Sinus Rhythm
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PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0260834
Hao-Tien Liu ◽  
Chia-Hung Yang ◽  
Hui-Ling Lee ◽  
Po-Cheng Chang ◽  
Hung-Ta Wo ◽  

Background The therapeutic effect of low-voltage area (LVA)-guided left atrial (LA) linear ablation for non-paroxysmal atrial fibrillation (non-PAF) is uncertain. We aimed to investigate the efficacy of LA linear ablation based on the preexisting LVA and its effects on LA reverse remodeling in non-PAF patients. Methods We retrospectively evaluated 145 consecutive patients who underwent radiofrequency catheter ablation for drug-refractory non-PAF. CARTO-guided bipolar voltage mapping was performed in atrial fibrillation (AF). LVA was defined as sites with voltage ≤ 0.5 mV. If circumferential pulmonary vein isolation couldn’t convert AF into sinus rhythm, additional LA linear ablation was performed preferentially at sites within LVA. Results After a mean follow-up duration of 48 ± 33 months, 29 of 145 patients had drugs-refractory AF/LA tachycardia recurrence. Low LA emptying fraction, large LA size and high extent of LVA were associated with AF recurrence. There were 136 patients undergoing LA linear ablation. The rate of linear block at the mitral isthmus was significantly higher via LVA-guided than non-LVA-guided linear ablation. Patients undergoing LVA-guided linear ablation had larger LA size and higher extent of LVA, but the long-term AF/LA tachycardia-free survival rate was higher than the non-LVA-guided group. The LA reverse remodeling effects by resuming sinus rhythm were noted even in patients with a diseased left atrium undergoing extensive LA linear ablation. Conclusions LVA-guided linear ablation through targeting the arrhythmogenic LVA and reducing LA mass provides a better clinical outcome than non-LVA guided linear ablation, and outweighs the harmful effects of iatrogenic scaring in non-PAF patients.

2021 ◽  
Vol 10 (23) ◽  
pp. 5679
Brototo Deb ◽  
Prasanth Ganesan ◽  
Ruibin Feng ◽  
Sanjiv M. Narayan

Atrial fibrillation (AF) is a major cause of heart failure and stroke. The early maintenance of sinus rhythm has been shown to reduce major cardiovascular endpoints, yet is difficult to achieve. For instance, it is unclear how discoveries at the genetic and cellular level can be used to tailor pharmacotherapy. For non-pharmacologic therapy, pulmonary vein isolation (PVI) remains the cornerstone of rhythm control, yet has suboptimal success. Improving these therapies will likely require a multifaceted approach that personalizes therapy based on mechanisms measured in individuals across biological scales. We review AF mechanisms from cell-to-organ-to-patient from this perspective of personalized medicine, linking them to potential clinical indices and biomarkers, and discuss how these data could influence therapy. We conclude by describing approaches to improve ablation, including the emergence of several mapping systems that are in use today.

Dimitrios Karelas ◽  
John Papanikolaou ◽  
Charalampos Kossyvakis ◽  
Dimitrios Platogiannis

Abstract Background Atrial Fibrillation in Wolff-Parkinson-White syndrome may result in life-threateningly rapid antegrade conduction over a bypass tract, manifested by an irregular broad-complex (pre-excited) tachycardia that can degenerate to ventricular fibrillation. Shortest pre-excited RR interval below 250msec during atrial fibrillation predicts increased risk of sudden cardiac death. Case summary We report a case of a 43-year-old man with unremarkable cardiac history who presented due to sudden-onset feeling of palpitations and pre-syncope after strenuous lifting. Electrocardiography depicted fast pre-excited atrial fibrillation. The shortest pre-excited RR interval was estimated at 160msec, indicating an accessory pathway with short antegrade refractory period at risk for mediating sudden cardiac death. Direct current cardioversion restored sinus rhythm unraveling delta-waves. The patient was put on propafenone 450 mg/day having an uneventful clinical course. On day-10 post-admission, electrophysiological study induced rapid atrial fibrillation but the shortest pre-excited RR interval was substantially increased to 264msec. A left anterolateral accessory pathway was ablated. The patient remained symptom-free until his latest follow-up in the third month post-ablation without manifest pre-excitation on surface electrocardiogram. Discussion Treatment options of pre-excited atrial fibrillation include anti-arrhythmic agents but mainly electrical cardioversion. Cardioversion can safely restore sinus rhythm, while use of anti-arrhythmics often requires ICU monitoring due to risk of QT prolongation. Catheter ablation is the mainstay of therapy for symptomatic patients. Our rare report highlights the direct impact of propafenone on prolonging the refractoriness of the accessory pathway, effectively and safely, and reappraises propafenone’s worthiness as a protective measure following pre-excited atrial fibrillation episode until ablation.

2021 ◽  
Vol 12 ◽  
Bo Hu ◽  
Wen Ge ◽  
Yuliang Wang ◽  
Xiaobin Zhang ◽  
Tao Li ◽  

Atrial fibrillation (AF) is an abnormal heart rhythm related to an increased risk of heart failure, dementia, and stroke. The distinction between valvular and non-valvular AF remains a debate. In this study, proteomics and metabolomics were integrated to describe the dysregulated metabolites and proteins of AF patients relative to sinus rhythm (SR) patients. Totally 47 up-regulated and 41 down-regulated proteins in valvular AF, and 59 up-regulated and 149 down-regulated proteins in non-valvular AF were recognized in comparison to SR patients. Moreover, 58 up-regulated and 49 significantly down-regulated metabolites in valvular AF, and 47 up-regulated and 122 down-regulated metabolites in persistent non-valvular AF patients were identified in comparison to SR patients. Based on analysis of differential levels of metabolites and proteins, 15 up-regulated and 22 down-regulated proteins, and 13 up-regulated and 122 down-regulated metabolites in persistent non-valvular AF were identified relative to valvular AF. KEGG pathway enrichment analysis showed the altered proteins and metabolites were significantly related to multiple metabolic pathways, such as Glycolysis/Gluconeogenesis. Interestingly, the enrichment pathways related to non-valvular AF were obviously different from those in valvular AF. For example, valvular AF was significantly related to Glycolysis/Gluconeogenesis, but non-valvular AF was more related to Citrate cycle (TCA cycle). Correlation analysis between the differentially expressed proteins and metabolites was also performed. Several hub proteins with metabolites were identified in valvular AF and non-valvular AF. For example, Taurine, D-Threitol, L-Rhamnose, and DL-lactate played crucial roles in valvular AF, while Glycerol-3-phosphate dehydrogenase, Inorganic pyrophosphatase 2, Hydroxymethylglutaryl-CoAlyase, and Deoxyuridine 5-triphosphate nucleotidohydrolase were crucial in non-valvular AF. Then two hub networks were recognized as potential biomarkers, which can effectively distinguish valvular AF and non-valvular persistent AF from SR samples, with areas under curve of 0.75 and 0.707, respectively. Hence, these metabolites and proteins can be used as potential clinical molecular markers to discriminate two types of AF from SR samples. In summary, this study provides novel insights to understanding the mechanisms of AF progression and identifying novel biomarkers for prognosis of non-valvular AF and valvular AF by using metabolomics and proteomics analyses.

2021 ◽  
Lotfi Mostefai ◽  
Benouis Mohamed ◽  
Denai Mouloud ◽  
Bouhamdi Merzoug

Abstract Electrocardiogram (ECG) signals have distinct features of the electrical activity of the heart which are unique among individuals and have recently emerged as a potential biometric tool for human identification. The paper attempts to address the problem of ECG identification based on non-fiducial approach using unsupervised classifier and a Deep Learning approaches. This work investigates the ability of local binary pattern to extract the significant pattern/feature that describes the heartbeat activity for each person’s ECG and the use of staked autoencoders and deep belief network to further enhance the extracted features and classify them based on their heartbeat activity. The proposed approach is validated using experimental datasets from two publicly available databases MIT-BIH Normal Sinus Rhythm and ECG-ID and the results demonstrate the effectiveness of this approach for ECG-based human authentication.

2021 ◽  
Joey Junarta ◽  
Sean J. Dikdan ◽  
Naman Upadhyay ◽  
Sairamya Bodempudi ◽  
Michael Y. Shvili ◽  

Abstract Introduction High-power short-duration (HPSD) ablation is a novel strategy using contact force-sensing catheters optimized for radiofrequency ablation for atrial fibrillation (AF). No study has directly compared HPSD versus standard-power standard-duration (SPSD) contact force-sensing settings in patients presenting for repeat ablation with AF recurrence after initial ablation. Methods We studied consecutive cases of patients with AF undergoing repeat ablation with SPSD or HPSD settings after their initial pulmonary vein isolation (PVI) with temperature controlled non-contact force, SPSD or HPSD settings between 6/23/14 and 3/4/20. Procedural data collected included radiofrequency ablation delivery time (RADT). Clinical data collected include sinus rhythm maintenance post-procedure. Results A total of 61 patients underwent repeat ablation (36 SPSD, 25 HPSD). A total of 51 patients (83.6%) were found to have pulmonary vein reconnections necessitating repeat isolation, 10 patients (16.4%) had durable PVI and ablation targeted non-PV sources. RADT was shorter when comparing repeat ablation using HPSD compared to SPSD (22 vs 35 min; p = 0.01). There was no difference in sinus rhythm maintenance by Kaplan–Meier survival analysis (log rank test p = 0.87), after 3 or 12-months between groups overall, and when stratified by AF type, left atrial volume index, CHA2DS2-VASc score, or left ventricular ejection fraction. Conclusion We demonstrated that repeat AF ablation with HPSD reduced procedure times with similar sinus rhythm maintenance compared to SPSD in those presenting for repeat ablation.

2021 ◽  
Vol 20 (7) ◽  
pp. 2783
E. S. Mazur ◽  
V. V. Mazur ◽  
N. D. Bazhenov ◽  
Yu. A. Orlov

Aim. To study the potential of stroke risk assessment to evaluate the probability of detecting left atrial appendage (LAA) thrombus in patients with persistent atrial fibrillation (AF) to consider performing transesophageal echocardiography (TEE) before cardioversion.Material and methods. TEE before elective cardioversion was performed in 590 patients with persistent AF, of whom 316 (53,6%) had a high stroke risk (valvular AF, hypertrophic cardiomyopathy, CHA2DS2-VASc score >1 in men and >2 in women), and 274 (46,4%) — not high. Adequate anticoagulation at least 3 weeks prior to elective cardioversion was received by 164 (51,9%) patients with a high stroke risk and 151 (55,1%) patients with a low risk. The rest of patients either did not receive adequate anticoagulation or received it for less than 3 weeks.Results. In the group of patients who received anticoagulation at least 3 weeks, LAA thrombus was detected in 23 (14,0%) patients with a high stroke risk and in 8 (5,3%) patients with a low risk (p<0,05). In patients who did not receive adequate anticoagulation or received it for less than 3 weeks, LAA thrombus was identified in 60 (39,5%) patients with a high stroke risk and in 22 (17,9%) patients with a low risk (p<0,005). Thus, a  high stroke risk almost 3 times increases the likelihood of LAA thrombus detection in patients who did not receive adequate anticoagulation (odds ratio, 2,99; 95% confidence interval: 1,70-5,26;p<0,001) and in patients receiving adequate anticoagulation (odds ratio, 2,92; 95% confidence interval: 1,26-6,74; p=0,012).Conclusion. In patients with persistent AF with a low stroke risk according to CHA2DS2-VASc score, TEE before sinus rhythm restoration in patients without 3-week anticoagulation should be considered. In patients with a high stroke risk, performing pre-cardioversion TEE is advisable even after adequate anticoagulation.

2021 ◽  
Vol 10 (23) ◽  
pp. 5536
Lianne N. van Staveren ◽  
Willemijn F. B. van der Does ◽  
Annejet Heida ◽  
Yannick J. H. J. Taverne ◽  
Ad J. J. C. Bogers ◽  

We investigated whether patterns of activation at Bachmann’s bundle are related to AF inducibility. Epicardial mapping of Bachmann’s bundle during sinus rhythm was performed prior to cardiac surgery (192 electrodes, interelectrode distances: 2 mm). Compared to non-inducible patients (N = 20), patients with inducible AF (N = 34) had longer lines of conduction block (18(2–164) mm vs. 6(2–28) mm, p = 0.048), prolonged total activation time (55(28–143) ms vs. 46(24–73) ms, p = 0.012), multiple wavefronts entering Bachmann’s bundle more frequently (64% vs. 37%, p = 0.046) and more often areas of simultaneous activation (conduction velocity > 1.7 m/s, 45% vs. 16%, p = 0.038). These observations further support a relation between conduction abnormalities at Bachmann’s bundle and AF inducibility. The next step is to examine whether Bachmann’s bundle activation patterns can also be used to identify patients who will develop AF after cardiac surgery during both short- and long-term follow-up.

Anders Sjørslev Schmidt ◽  
Kasper Glerup Lauridsen ◽  
Dorthe Svenstrup Møller ◽  
Per Dahl Christensen ◽  
Karen Kaae Dodt ◽  

Background: Smaller randomized studies have reported conflicting results regarding the optimal electrode position for cardioverting atrial fibrillation. However, anterior-posterior electrode position is widely used as a standard and believed to be superior to anterior-lateral electrode position. Therefore, we aimed to compare anterior-lateral and anterior-posterior electrode position for cardioverting atrial fibrillation in a multicenter randomized trial. Methods: In this multicenter, investigator-initiated, open-label trial, we randomly assigned patients with atrial fibrillation scheduled for elective cardioversion to anterior-lateral or anterior-posterior electrode position. The primary outcome was the proportion of patients in sinus rhythm after the first shock. The secondary outcome was the proportion of patients in sinus rhythm after up to four shocks escalating to maximum energy. Safety outcomes were any cases of arrhythmia during or after cardioversion, skin redness, and patient-reported peri-procedural pain. Results: We randomized 468 patients. The primary outcome occurred in 126 patients (54%) assigned to anterior-lateral electrode position and in 77 patients (33%) assigned to anterior-posterior electrode position, a risk difference of 22 percentage-points, 95%-confidence interval: 13-30, P<0.001. The number of patients in sinus rhythm after the final cardioversion shock was 216 patients (93%) assigned to anterior−lateral electrode position and 200 patients (85%) assigned to anterior-posterior electrode position, a risk difference of 7 percentage−points, 95%−confidence interval: 2−12. There were no significant differences between groups in any safety outcomes. Conclusions: Anterior-lateral electrode position was more effective than anterior-posterior electrode position for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome.

2021 ◽  
Vol 11 (1) ◽  
Pietro Melzi ◽  
Ruben Tolosana ◽  
Alberto Cecconi ◽  
Ancor Sanz-Garcia ◽  
Guillermo J. Ortega ◽  

AbstractAtrial fibrillation (AF) is an abnormal heart rhythm, asymptomatic in many cases, that causes several health problems and mortality in population. This retrospective study evaluates the ability of different AI-based models to predict future episodes of AF from electrocardiograms (ECGs) recorded during normal sinus rhythm. Patients are divided into two classes according to AF occurrence or sinus rhythm permanence along their several ECGs registry. In the constrained scenario of balancing the age distributions between classes, our best AI model predicts future episodes of AF with area under the curve (AUC) 0.79 (0.72–0.86). Multiple scenarios and age-sex-specific groups of patients are considered, achieving best performance of prediction for males older than 70 years. These results point out the importance of considering different demographic groups in the analysis of AF prediction, showing considerable performance gaps among them. In addition to the demographic analysis, we apply feature visualization techniques to identify the most important portions of the ECG signals in the task of AF prediction, improving this way the interpretability and understanding of the AI models. These results and the simplicity of recording ECGs during check-ups add feasibility to clinical applications of AI-based models.

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