was a significant reduction in the cardiothoracic ratio on chest X-rays and of the left ventricular end-diastolic diameter on echocardiography; fractional shortening increased (27.7 +/- 4.3% vs 20.3 +/- 2.7%, P less than 0.01). A third evaluation was realized after a mean delay of 11.7 months in the patients with successful cardioversion. Sinus rhythm was present in 83% (10/12) of the patients: seven patients were reevaluated by radionuclide angiography. The improvement in left ventricular function observed at the 4.7 months evaluation was still present. In two patients with recurrence of atrial fibrillation, there was a severe deterioration of left ventricular systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)     

Open heart radio frequency left atrial compartmentation during mitral valve surgery: an alternative to the labyrinth procedure?

The authors report their experience of radiofrequency left atrial compartimentation during open heart mitral valve surgery on 37 patients with a 42 +/- 12 months history of atrial fibrillation. The preoperative left ventricular ejection fraction was 62 +/- 8%; the left atrial diameter was 59 +/- 11 mm. The mean operative time was 245 +/- 60 minutes, which included 19 +/- 5 minutes for the ablation procedure. There were 2 early postoperative deaths and 2 deaths from non-cardiac causes at 3 and 6 months. The left ventricular ejection fraction and left atrial dimension were significantly decreased at the time of hospital discharge (54 +/- 12% and 51 +/- 7 mm respectively) (p < 0.01). After an average follow-up of 1 year, 81% of patients were free of atrial fibrillation: 6 patients had undergone DC cardioversion and 1 had a dual-chamber pacemaker. Patients in sinus rhythm after the ablation were associated with shorter periods of atrial fibrillation and smaller left atrial dimensions postoperatively than those who remained in fibrillation. The authors conclude that radiofrequency compartimentation of the left atrium associated with antiarrhythmic therapy can interrupt atrial fibrillation in 81% of patients at 1 year: the ablation procedure takes only 8% of the operation time. Predictive factors of success of ablation should be defined to determine which patients benefit most from this technique.     

Ibutilide in persistent atrial fibrillation refractory to conventional cardioversion methods

BACKGROUND: Electrical cardioversion of atrial fibrillation seems to be enhanced by pretreatment with ibutilide, but only few is known about the effects of ibutilide in atrial fibrillation which failed to convert with class III antiarrhythmic agents and electrical cardioversion. The objectives of this study were to evaluate the efficacy and safety of ibutilide administration in patients with persistent atrial fibrillation refractory to long-term therapy with class III antiarrhythmic drugs and transthoracic cardioversion. METHODS: Prospective study in 22 patients (16 men and 6 women, mean age 63+/-9 years) with structural heart disease and persistent atrial fibrillation for a mean duration of 39+/-50 (range 1-145) months. All patients had failed to convert to sinus rhythm after transthoracic cardioversion while on treatment with class III antiarrhythmic drugs (amiodarone in 82%, sotalol in 18%). One milligram of ibutilide was administered in all patients and electrical cardioversion was performed again, if necessary. RESULTS: The total conversion rate to sinus rhythm was 95% (21 of 22 patients). Two patients (9%) were successfully converted after ibutilide alone and 19 patients (86%) when transthoracic cardioversion was repeated after ibutilide. The QTc intervals increased from 451+/-28 to 491+/-49 ms (p<0.001) after ibutilide. No adverse effects occurred. The rate of freedom from atrial fibrillation after 1 month of follow-up was 64%. CONCLUSIONS: The efficacy of concomitant use of ibutilide infusion and, if necessary, repeated transthoracic cardioversion for restoration of sinus rhythm in long-term persistent atrial fibrillation and previously failed antiarrhythmic and electrical cardioversion was 95%. There were no adverse effects associated with ibutilde administration. Our results suggest that this combined strategy may be safe and successful in patients with atrial fibrillation resistant to conventional cardioversion methods and may be an alternative to internal cardioversion.     

Low-energy internal cardioversion in patients with long-lasting atrial fibrillation refractory to external electrical cardioversion: results and long-term follow-up.

AIM: Low-energy internal cardioversion is a new electrical treatment for patients with persistent atrial fibrillation. This paper evaluates the efficacy and safety of low-energy internal cardioversion in patients with long-lasting atrial fibrillation refractory to external electrical cardioversion, and the clinical outcome of such patients. METHOD AND RESULTS: The study population consisted of 55 patients [32 male, mean age 65 +/- 10 years, 48 (87%) with underlying heart disease] with long-lasting (mean 18 +/- 34 months) atrial fibrillation in whom external cardioversion had failed to restore sinus rhythm. Two custom-made catheters were used: one positioned in the right atrium and one in the coronary sinus or the left pulmonary artery. A standard catheter was inserted into the right ventricular apex to provide R wave synchronization. Sinus rhythm was restored in 52 patients (95%) with a mean defibrillating energy of 6.9 +/- 2.6 J (320 +/- 60 V). No complications were observed. During follow-up (mean 18 +/- 9 months), 16 patients (31%) suffered early recurrence (< or = 1 week) of atrial fibrillation and 20 patients (38%) had late recurrence (> 1 week, mean 3.5 +/- 3.6 months) of atrial fibrillation. Six patients with a late recurrence again underwent cardioversion and five of these maintained sinus rhythm. Therefore, a total of 21/52 patients (40%) were in sinus rhythm at the end of follow-up. No clinical difference was found between patients with and without recurrences. CONCLUSIONS: Low-energy internal cardioversion is a useful means of restoring sinus rhythm in patients with long-lasting atrial fibrillation refractory to external electrical cardioversion. More than one-third of patients maintained sinus rhythm during long-term follow-up.     

Efficacy and safety of moricizine in the maintenance of sinus rhythm in patients with recurrent atrial fibrillation

Maintenance of sinus rhythm is the primary goal of antiarrhythmic drug therapy for recurrent atrial fibrillation (AF). However, concern about proarrhythmic and negative inotropic effects has led to increasing reluctance to administer antiarrhythmic agents for this non-life-threatening arrhythmia. Moricizine is well tolerated in a wide variety of patients, and therefore, may be a safe and effective agent for treating AF. We retrospectively assessed the efficacy and safety of moricizine (mean dose 609 +/- 9 mg/day) in 85 consecutive patients with recurrent AF (2.6 +/- 0.5 years duration, 1.6 +/- 1 failed antiarrhythmic drugs). Structural heart disease was present in 69 (81%), but no recent myocardial infarct (< or =90 days) was present; mean left atrial size was 46 +/- 1 mm, and mean left ventricular ejection fraction was 0.51 +/- 0.01. Moricizine was discontinued because of unsuccessful direct-current cardioversion (n = 5) or clinically unacceptable side effects (n = 6); 6 patients developed transient side effects not requiring discontinuation. Of the 74 patients continuing therapy, 68% remained in sinus rhythm after 6 months, and 59% after 12 months. During a follow-up (21 +/- 2 months), there were neither deaths nor adverse effects requiring discontinuation of therapy. Thus, moricizine was effective, safe, and well tolerated in our patient cohort with AF.     

Prediction of atrial fibrillation recurrence after cardioversion by P wave signal-averaged electrocardiography.

The purpose of this report was to determine prospectively whether P wave signal-averaged electrocardiography (ECG) is useful for the prediction of recurrences of atrial fibrillation after cardioversion. The P wave signal-averaged ECG was recorded in 73 patients after successful cardioversion. Duration of the filtered P wave and the root mean square voltages for the last 20 ms of the P wave were calculated. In addition to signal-averaged ECG P wave analysis, all patients were evaluated by echocardiography. During 6 months follow-up period recurrence of atrial fibrillation was observed in 31 (42.5%) patients and in 42 (57.5%) patients sinus rhythm was maintained. There was no difference in gender, age, presence of organic heart disease, left atrial diameter, left ventricular ejection fraction, use of antiarrhythmic drug, and duration of atrial fibrillation (P>0.05). The filtered P-wave duration was longer and the root mean square voltages for the last 20 ms of the P wave was lower in patients with recurrence of atrial fibrillation than in patients who maintained sinus rhythm (138.3+/-12.5 ms vs. 112.4+/-11.8 ms, P = 0.001; 1.9+/-0.7 microV vs. 2.5+/-0.6 microV, P = 0.001). A filtered P-wave duration > or =128 ms associated with a root mean square voltage for the last 20 ms of the P wave < or =2.1 microV had a sensitivity of 70% and specificity of 76% for the detection of patients with recurrence of atrial fibrillation after successful cardioversion of atrial fibrillation. We found that the likelihood of recurrence of atrial fibrillation after cardioversion was increased 4.31-fold (95% confidence interval 2.08-9.83) if these parameters were used. These results suggest that P wave signal-averaged ECG could be useful to identify patients at risk for recurrence of atrial fibrillation after cardioversion.     

Determinants of recurrent atrial flutter after cardioversion.

Eighteen male patients (mean age 59 years) who were electrically cardioverted for pure atrial flutter were retrospectively studied to determine those factors influencing the maintenance of regular sinus rhythm or reversion to atrial flutter. Six months after successful cardioversion, 10 patients (55%) had recurrent atrial flutter and eight patients (45%) were still in sinus rhythm. The two groups were not significantly different with respect to age, symptomatology, abnormalities on the 12 lead electrocardiogram (during sinus rhythm), or the administration of digoxin and a class Ia antiarrhythmic agent (after cardioversion). There was a trend for those patients with recurrent atrial flutter to have a higher incidence of underlying heart disease and previous episodes of atrial flutter than the non-recurrent group. There were statistically significant differences between the recurrent and non-recurrent groups with respect to echocardiographically determined left atrial size and left ventricular ejection fraction. Patients with a left atrial size greater than 45 mm or with an ejection fraction less than 45% were all at high risk for recurrent atrial flutter after successful cardioversion.     

Prognostic significance of atrial fibrillation in advanced heart failure. A study of 390 patients

BACKGROUND. Atrial fibrillation is common in advanced heart failure, but its prognostic significance is controversial. METHODS AND RESULTS. We evaluated the relation of atrial rhythm to overall survival and sudden death in 390 consecutive advanced heart failure patients. Etiology of heart failure was coronary artery disease in 177 patients (45%) and nonischemic cardiomyopathy or valvular heart disease in 213 patients (55%). Mean left ventricular ejection fraction was 0.19 +/- 0.07. Seventy-five patients (19%) had paroxysmal (26 patients) or chronic (49 patients) atrial fibrillation. Compared with patients with sinus rhythm, patients with atrial fibrillation did not differ in etiology of heart failure, mean pulmonary capillary wedge pressure on therapy, or embolic events but were more likely to be receiving warfarin and antiarrhythmic drugs and had a slightly higher left ventricular ejection fraction. After a mean follow-up of 236 +/- 303 days, 98 patients died: 56 (57%) died suddenly, and 36 (37%) died of progressive heart failure. Actuarial 1-year overall survival was 68%, and sudden death-free survival was 79%. Actuarial survival was significantly worse for atrial fibrillation than for sinus rhythm patients (52% versus 71%, p = 0.0013). Similarly, sudden death-free survival was significantly worse for atrial fibrillation than for sinus rhythm patients (69% versus 82%, p = 0.0013). By Cox proportional hazards model, pulmonary capillary wedge pressure on therapy, left ventricular ejection fraction, coronary artery disease, and atrial fibrillation were independent risk factors for total mortality and sudden death. For patients who had pulmonary capillary wedge pressure of less than 16 mm Hg on therapy, atrial fibrillation was associated with poorer 1-year survival (44% versus 83%, p = 0.00001); however, in the high pulmonary capillary wedge pressure group, atrial fibrillation did not confer an increased risk (58% versus 57%). CONCLUSIONS. Atrial fibrillation is a marker for increased risk of death, especially in heart failure patients who have lower filling pressures on vasodilator and diuretic therapy. Whether aggressive attempts to maintain sinus rhythm will reduce this risk is unknown.     

Efficacy of internal cardioversion for chronic atrial fibrillation in patients with and without left ventricular dysfunction

Internal cardioversion can restore sinus rhythm with energies below 6-10 J, often without anaesthesia/sedation. We investigated its safety and short-/medium-term efficacy in patients with persistent atrial fibrillation (AF) with left ventricular dysfunction (defined as ejection fraction < or = 40%). Among 34 patients with persistent AF who agreed to receive internal cardioversion, 16 had left ventricular dysfunction and 18 did not (the groups were similar as regards age, duration of AF and pretreatment with amiodarone). Internal CV was performed delivering 3.0/3.0-ms biphasic shocks between coil catheters using a step-up protocol. Sinus rhythm was always restored. General anaesthesia (administered only when discomfort was not tolerated) was required only in 2 of the 16 (12.5%) patients with left ventricular dysfunction. The defibrillation threshold was similar in patients with and without left ventricular dysfunction (10.2+/-6.9 vs. 8.4+/-4.9 J; p=0.37). Short-term (within 72 h) AF recurrence rates in the presence and absence of left ventricular dysfunction were 19% (3/16) and 6% (1/18), respectively (p=0.51). After cardioversion, all patients received antiarrhythmic drugs (mostly amiodarone in patients with left ventricular dysfunction and class IC agents in the remainder). With mean follow-up periods of about 220 days, AF recurrence rates among patients with and without left ventricular dysfunction were 50% (8/16) and 28% (5/18), respectively (p=0.328). We conclude that even in patients with left ventricular dysfunction, internal CV is safe and effective, minimizing risks from anaesthesia. Although these patients may have a higher risk of short- or medium-term AF recurrence, 6-month maintenance of sinus rhythm is possible in about 50% of cases.     

Efficacy of a dual chamber defibrillator with atrial antitachycardia functions in treating spontaneous atrial tachyarrhythmias in patients with life-threatening ventricular tachyarrhythmias.

BACKGROUND: Atrial fibrillation has a high incidence in patients wearing an implantable cardioverter defibrillator for ventricular tachyarrhythmias and may lead to palpitations, heart failure, angina, stroke and inappropriate defibrillator discharge. The aim of the study was to evaluate the efficacy of a dual chamber defibrillator with atrial antitachycardia functions in treating spontaneous atrial tachyarrhythmias. METHODS: One hundred and twelve patients, 88 male, mean age 64+/-11 years, were enrolled. Seventy-six had ischaemic heart disease, 21 idiopathic dilated cardiomyopathy, nine other heart diseases, six no structural heart disease. The mean left ventricular ejection fraction was 40+/-11%. Sixty-two had prior atrial tachyarrhythmias. RESULTS: Follow-up lasted 11+/-9 months (range 1-42). Among 933 ventricular tachyarrhythmia episodes, 100% of ventricular fibrillation and 92% of ventricular tachycardia were successfully cardioverted. Among 414 detected sustained atrial tachyarrhythmias, 195 were classified as atrial tachycardia (47.1%), 192 as atrial fibrillation (46.4%) and 27 (6.5%) as sinus rhythm. The detection-positive predictive value was 93.5%. Therapy success rates: antitachy pacing on atrial tachycardia = 71.3% (crude estimate); 66.1% (adjusted estimate); 50 Hertz on atrial fibrillation=36.2% (crude estimate); 13.5% (adjusted estimate); atrial shock on atrial fibrillation = 62.5% (mean energy 7.8+/-14.1J). Shock efficacy was 32% when delivered energy was < or = 2 atrial defibrillation threshold at implant and 92% when >2. Duration of successfully treated atrial episodes was significantly lower than that of unsuccessfully treated (6+/-26 min vs 42+/-60). CONCLUSIONS: Atrial antitachy pacing and shock therapies demonstrated very high efficacy in treating atrial tachyarrhythmias in defibrillator patients.     

Relation of C-reactive protein to long-term risk of recurrence of atrial fibrillation after electrical cardioversion

The aim of this study is to assess the role of C-reactive protein (CRP) in predicting long-term risk of atrial fibrillation (AF) recurrence after electrical cardioversion. CRP levels are associated with the presence of AF and failure of electrical or pharmacologic cardioversion, but no previous study has assessed their predictive role in long-term follow-up after successful electrical cardioversion. One hundred two consecutive patients (age 67 +/- 11 years; 58 men) with nonvalvular persistent AF who underwent successful biphasic electrical cardioversion were studied. High-sensitivity CRP was measured immediately before cardioversion. Follow-up was performed up to 1 year in all cases. Patients were divided into 4 groups according to CRP quartiles. Patients in the lowest CRP quartile (<1.9 mg/L) had significantly lower rates of AF recurrence (4% vs 33% at 3 months in the other 3 groups combined, p = 0.007, and 28% vs 60% at 1 year, p = 0.01). The 4 groups were similar in age, gender, ejection fraction, and left atrial size. Survival analysis confirmed that patients in the lowest CRP quartile had a lower recurrence rate (p = 0.02). Cox regression analyses using age, gender, hypertension, diabetes, ejection fraction, left atrial diameter, use of antiarrhythmic drugs, angiotensin-converting enzyme inhibitors or angiotensin II antagonists, and statins, and CRP quartiles as covariates showed that only CRP was independently associated with AF recurrence during follow-up (hazard ratio 4.98, 95% confidence interval 1.75 to 14.26, p = 0.003). In conclusion, low CRP is associated with long-term maintenance of sinus rhythm after cardioversion for nonvalvular AF.     

Brain natriuretic peptide predicts successful cardioversion in patients with atrial fibrillation and maintenance of sinus rhythm

BACKGROUND: Brain natriuretic peptide (BNP) is released from the heart by hemodynamically induced muscle stretch. Patients with atrial fibrillation have higher levels of BNP than those in sinus rhythm. OBJECTIVE: To assess the usefulness of BNP as a predictor of successful cardioversion in patients with persistent atrial fibrillation and subsequent maintenance of sinus rhythm. SUBJECTS AND METHODS: Twenty patients undergoing cardioversion for persistent atrial fibrillation were enrolled. BNP levels were measured before electric cardioversion, and 30 min and two weeks after cardioversion. Baseline echocardiograms and 12-lead electrocardiograms were obtained from all patients. Patients with valvular disease, previous mitral valve surgery or significant left ventricular dysfunction were excluded. RESULTS: The mean BNP level and the mean heart rate were significantly higher before cardioversion than 30 min after (197+/-132 pg/mL versus 164+/-143 pg/mL, P=0.02, and 77+/-17 beats/min versus 57+/-12 beats/min, P=0.0007, respectively). Patients who reverted back to atrial fibrillation after two weeks had a baseline BNP of 293+/-106 pg/mL, while those who remained in sinus rhythm for two weeks had a lower baseline BNP of 163+/-122 pg/mL (P=0.02). CONCLUSION: In patients with persistent atrial fibrillation, BNP levels are associated with successful cardioversion and maintenance of sinus rhythm two weeks after cardioversion.     

Clinical value of left atrial appendage flow velocity for predicting of cardioversion success in patients with non-valvular atrial fibrillation.

BACKGROUND: Echocardiographic parameters for predicting cardioversion outcome in patients with non-valvular atrial fibrillation are not accurately defined. OBJECTIVE: To evaluate the role of left atrial appendage flow velocity detected by transoesophageal echocardiography for prediction of cardioversion outcome in patients with non-valvular atrial fibrillation enrolled in a prospective. multicentre, international study. METHODS: Four hundred and eight patients (257 males, mean age: 66 +/- 10 years) with non-valvular atrial fibrillation lasting more than 48 h but less than 1 year underwent transthoracic echocardiography and transoesophageal echocardiography before either electrical (n=324) or pharmacological (n=84) cardioversion. RESULTS: Cardioversion was successful in restoring sinus rhythm in 328 (80%) and unsuccessful in 80 patients (20%). Mean left atrial appendage peak emptying flow velocity was significantly higher in patients with successful than in those with unsuccessful cardioversion (32.4 +/- 17.7 vs 23.5 +/- 13.6 cm x s(-1); P<0.0001). At multivariate logistic regression analysis, three parameters proved to be independent predictors of cardioversion success: the atrial fibrillation duration <2 weeks (P=0.011, OR=4.9, CI 95%=1.9-12.7), the mean left atrial appendage flow velocity >31 cm x s(-1) (P=0.0013, OR=2.8, CI 95%=1.5-5.4) and the left atrial diameter <47 mm (P=0.093, OR=2.0, CI 95%=1.2-3.4). These independent predictors of cardioversion success outperformed other univariate predictors such as left ventricular end-diastolic diameter <58 mm, ejection fraction >56% and the absence of left atrial spontaneous echo contrast. CONCLUSION: In patients with non-valvular atrial fibrillation, measurement of the left atrial appendage flow velocity profile by transoesophageal echocardiography before cardioversion provides valuable information for prediction of cardioversion outcome.     

The dubious value of echocardiographic and plasma ANP measurements in predicting outcome of cardioversion in patients with persistent atrial fibrillation

Atrial fibrillation (AF) is a common arrhythmia with important therapeutic and prognostic implications. An attempt to restore sinus rhythm is considered in most patients with AF. The aim of this study was to assess the value of echocardiographic examination and plasma atrial natriuretic peptide (ANP) evaluation in predicting the outcome of cardioversion and maintenance of sinus rhythm in patients with persistent AF. METHODS: Eighty-one consecutive patients, aged 62+/-9 years, with AF of duration 4.7 months were subjected to an echocardiography examination and ANP assessment before cardioversion. The patients were predominantly hypertensive men with moderately enlarged left atrium and ejection fraction of left ventricle of about 50%. All patients were in controlled AF and had normalized blood pressure. In order to predict the outcome of cardioversion, and maintenance of sinus rhythm over a 1 month period, a multivariate logistic regression method was performed using the following variables: left atrial and left ventricular dimensions, left ventricular ejection fraction and plasma ANP levels. RESULTS: Sixty-nine out of the 81 patients were successfully converted to sinus rhythm. At 1 month 57 patients remained in sinus rhythm. There were no statistical differences between sinus rhythm and AF group in baseline ANP levels (59.4 vs 64.2 pg/ml, consecutively), clinical and echocardiographic characteristics. In logistic regression analysis neither baseline echocardiographic variable nor ANP level, predicts successful cardioversion over a 1-month period of observation. CONCLUSION: Echocardiographic data and ANP level should not be included as an important variable when considering patients for cardioversion.     

Pulmonary vein flow analysis by transoesophageal echocardiogr phy in patients with chronic atrial fibrillation; 1 year follow-up after cardioversion.

AIMS: Left and right upper pulmonary vein flow can be adequately recorded by transoesophageal Doppler echocardiography. The aim of this study was to investigate whether analysis of the pulmonary venous flow velocity pattern can predict the long-term maintenance of sinus rhythm after successful cardioversion of chronic atrial fibrillation. METHODS AND RESULTS: Thirty-six consecutive patients, aged 53+/-9 years, with chronic atrial fibrillation of 5.33+/-2 months duration, were subjected to transoesophageal Doppler echocardiography to record left and right upper pulmonary venous flow, 24 h and 3 months following successful cardioversion. One year following cardioversion, 12 patients (33.3%) were in sinus rhythm (sinus rhythm group) while the remaining 24 patients were in atrial fibrillation (atrial fibrillation group). At 24 h following cardioversion, biphasic systolic forward flow in the left and/or right upper pulmonary venous flow velocity was detected in 10 patients of the sinus rhythm group and in four patients of the atrial fibrillation group (P<0001). The systolic fraction was significantly higher in the sinus rhythm group, 0.48+/-0.04 and 0.39+/-0.06, P<0.001 for the left upper pulmonary venous flow, and 0.52+/-0.05 and 0.41+/-0.04, P<0.001 for the right upper pulmonary venous flow, respectively. In patients who displayed a biphasic systolic forward flow and in whom the right upper pulmonary venous flow systolic fraction was higher than 0.50 at 24 h post-cardioversion, the probability of maintenance of sinus rhythm at 1 year exceeded 95%. CONCLUSION: The detection of a biphasic systolic forward flow in the pulmonary venous flow velocity, and of a right upper pulmonary vein systolic fraction higher than 0.50 as early as 24 h following cardioversion of chronic atrial fibrillation, identifies patients who will remain in sinus rhythm 1 year after cardioversion.     

Effect of percutaneous transvenous mitral commissurotomy for the preservation of sinus rhythm in patients with mitral stenosis

OBJECTIVES: Atrial fibrillation is frequently associated with mitral stenosis and is considered to be an unfavorable factor for the long-term prognosis. The efficacy of percutaneous transvenous mitral commissurotomy(PTMC) was examined for the preservation of sinus rhythm in patients with mitral stenosis after PTMC. METHODS: Long-term clinical data after PTMC were obtained from 71 patients who had undergone PTMC from March 1989 to September 1999. Eighteen patients in sinus rhythm before PTMC were divided into two groups: the SR group(n = 5) who remained in sinus rhythm, and the Af group(n = 13) who showed change from sinus rhythm to persistent or paroxysmal atrial fibrillation after PTMC. RESULTS: Age, sex, mitral valve area(1.4 +/- 0.3 vs 1.2 +/- 0.3 cm2), mean mitral pressure gradient(14.3 +/- 5.5 vs 12.6 +/- 5.9 mmHg), mean left atrial pressure(15.9 +/- 7.6 vs 19.0 +/- 7.7 mmHg), left ventricular end-diastolic pressure(7.5 +/- 2.8 vs 9.3 +/- 3.9 mmHg), left ventricular end-diastolic volume index(77 +/- 13 vs 82 +/- 14 ml/m2), left ventricular ejection fraction(60 +/- 6% vs 55 +/- 4%) and cardiac output(5.1 +/- 0.4 vs 4.9 +/- 0.8 l/m2) before PTMC were not different between the two groups. Changes in mean mitral pressure gradient, mean left atrial pressure and cardiac output immediately after PTMC were not different statistically. Mitral valve area immediately after PTMC was significantly greater in the SR group compared to the Af group(2.3 +/- 0.3 vs 1.8 +/- 0.3 cm2, p < 0.05). The change in mitral valve area was also greater in the SR group(1.0 +/- 0.2 vs 0.6 +/- 0.4 cm2, p < 0.05), but there was no statistical difference in the percentage change of mitral valve area between before and immediately after PTMC(SR group 78 +/- 35% vs Af group 50 +/- 35%). End-diastolic pressure, end-diastolic volume index and ejection fraction immediately after PTMC were not statistically different. CONCLUSIONS: The final mitral valve area immediately after PTMC in the patients with mitral stenosis in sinus rhythm, but not the changes of mean mitral pressure gradient, mean left atrial pressure or cardiac output, is important for the maintenance of sinus rhythm.