Management Strategies for Atrial Fibrillation and Flutter in Patients with Transthyretin Cardiac Amyloidosis

Abstract Background Atrial fibrillation (AF) and flutter (AFL) are common in transthyretin cardiac amyloidosis (ATTR-CM). Ventricular rate control drugs in ATTR-CM are poorly tolerated but data addressing tolerability and efficacy of rhythm control strategies is limited. Purpose We report characteristics and outcomes of AF/AFL in a cohort with ATTR-CM. Methods A single center observational study of patients seen at our Amyloidosis Center with wild-type or hereditary ATTR-CM diagnosed between 2005–2019. Treatment was prescribed as per treating cardiologists. Results Eighty-four patients with ATTR-CM (average age 74±10 years, 94% male) had mean follow-up of 27.6±22.8 months. AF/AFL occurred in 61 patients (73%). Clinically significant rapid ventricular response (RVR) was common as well attempted rate control with AV node blockers (Table 1). However, discontinuation was frequent (80%), often for adverse effects of hypotension (33%), bradycardia (15%), or presyncope/syncope (10%). Rhythm control was initiated in 64%, most often with cardioversion (DCCV) or ablation (Table 2). Post-DCCV recurrence was common (91%) and time to recurrence did not differ with use of anti-arrhythmic drugs (AAD; 5.8 months (IQR 1.9–12.5) vs without AAD 6.2 months (IQR 1.9–12.5) p=0.83). TEE was performed for 33% of DCCV with thrombus seen in 11% of cases – all patients who were not anticoagulated at the time. TEE was otherwise deferred due to known AF/AFL duration <48 hours (13%) or adequate anticoagulation (54%). Ablation was performed in 23% of patients with AFL (all for typical AFL) with 2 patients (14%) having recurrence after mean of 60.9 months. Pulmonary vein isolation for AF was performed in 12% (86% for persistent AF) with 86% recurrence after median of 6.2 months (IQR 5.6–12.3). Most patients (62%) with rhythm control had subjective improvement (≥1 NYHA class or resolved palpitations). Among AAD, amiodarone was most well tolerated with only 8% of patient discontinuing due to side effects. DCCV and ablation resulted in no direct complications although one patient had a perforation of a previously unknown Zenker diverticulum during TEE pre-DCCV. Conclusions In our ATTR-CM cohort, AF/AFL was common. Rate control was poorly tolerated and often abandoned. While rhythm control of AF/AFL had a favorable safety profile and successful conversion to sinus rhythm led to symptomatic improvement in a majority of cases, durable success with rhythm control was limited, often requiring multiple therapies. DCCV is only modestly successful and not significant improved with AAD. Ablation was successful in cases of cavo-tricuspid isthmus dependent AFL but had limited success in AF. FUNDunding Acknowledgement Type of funding sources: None.

Download Full-text

Atrial Fibrillation in the Elderly: The Role of Sub-Clinical Isolated Cardiac Amyloidosis

Scientific Reports ◽

10.1038/s41598-019-53119-z ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 2

Author(s):

Darshan Krishnappa ◽

Richard Dykoski ◽

Ilknur Can ◽

Mackenzie Mbai ◽

Inder S. Anand ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Disease ◽

Valvular Heart Disease ◽

Cardiac Amyloidosis ◽

Management Strategies ◽

The Elderly ◽

P Wave ◽

Amyloid Deposits ◽

Increased Risk

Abstract Amyloid infiltration of the atrium is described in patients with valvular heart disease and is associated with an increased risk for atrial fibrillation(AF) while amyloid deposits in the ventricles is increasingly being diagnosed in patients with HFpEF. The role of amyloid deposits in patients with AF without valvular heart disease, which represents the most common form of AF globally, is undefined. In this study, we sought to assess the prevalence of sub-clinical isolated cardiac amyloidosis (ICA) at autopsy and the odds of AF in these patients. A total of 1083 patients were included in the study and 3.1% of patients were found to have asymptomatic ICA. Patients with ICA were older and had a higher odds of AF independent of age and CHA2DS2VASc score. Amongst patients with AF, those with ICA were more likely to have persistent forms of AF and had a lower sinus rhythm P-wave amplitude. Further studies are required to further define this entity, identify imaging modalities to aid in antemortem diagnosis of ICA and to establish the optimal management strategies in these patients.

Download Full-text

Faculty Opinions recommendation of Results from a single-blind, randomized study comparing the impact of different ablation approaches on long-term procedure outcome in coexistent atrial fibrillation and flutter (APPROVAL).

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.717999159.793477751 ◽

2013 ◽

Author(s):

Paolo Della Bella ◽

Pasquale Vergara

Keyword(s):

Atrial Fibrillation ◽

Randomized Study ◽

Atrial Fibrillation And Flutter ◽

The Impact ◽

Single Blind

Download Full-text

March 2020 at a glance: heart failure with preserved ejection fraction, left atrial myopathy, atrial fibrillation and cardiac amyloidosis

European Journal of Heart Failure ◽

10.1002/ejhf.1509 ◽

2020 ◽

Vol 22 (3) ◽

pp. 389-390

Author(s):

Marianna Adamo ◽

Carlo Mario Lombardi ◽

Marco Metra

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Left Atrial ◽

Cardiac Amyloidosis ◽

Preserved Ejection Fraction

Download Full-text

Thromboembolic events following cardioversion of acute atrial fibrillation and flutter: a systematic review and meta-analysis

CJEM ◽

10.1007/s43678-021-00103-0 ◽

2021 ◽

Author(s):

Brenton M. Wong ◽

Jeffrey J. Perry ◽

Wei Cheng ◽

Bo Zheng ◽

Kevin Guo ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Meta Analysis ◽

Thromboembolic Events ◽

Atrial Fibrillation And Flutter

Download Full-text

Subacute postoperative atrial fibrillation after heart surgery: incidence and predictive factors in cardiac rehabilitation

European Journal of Preventive Cardiology ◽

10.1093/eurjpc/zwab061.326 ◽

2021 ◽

Vol 28 (Supplement_1) ◽

Author(s):

V Rizza ◽

F Maranta ◽

L Cianfanelli ◽

R Grippo ◽

C Meloni ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Hospital Stay ◽

Heart Surgery ◽

Troponin T ◽

Management Strategies ◽

Inpatient Rehabilitation ◽

Postoperative Atrial Fibrillation ◽

Funding Sources ◽

Valvular Surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background. Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. It may occur between the second and fourth postoperative days as acute POAF, or within 30 days as subacute POAF (sPOAF). The incidence varies from 15% to 60%, with the highest rates observed in patients undergoing valvular surgery. POAF is associated with longer hospital stay and higher thromboembolic risk, which consistently increase patients’ morbidity and mortality. Identification of high-risk categories may allow optimization of in-hospital prevention and treatment, possibly improving clinical outcomes. Aim of the study. The aim of this study was to assess the incidence of sPOAF and to identify possible predictors in patients performing Cardiovascular Rehabilitation (CR) after Cardiac Surgery (CS). Methods. A single-centre retrospective study was performed on 383 post-cardiac surgery patients hospitalised in our CR Unit for inpatient rehabilitation. The entire population was on sinus rhythm at the admission in CR and continuous monitoring with 12-lead ECG telemetry was performed during the hospital stay. We calculated the incidence of sPOAF and then evaluated the predictive value of the following variables: anamnestic data, type of cardiac intervention, clinical course in both CS and CR Unit, laboratory parameters including baseline neutrophil-to-lymphocyte ratio (NLR). Results. Median age was 65 years (63% male). sPOAF was documented in 122 cases (31.9%). Patients developing sPOAF were older [median age 69 (63-76) vs. 61 (51-70); p < 0.001)], more frequently underwent complex surgical procedures (50% vs. 36%; p = 0.009) and were known for previous episodes of atrial fibrillation (27.9% vs. 11.2%; p < 0.001). On the first day after surgery (T1), sPOAF group showed higher values of glycemia [median 155 (126.5–186.8) vs. 129 (106.5–164); p < 0.001] and troponin T [median 721.5 (470.1–1084.3) vs. 488 (301.6-776.2); p < 0.001]. The multivariate analysis identified advanced age (OR 1.04, 95% CI 1.01-1.08; p = 0.023), acute POAF in the Cardiac Surgery Unit (OR 3.51, 95% CI 1.62-7.59; p = 0.001), baseline NLR (OR 1.46, 95% CI 1.10-1.93; p = 0.008) and T1-troponin > 552 ng/L (OR 4.16 95% CI 1.50-11.53; p = 0.006) as independent risk predictors of sPOAF during the CR period. Conclusions. sPOAF is common after cardiac surgery occurring in 31.9% of patients during CR. Age, acute POAF, baseline NLR and elevated troponin T on the first postoperative day were shown predictors of increased sPOAF risk. Recognition of new predictors of POAF could be helpful to better stratify patients, improving management strategies and outcomes.

Download Full-text