scholarly journals Catheter, Surgical, or Hybrid Procedure: What Future for Atrial Fibrillation Ablation?

2021 ◽  
Author(s):  
Giuseppe Nasso ◽  
Roberto Lorusso ◽  
Marco Moscarelli ◽  
Giuseppe De Martino ◽  
Angelo M. Dell’Aquila ◽  
...  
Keyword(s):  
Sinus Rhythm ◽  
Hybrid Approach ◽  
Left Ventricular ◽  
Hybrid Procedure ◽  
Left Ventricular Ejection ◽  
Epicardial Ablation ◽  
Af Ablation ◽  
Linear Lesions ◽  
Af Recurrence

Abstract Background - The debate on the best treatment strategy for AF has expanded following the introduction of the so-called “hybrid procedure” that combines minimally invasive epicardial ablation with endocardial catheter ablation. However, the advantage of the hybrid approach over conventional epicardial ablation remains to be established.Methods -From June 2008 to December 2020, 609 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency (RF) device was used, whereas from 2011 to 2020 a bipolar RF device was used. In addition, between September 2016 and April 2017, 60 patients underwent endocardial completion of epicardial linear ablation. In 30 of these latter patients, surgical isolation of the Bachmann’s bundle (BB) was also performed. Starting from 2021, surviving patients at follow-up were asked to undergo ECG evaluation and left ventricular function assessment and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF. Results - The ablation procedure was completed in all patients. Upon discharge, 30 (4.9%) patients showed recurrence of AF, whereas the remaining patients (95.1%) were in sinus rhythm. All patients in whom a hybrid approach was used either with or without BB ablation were discharged in sinus rhythm. After a mean follow-up of 74 months, 122 (20%) patients developed recurrent AF, including 19.9% in whom a unipolar RF device was used, 21% in whom a bipolar RF device was used, 23% who had undergone a hybrid procedure without BB ablation and 3.3% who had undergone a hybrid procedure. On multivariate analysis, reduced left ventricular ejection fraction, worsening of EHRA symptom class, and cognitive impairment or depression during follow-up were found to be significantly associated with AF recurrence. Conclusions - Surgical AF ablation through a right minithoracotomy is safe and may allow the creation of additional linear lesions, particularly in the BB. The placement of adjunctive linear lesions in the setting of a hybrid procedure is more effective in reducing the risk for AF recurrence than isolated surgical ablation or hybrid ablation without the addition of further linear lesions, with no incremental risk to the patient.

scholarly journals Catheter, surgical, or hybrid procedure: what future for atrial fibrillation ablation?

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Giuseppe Nasso ◽  
Roberto Lorusso ◽  
Marco Moscarelli ◽  
Giuseppe De Martino ◽  
Angelo M. Dell’Aquila ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Hybrid Approach ◽  
Left Ventricular ◽  
Hybrid Procedure ◽  
Epicardial Ablation ◽  
Af Ablation ◽  
Linear Lesions ◽  
Af Recurrence

Abstract Background The debate on the best treatment strategy for atrial fibrillation (AF) has expanded following the introduction of the so-called “hybrid procedure” that combines minimally invasive epicardial ablation with endocardial catheter ablation. However, the advantage of the hybrid approach over conventional epicardial ablation remains to be established. Methods From June 2008 to December 2020, 609 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency (RF) device was used, whereas from 2011 to 2020 a bipolar RF device was used. In addition, between September 2016 and April 2017, 60 patients underwent endocardial completion of epicardial linear ablation. In 30 of these latter patients, surgical isolation of the Bachmann’s bundle (BB) was also performed. Starting from 2021, surviving patients at follow-up were asked to undergo electrocardiographic evaluation and left ventricular function assessment and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF. Results The ablation procedure was completed in all patients. Upon discharge, 30 (4.9%) patients showed recurrence of AF, whereas the remaining patients (95.1%) were in sinus rhythm. All patients in whom a hybrid approach was used either with or without BB ablation were discharged in sinus rhythm. After a mean follow-up of 74 months, 122 (20%) patients developed recurrent AF, including 19.9% in whom a unipolar RF device was used, 21% in whom a bipolar RF device was used, 23% who had undergone a hybrid procedure without BB ablation and 3.3% who had undergone a hybrid procedure with BB ablation. On multivariate analysis, reduced left ventricular ejection fraction, worsening of European Heart Rhythm Association symptom class, and cognitive impairment or depression during follow-up were found to be significantly associated with AF recurrence. Conclusions Surgical AF ablation through a right minithoracotomy is safe and may allow the creation of additional linear lesions, particularly in the BB. The placement of adjunctive linear lesions in the setting of a hybrid procedure can be more effective in reducing the risk for AF recurrence than isolated surgical ablation or hybrid ablation without the addition of further linear lesions, with no incremental risk to the patient.

scholarly journals Early assessment of left atrial function after cardioversion predicts recurrence of atrial fibrillation

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
K Kupczynska ◽  
BW Michalski ◽  
E Trzos ◽  
D Miskowiec ◽  
L Szyda ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Left Atrial ◽  
Left Ventricular ◽  
Volume Index ◽  
Left Ventricular Ejection ◽  
Early Assessment ◽  
Ventricular Ejection Fraction ◽  
Af Recurrence

Abstract Funding Acknowledgements Type of funding sources: None. Background The restoration of sinus rhythm (SR) improves the mechanical function of the heart. Purpose To assess left atrial (LA) function before and within 24 hours after successful electrical cardioversion (EC) and its prognostic value for atrial fibrillation (AF) recurrence during 24 months follow-up. Methods Prospective study involved 71 patients with non-valvular AF (mean age 64 ± 13 years, 61% male). All patients underwent echocardiography before and after EC. We analysed standard parameters in two-dimensional echo, pulse-wave Doppler and tissue Doppler echocardiography. Using speckle-tracking method we assessed peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS). Results During follow-up we noticed AF recurrence in 48 (68%) patients. Median time to AF recurrence was 2.4 (IQR 1 to 6.9) months. Left ventricular ejection fraction as well as E/E’ and PALS assessed during AF were statistically insignificant as potential predictors in univariate regression model. Receiver operating characteristic curve analysis revealed that left atrial volume index >37 ml/m² (AUC = 0.811, p < 0.0001), E/A ratio >2.1 (AUC = 0.828, p < 0.0001), A wave ≤0.4 m/s (AUC = 0.662, p = 0.01), mean E/E’ ratio during sinus rhythm >8.5 (AUC = 0.815, p < 0.0001), mean A’ wave of ≤5.5 cm/s (AUC = 0.848, p < 0.0001), PALS-SR ≤14.1% (AUC = 0.767, p < 0.0001), PACS ≤4.3% (AUC = 0.883, p < 0.0001) were the optimal cut-off values for predicting AF recurrence. Conclusions The assessment of LA and diastolic function conducted within 24 hours after successful cardioversion predicts long-term maintenance of sinus rhythm.

scholarly journals Signs of heart failure with preserved ejection fraction in atrial fibrillation patients normalise in many patients after restoration of sinus rhythm

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M.C.P Wagemakers ◽  
R Wesselink ◽  
J Neefs ◽  
A Kougioumtzoglou ◽  
N.W.E Van Den Berg ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Ejection Fraction ◽  
Sinus Rhythm ◽  
Diastolic Dysfunction ◽  
Left Ventricular Ejection ◽  
Preserved Ejection Fraction ◽  
Af Ablation ◽  
Af Recurrence

Abstract Background Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) coexist in many patients. AF and HFpEF are closely intertwined, but there are important knowledge gaps in the pathogenesis, risk, prevention and treatment of AF with concomitant HFpEF, in particular with respect to reversal of HFpEF signs. Purpose To assess the proportion of AF patients with (any) HFpEF criteria (including patients with heart failure with moderately reduced ejection fraction (HFmrEF)) who – after successful AF ablation – no longer meet the criteria for HFpEF on neurohumoral and echocardiographic level. Furthermore, to assess whether normalisation of HFpEF criteria positively affects AF recurrence. Methods Patients (n=526) underwent thoracoscopic AF ablation, consisting of pulmonary vein isolation (PVI) alone or PVI with additional lines in the case of persistent AF and were prospectively followed-up. Patients (n=338) with a left ventricular ejection fraction (LVEF) ≥40% and a successful ablation at 6 months follow-up, that is freedom of AF, or any atrial tachycardia of more than 30 seconds, were included in this study. Participants were grouped based on N-terminal pro-b type natriuretic peptide (NT-proBNP) into those with a NT-proBNP <125pg/ml, defined as control patients (group 1), and those with a NT-proBNP level ≥125pg/ml, defined as HFpEF patients (group 2). HFpEF patients were further classified in different degrees of HFpEF severity, based on the number of diagnostic echocardiographic criteria for diastolic dysfunction present into possible HFpEF (group 2a, <2 criteria), likely HFpEF (group 2b, 2 criteria) and definite HFpEF (2c, ≥3 criteria). The primary outcome was the change in HFpEF defining signs on neurohumoral (NT-proBNP) level and echocardiographic (number of echocardiographic criteria for diastolic dysfunction) level 6 months after restoration of sinus rhythm. Results In total, 69% of AF patients (with a preserved ejection fraction of ≥40%) fulfilled the criteria for HFpEF. In 23% of these patients, neurohumoral levels normalised after elimination of AF, and a normalisation of echocardiographic markers was seen in 58% of patients. Normalisation of HFpEF on a neurohumoral level was associated with numerically fewer AF recurrence at 1 year follow-up (23% versus 33% in patients with and without NT-proBNP <125 pg/ml respectively, p=0.212). This favourable outcome was not observed in patients with a normalisation of echocardiographic markers. Conclusion In AF patients with definite restoration of sinus rhythm HFpEF may be reversed. This suggests that neurohumoral and echographic changes are caused by AF rather than by HFpEF. Normalisation of neurohumoral changes after definite restoration of sinus rhythm led to better outcome with regards to AF-recurrence, which could be used in prediction of prognosis. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals The fate of patients after failed epicardial ablation of atrial fibrillation

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Giuseppe Nasso ◽  
Roberto Lorusso ◽  
Arash Motekallemi ◽  
Angelo M. Dell’Aquila ◽  
Nicola Di Bari ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Atrial Fibrillation ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Long Term Outcome ◽  
Af Ablation ◽  
Af Recurrence

Abstract Background Much debate is still going on about the best ablation strategy—via endocardial or epicardial approach—in patients with atrial fibrillation (AF), and evidence gaps exist in current guidelines in this area. More specifically, there are no clear long-term outcome data after failed surgical AF ablation. Methods Since June 2008, 549 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency device was used (151 patients), whereas from 2011 to 2020 a bipolar radiofrequency device was used (398 patients). Patients were scheduled for surgery on the basis of the following criteria: recurrent episodes of paroxysmal or persistent lone AF refractory to maximally tolerated antiarrhythmic drug dosing and at least one failed cardioversion attempt. Besides the recommended follow-up by the local cardiologist, starting from 2021, surviving patients were asked to undergo assessment of left ventricular function and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF. Results At a mean follow-up of 77 months, the rate of AF recurrence was 20.7% (n = 114). On multivariate analysis, impaired left ventricular ejection fraction (58 patients, 51%, p = 0.002), worsening of European Heart Rhythm Association (EHRA) symptom class (37 patients, 32%, p = 0.003) and cognitive decline or depression (23 patients, 20%, p = 0.023) during follow-up were found to be significantly associated with AF recurrence. Conclusions Surgical AF ablation through a right minithoracotomy is safe, but a better outcome could be achieved using a hybrid approach. Patients after initial failed surgical AF ablation show worsening of cardiac function, clinical status and quality of life at follow-up compared to patients with successful AF ablation.

Early change in left atrial and left ventricular strain predicts sinus rhythm maintenance after cardioversion

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
K Kupczynska ◽  
D Miskowiec ◽  
B Michalski ◽  
L Szyda ◽  
K Wierzbowska-Drabik ◽  
...  
Keyword(s):  
Sinus Rhythm ◽  
Left Atrial ◽  
Speckle Tracking ◽  
Longitudinal Strain ◽  
Global Longitudinal Strain ◽  
Recurrence Risk ◽  
Left Ventricular ◽  
Mechanical Function ◽  
Af Recurrence

Abstract Background Atrial fibrillation (AF) impairs mechanical function of the heart, especially atria and restoration of sinus rhythm (SR) leads to improvement of mechanics. The predicting role of changes in strain parameters for AF recurrence is not established yet. Purpose To analyse changes in left atrial (LA) and left ventricular (LV) mechanical function after conversion to SR and their prognostic values for AF recurrence during 24 months follow-up. Methods Prospective study involved 59 patients after successful electrical cardioversion (EC) because of nonvalvular AF (mean age 65±4 years, 47% female). Speckle tracking analysis (STE) was applied to calculate longitudinal strain of LV and LA before EC and within 24 hours after restoration of SR and additionally total left heart strain (TS) defined as a sum of absolute peak LV and LA strain. We calculated change in strain between AF and SR analyses expressed as delta (Δ). During follow-up we noticed AF recurrence in 42 (71%) patients, most of them (93%) during 1st year after EC. Median time of AF recurrence was 3 months. Results We noticed significant immediate post-EC improvement in peak LA longitudinal strain (PALS) and LV global longitudinal strain (LVGLS) (table). Unlike CHA2DS2-VASc score, strain parameters were predictors of AF recurrence. Every 1% increment in ΔLVGLS was related with 13% increase in AF recurrence risk (p=0.02) and every 1% increment in ΔPALS and ΔTS were related with 9% decrease in AF recurrence risk (p=0.007 and p=0.0014, respectively). Multivariate analysis revealed ΔTS as a strongest predictor with 9% decrease in AF risk per every 1% increment. The criterion of ΔTS ≤7.5% allows to predict AF recurrence with 81% sensitivity and 63% specificity. Conclusions Speckle tracking measurements are able to detect early mechanical changes in LA even within 24 hours of SR and these absolute changes in LVGLS as well as PALS can predict AF recurrence, with optimal stratification by novel parameter - TS. Funding Acknowledgement Type of funding source: None

Long-term results of thoracoscopic ablation of paroxysmal atrial fibrillation: is the glass half full or half empty?

2021 ◽  
Author(s):  
Igor Belluschi ◽  
Elisabetta Lapenna ◽  
Davide Carino ◽  
Cinzia Trumello ◽  
Manuela Cireddu ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Confidence Interval ◽  
Paroxysmal Atrial Fibrillation ◽  
Left Ventricular ◽  
Class I ◽  
Long Term Results ◽  
Left Ventricular Ejection ◽  
Af Recurrence

Abstract OBJECTIVES Previous series showed the outcomes of thoracoscopic ablation of stand-alone symptomatic paroxysmal atrial fibrillation (AF) for up to 7 years of follow-up. The goal of this study was to assess the long-term durability of surgical pulmonary vein isolation (PVI) beyond 7 years. METHODS Fifty consecutive patients {mean age 55 [standard deviation (SD): 11.2] years, previous catheter ablation in 56%, left ventricular ejection fraction 60% (SD: 4.6), left atrium volume 65 ml (SD: 17)} with stand-alone symptomatic paroxysmal AF underwent PVI through bilateral thoracoscopy ablation between 2005 and 2014. The CHA2DS2-VASc score was ≥2 in 12 patients (24%). RESULTS No hospital deaths occurred. At hospital discharge all patients but 1 (2%) were in sinus rhythm (SR). Follow-up was 100% complete [mean 8.4 years (SD: 2.3), max 15]. The 8-year cumulative incidence function of AF recurrence, with death as a competing risk, on or off class I/III antiarrhythmic drugs (AADs)/electrocardioversion/re-transcatheter ablation (TCA) was 20% (SD: 5; 95% confidence interval: 10, 32); and off class I/III AADs/electrocardioversion/re-TCA was 52% (SD: 7; 95% confidence interval: 0.83, 8.02). At 8 years, the predicted prevalence of patients in SR was 87% and 53% were off class I/III AADs/electrocardioversion/re-TCA. The recurrent arrhythmia was AF in all patients except 2, who had atypical atrial flutter (4%). No predictors of AF recurrence were identified. At the last follow-up, 76% of the patients showed European Heart Rhythm Association class I. No strokes or thromboembolic events were documented and 76% of the subjects were off anticoagulation therapy. CONCLUSIONS Despite a considerable AF recurrence rate, our single-centre, long-term outcome of surgical PVI showed encouraging data, with the majority of patients remaining in SR, although many of them were on antiarrhythmic therapy.

scholarly journals Bucindolol Decreases Atrial Fibrillation Burden in Patients with Heart Failure and the ADRB1 Arg389Arg Genotype

2021 ◽  
Author(s):  
Jonathan P. Piccini ◽  
Christopher Dufton ◽  
Ian A. Carroll ◽  
Jeff S. Healey ◽  
William T. Abraham ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Normal Sinus Rhythm ◽  
Left Ventricular ◽  
Rhythm Control ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Normal Sinus

Background - Bucindolol is a genetically targeted β-blocker/mild vasodilator with the unique pharmacologic properties of sympatholysis and ADRB1 Arg389 receptor inverse agonism. In the GENETIC-AF trial conducted in a genetically defined heart failure (HF) population at high risk for recurrent atrial fibrillation (AF), similar results were observed for bucindolol and metoprolol succinate for the primary endpoint of time to first atrial fibrillation (AF) event; however, AF burden and other rhythm control measures were not analyzed. Methods - The prevalence of ECGs in normal sinus rhythm, AF interventions for rhythm control (cardioversion, ablation and antiarrhythmic drugs), and biomarkers were evaluated in the overall population entering efficacy follow-up (N=257). AF burden was evaluated for 24 weeks in the device substudy (N=67). Results - In 257 patients with HF the mean age was 65.6 ± 10.0 years, 18% were female, mean left ventricular ejection fraction (LVEF) was 36%, and 51% had persistent AF. Cumulative 24-week AF burden was 24.4% (95% CI: 18.5, 30.2) for bucindolol and 36.7% (95% CI: 30.0, 43.5) for metoprolol (33% reduction, p < 0.001). Daily AF burden at the end of follow-up was 15.1% (95% CI: 3.2, 27.0) for bucindolol and 34.7% (95% CI: 17.9, 51.2) for metoprolol (55% reduction, p < 0.001). For the metoprolol and bucindolol respective groups the prevalence of ECGs in normal sinus rhythm was 4.20 and 3.03 events per patient (39% increase in the bucindolol group, p < 0.001), while the rate of AF interventions was 0.56 and 0.82 events per patient (32% reduction for bucindolol, p = 0.011). Reductions in plasma norepinephrine (p = 0.038) and NT-proBNP (p = 0.009) were also observed with bucindolol compared to metoprolol. Conclusions - Compared with metoprolol, bucindolol reduced AF burden, improved maintenance of sinus rhythm, and lowered the need for additional rhythm control interventions in patients with HF and the ADRB1 Arg389Arg genotype.

P450The difference in the prognosis among three categories of the post-procedural left ventricular ejection fraction in patients undergoing atrial fibrillation ablation

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
K Yazaki ◽  
K Ejima ◽  
M Kanai ◽  
S Kataoka ◽  
S Higuchi ◽  
...  
Keyword(s):  
Systolic Function ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Composite Outcome ◽  
Ventricular Ejection Fraction ◽  
Index Procedure ◽  
Af Ablation ◽  
One Year ◽  
The Impact

Abstract Funding Acknowledgements None Background Atrial fibrillation (AF) ablation has been known to contribute to a good prognosis in heart failure patients and improve their systolic function. However, the impact of the post-procedural systolic function on the prognosis in them remains unclear.  Purpose To investigate the impact of the left ventricular ejection fraction (LVEF) following AF ablation in patients with systolic dysfunction.  Methods Out of 1078 consecutive patients who underwent AF ablation including extensive pulmonary vein and superior vena cava isolation, 170 with an impaired pre-procedural LVEF (&lt; 50%) were evaluated. They experienced at least one echocardiographic follow-up within one year after the index procedure. The primary outcome was the composite of all-cause death or heart failure hospitalisations (HFHs). In addition, we categorised the patients into three groups according to the post-procedural LVEF within one year to evaluate the outcome: reduced LVEF (rEF, LVEF &lt; 40%), mid-range EF (mrEF, 40% ≤ LVEF &lt; 50%) and preserved LVEF (pEF, LVEF &gt; 50%).  Results After the index procedure, the patients’ LVEF improved with an average increase of 8%, and the post-procedural LVEF consisted of an rEF in 27 (16%), mrEF in 41 (24%), and pEF in 102 (60%) patients. During a median follow-up of 31 months, a total of 22 (13%) patients experienced the composite outcome, including 18 (11%) HFHs and 10 (6%) all-cause deaths (5 with cardiac issues, 2 any malignancies, and 3 other issues). In the Kaplan-Meier analysis using a Bonferroni correction, there was a significant difference in achieving the outcome between the rEF and mrEF, and rEF and pEF, but not between the mrEF and pEF groups (Figure). In a univariate analysis, the hazard ratio of the outcome was shown as follows: an age ≥ 65 years (hazard ratio, HR: 3.4 [95% confidence interval, CI: 1.4–8.5], p = 0.006), history of HFHs for AF (HR: 1.7 [95%CI: 0.7–4.0], p = 0.25), known underlying heart disease (HR: 1.9 [95%CI: 0.8–1.2], p = 0.13), pre-procedural LVEF &lt; 40% (HR: 3.1 [95%CI: 1.3–7.5], p = 0.009), atrial tachyarrhythmia recurrence (HR: 3.0 [95%CI: 1.2–7.8], p = 0.01), and the post-procedural LVEF category (mrEF and rEF, compared with pEF) (HR: 2.0 [95%CI: 0.4–7.7], p = 0.34; and HR: 8.6 [95%CI: 2.7–37.5], p &lt; 0.0001). Furthermore, in a multivariate analysis, patients with a rEF was the sole independent predictor of the composite outcome after adjusting for confounders including an age≥65 years and pre-procedural LVEF &lt; 40% (HR: 12.0 [95%CI: 3.9–40.0], p &lt; 0.0001), whereas those with a mrEF was not (HR: 1.8 [95%CI: 0.4–7.3], p = 0.42), as compared to those with a pEF.  Conclusions Patients with a mrEF had a comparable prognosis to those with a pEF in a relatively long follow-up, while those with a rEF had the poorest outcome of the three categories, regardless of the pre-procedural LVEF severity. Abstract Figure. The difference in the rate of outcome

Abstract 17223: Castle of Stone or Straw, Radiofrequency Ablation of Atrial Fibrillation in Heart Failure?

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Brian D McCauley ◽  
Esseim Sharma ◽  
John Dudley ◽  
Antony Chu
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Sinus Rhythm ◽  
Meta Analysis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Prospective Trials

Introduction: Based on the data from CASTLE-AF trial, in patient with Atrial Fibrillation (AF) and heart failure (HF) catheter ablation may offer a significant reduction in both death, and hospitalization, while promoting maintenance of sinus rhythm as well as improvement in left ventricular ejection fraction (LVEF). This multi-center randomized trial is hailed as a paradigm shifting study in catheter ablation, however it is not without fault. One of the critiques of the CASTLE-AF trial was the high frequency of crossover between the treatment arms. To help sort out this potential source of confounding, we performed a systematic meta-analysis of prospective trials for catheter ablation in AF in patients with Class II through IV heart failure. Hypothesis: The reduction in death, and hospitalization, as well as the maintenance in sinus rhythm and improvement in LVEF seen CASTLE-AF trial are support by other similarly designed AF ablation trials. Methods: Using the inclusion/exclusion criteria from the CASTLE-AF trial, we performed a systematic meta-analysis of 28 published studies. Randomized and non-randomized observational studies comparing the impact of catheter ablation of AF in HF. Studies were identified using the Cochrane Library, EMBASE, and PubMed. Results: A total of 29 studies were identified (n =2,339). Mean follow-up was 25 (95% confidence interval, 18-40) months. Efficacy in maintaining sinus rhythm at follow-up end was 60% (43%-76%). Left ventricular ejection fraction improved significantly during follow-up by 15% (P<0.001). Conclusions: Following our meta-analysis, we found data to support the findings of improved LVEF and maintenance of sinus rhythm reported in the CASTLE-AF trial. However, due to differences in study design, we were unable to further validate the reduction in both hospitalization and death seen in CASTLE-AF. We recommend future prospective trials be conducted without cross over to further explore this topic.

scholarly journals Speckle tracking-derived left atrial stiffness predicts adverse events after successful electrical cardioversion

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
K Kupczynska ◽  
D Miskowiec ◽  
B Michalski ◽  
J D Kasprzak
Keyword(s):  
Sinus Rhythm ◽  
Median Time ◽  
Left Atrial ◽  
Speckle Tracking ◽  
Longitudinal Strain ◽  
Left Ventricular ◽  
Electrical Cardioversion ◽  
Reservoir Function ◽  
Af Recurrence

Abstract Background Atrial fibrillation (AF) impairs cardiac mechanics and leads to adverse remodelling. Increased left atrial (LA) stiffness reflecting LA reservoir function and left ventricular (LV) filling pressure is one of the symptoms of LA remodelling. Purpose To analyse LA stiffness within 24 hours after successful electrical cardioversion and its prognostic value during 2-years follow-up. Methods Prospective study involved 71 patients with nonvalvular AF (mean age 64±13 years, 61% male). All patients underwent echo during 24 hours after conversion to sinus rhythm. We analysed standard echocardiographic and Doppler parameters. Using speckle-tracking method we assessed peak LA longitudinal strain in 4- and 2-chamber view. LA stiffness was calculated as the quotient of peak LA longitudinal strain (LA reservoir function) and mean E/E' ratio. The clinical endpoints were predefined as AF recurrence and cardiovascular hospitalization. Results Median time of current AF episode was 2 (IQR 0.4–5) months. Standard echo measurements revealed median of LV ejection fraction 55% (IQR 45–58) and median of LA volume indexed to body surface area 42 ml/m2 (IQR 34–51). During follow-up we noticed AF recurrence in 48 (68%) patients and cardiovascular hospitalization in 43 (61%) patients. Median time-to-event was 2.4 (IQR 1 to 6.9) and 7 (IQR 2.1–11) months, respectively. Receiver operating characteristic curve analysis revealed that LA stiffness &gt;0.53 (AUC=0.821; p&lt;0.0001) and &gt;0.95 (AUC=0.788; p&lt;0.0001) were the optimal cut-off values for predicting AF recurrence and cardiovascular hospitalization. Figure presents Kaplan-Meier survival analysis for AF recurrence (A) and for hospitalization (B). Moreover LA stiffness remain statistically significant in multivariate Cox regression analysis even after adjustment for betablockers, antiarrhythmic drugs, coronary artery disease, heart failure and mitral regurgitation. Relative risk was 1.51 (95% CI 1.09–2.09), p=0.01 for AF recurrence and 1.49 (95% CI 1.05–2.13) for cardiovascular hospitalization. Conclusions Speckle tracking-derived LA stiffness assessed early after the restoration of sinus rhythm independently predicts AF recurrence and cardiovascular hospitalization. FUNDunding Acknowledgement Type of funding sources: None.

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