Atrial Fibrillation Caused by Intractable Hiccups: A Unique Cause and Cure

We present the case of a 61-year-old male who developed persistent hiccups concurrently with the onset of atrial fibrillation (AF). The hiccups were refractory to traditional treatment but resolved immediately upon electrical cardioversion (ECV) to normal sinus rhythm (NSR). The patient has remained in NSR and free of hiccups. The potential etiologies for hiccups are numerous and varied, and the management of persistent hiccups can be difficult. Cardiac associations including myocardial infarction and pericarditis have been described, while few cases of first-time onset of atrial fibrillation leading to hiccups have been documented. This case discusses a unique instance demonstrating a connection between hiccups and cardiac pathology and an overview of its management.

Characteristics of left atrial strain in patients with atrial fibrillatio after cardioversion

The aim of the study – to evaluate the parameters of left atrial myocardial strain in patients with atrial fibrillation who underwent electrical and drug cardioversion.Materials and methods. The study included 118 patients of the University Clinical Hospital No 1 of the First Sechenov Moscow State Medical University. The analysis was carried out in three groups of patients: group 1 (n=54) – patients with atrial fibrillation who underwent electrical cardioversion; group 2 (n=31) – patients with atrial fibrillation who underwent drug cardioversion; group 3 (n=43) – patients without a history of atrial fibrillation. The clinical and anamnestic data of the medical history of each patient, as well as ultrasound indicators were evaluated: global strain of the left atrial, the values of negative peaks as a reflection of the left atrial systole and the values of positive peaks as a reflection of the filling of the left atrium, LASI – the left atrial stiffness index.Results. The analysis showed that left atrial strain in patients with atrial fibrillation were reduced in all analyzed parameters: negative strain peaks (-9.00 vs. -12.6 in the control group, p<0.001), positive strain peaks (12.6 vs. 14.6 in the control group, p<0.001), global left atrial strain (21.5 in the atrial fibrillation group vs. 27.3 in the control group, p<0.001). Left Atrial Stiffness Index (LASI) was significantly higher in patients with a stopped episode of atrial fibrillation (0.50 vs. 0.40, p=0.006).Conclusions. The indicators of left atrial strain were significantly reduced, and the left atrial stiffness index was significantly increased both in the group with electrical cardioversion and in the group with drug-induced cardioversion, compared with patients with similar cardiovascular pathologies, but without a history of atrial fibrillation episodes.

Biomarker Levels in Patients with Atrial Fibrillation Before and After Electrical Cardioversion

Background Biomarkers may help to improve our knowledge about the complex pathophysiology of atrial fibrillation (AF), the most common sustained cardiac arrhythmia. We aimed to identify significant changes in biomarkers and clinical measures in patients with and without AF recurrence after electrical cardioversion. Methods Patients with persistent AF undergoing elective electrical cardioversion were enrolled. We measured 21 conventional and new biomarkers before and 30 days after electrical cardioversion and assessed the associations of changes in biomarker levels with rhythm status at follow-up using multivariable logistic regression models. Results Of the 100 patients included (mean [SD] age 66 (10) years, 25% women), 28 (28%) had an AF recurrence. Of the 21 biomarkers assessed, 4 reached the predefined between group significance of p<0.01. The most significant ones were bone morphogenetic protein 10 (BMP10), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and total bilirubin. Their respective changes were -10.4%, -62.0% and -25.6% in patients with sinus rhythm, and 3.1%, 1.1% and -9.4% in patients with recurrent AF, for a between group difference of -13.5% (95% confidence interval [CI], -19.3% to -7.6%; P<0.001), -63.1% (95% CI, -76.6% to -49.6%; P<0.001) and -16.3 (95% CI, -27.9% to -4.7%; P=0.007). In age and sex adjusted models, reductions of BMP10 and NT-proBNP were significantly associated with rhythm status at follow-up (β coefficient per 1-SD decrease, -2.03; 95% CI, -3.06 to -1.00; P<0.001 and -3.98; 95% CI, -5.75 to -2.22; P<0.001, respectively). After additional adjustment for demographic characteristics, risk factors for AF, and changes in clinical measures, the β coefficients per 1-SD were -3.85 (95% CI, -6.34 to -1.35; P=0.003) for BMP10 and -5.84 (95% CI, -10.22 to -1.47; P=0.009) for NT-proBNP. Conclusions Changes in BMP10 und NT-proBNP levels were strongly associated with rhythm status after electrical cardioversion, suggesting that these markers may be dependent on the actual heart rhythm.

Clinical experience of new antiarrhythmic drug refralon for pharmacological cardioversion in patients with atrial fibrillation after pulmonary vein cryoablation

We present two cases of successful pharmacological cardioversion using antiarrhythmic drug refralon in patients with persistent atrial fibrillation after pulmonary vein cryoablation and ineffective electrical cardioversion. These clinical cases represent the first experience of successful use of refralon in patients who underwent cryoablation.

Should we keep performing electrical cardioversion in atrial fibrillation/flutter?

Introduction Atrial fibrillation (AF) and atrial flutter (AFL) are frequently diagnosed arrhythmias in the outpatient setting or in the Emergency Department. Electrical cardioversion (EC) is a therapeutic option when a rhythm control strategy is pursued. Purpose To evaluate the clinical outcomes of patients with AF/AFL referred to EC and to analyse the procedures' complications. Methods We conducted a retrospective study enrolling patients with AF/AFL referred to EC in our Cardiology Department, from September 2011 to September 2020. Clinical characteristics, echocardiographic studies and follow-up data were analysed. Primary endpoint was the incidence of ischemic stroke during follow-up. Results A total of 719 patients were referred to EC during the 9-year period, with a median age of 67 years-old and 70,4% male predominance. Most patients were cardioverted in an outpatient setting (60,6%) and 21% had AFL. 62,1% had persistent AF/AFL, 19,6% presented with first diagnosed AF/AFL and 17,2% had paroxysmal episodes. EC was successfully performed in 93,2% and 0,3% had major non-fatal immediate complications. Arterial hypertension was present in 57,3% of patients, 20,4% had diabetes, 34,6% were obese, 13,3% mentioned alcohol consumption and 6,3% had sleep apnea. Previous stroke was diagnosed in 6,8% and 19% had ischemic heart disease. Left ventricular (LV) ejection fraction (LVEF) was preserved in 66,7%. Median CHA2DS2-VASc score was 2,0 and 89,8% were anticoagulated (75,7% with non-vitamin K antagonist oral anticoagulants). Antiarrhythmic therapy was prescribed in 85% and 64,5% maintained sinus rhythm one-year after EC. After EC, it was documented complete reversal of LV systolic dysfunction in 46,3% of patients with previously reduced LVEF, confirming the diagnosis of arrhythmia-induced cardiomyopathy (AIC). During a median follow-up of 1355 days, ischemic stroke occurred in 4,8%, but only 5 patients had an embolic event in the first week after EC (0,7% stroke rate at one week, the same at one month). AIC was associated to a lower rate of cardiovascular death (3,8% vs 25,5%; p=0,002), comparing to patients who did not recover LV function. Conclusion EC is a safe procedure, with a very low rate of immediate and embolic complications. AIC was diagnosed in 46,3% of patients with previously reduced LVEF and it was associated with a significantly lower rate of CV death. EC should be considered to relieve patients' symptoms and when there is suspicion of AIC. FUNDunding Acknowledgement Type of funding sources: None.

Maintaining sinus rhythm after electrical cardioversion

Introduction Atrial fibrillation (AF) and atrial flutter (AFL) are commonly terminated by electrical cardioversion (EC) when a rhythm control strategy is adopted. However, the long-term success following EC is variable. Purpose To determine the clinical characteristics and independent predictors of sinus rhythm (SR) maintenance after EC due to AF/AFL. Methods We conducted a retrospective study enrolling patients with AF/AFL referred to EC in our Cardiology Department, from September 2011 to September 2020. Clinical characteristics and echocardiographic studies were analysed. Primary endpoints were the incidence of ischemic stroke, all-cause and cardiovascular (CV) mortality. Independent predictors of SR maintenance were identified through a binary logistic regression analysis, considering p=0,05. Results A total of 719 patients with a median age of 67 years-old were included, and EC was successfully performed in 93,2%. AFL was diagnosed in 21%, 57,3% had arterial hypertension and 34,6% were obese. 62,1% had persistent AF/AFL, 19,6% presented with first diagnosed AF/AFL and 17,2% had paroxysmal episodes. Left ventricular ejection fraction (LVEF) was preserved in 66,7%. Maintenance of SR after one-year was documented in 64,7% of patients with successful EC. They had lower prevalence of chronic kidney disease (CKD) (2,6% vs 10,7%; p&lt;0,001) and received less electrical shocks during EC (1,20 vs 1,39; p=0,005). There were no differences regarding antiarrhythmic therapy between both groups. Complete LVEF recovery after EC was more frequent in patients who maintained SR (58,8% vs 31,9%; p=0,008), with a greater prevalence of preserved LVEF after EC (88,8% vs 73,6%; p&lt;0,001). During a median follow-up of 1368 days, these patients performed less additional EC (0,26 vs 0,65; p&lt;0,001) and were less referred to ablation procedures (7,1% vs 15,1%; p=0,011). No differences were found regarding stroke rate, but all-cause mortality (12,8% vs 25%; p=0,002) and CV death (3,8% vs 10,9%; p=0,005) were significantly lower in patients who maintained SR. Absence of CKD (p=0,013), applying fewer electric shocks during EC (p=0,013) and preserved LVEF after EC (p=0,004) were independent predictors of SR maintenance. Conclusion In our study, most patients maintained SR one year after EC, which was associated with a lower all-cause and CV mortality. Absence of CKD, applying fewer electric shocks during EC and preserved LVEF after EC were independent predictors of SR maintenance. FUNDunding Acknowledgement Type of funding sources: None.

Echocardiographic E/e for the prediction of recurrent atrial fibrillation after ablation or electrical cardioversion: a systematic review and meta-analysis

Background Atrial Fibrillation (AF) is the most common arrhythmia, with important sequelae if left untreated. Markers help to predict the recurrence of AF after an intervention like ablation or electrical cardioversion (ECV). E/e' ratio is an echocardiographic marker which is potentially useful in predicting AF recurrence, however, present data is conflicting. Adding a simple tool like E/e' ratio to evaluation of patients for AF intervention may help in advising patients better about their risk for recurrent AF after intervention without adding much cost to the diagnostic work-up. Purpose To determine if there is a significant difference in pooled mean E/e' ratio among AF patients with recurrence after ablation or ECV compared to those who maintained sinus rhythm, and to determine the odds ratio of recurrent AF given an abnormal E/e' ratio. Methods The investigators systematically searched Pubmed, Medline, Cochrane Database, and Google Scholar for articles on patients undergoing catheter ablation or ECV for AF and who were adjudicated on recurrence of the arrhythmia. We calculated the weighted mean difference of E/e' ratio between those with recurring AF and those who maintained sinus rhythm, and the odds ratio of AF recurrence given an abnormal E/e' ratio. Statistical analysis was done using RevMan 5.4.1 software. Results A total of 38 studies involving 7048 patients were included in the initial analysis (26 studies on ablation with continuous data and 2 with dichotomous data based on a set cutoff, and 10 studies on ECV). One study was excluded due to absence of a blanking period and and another due to outlaying data in funnel plot analysis. The remaining 36 studies with 6910 patients were analyzed. There was a significant difference in the weighted mean E/e' ratio between the two groups in AF patients undergoing ablation (Mean Difference (MD)=0.60 (95% CI [0.20,1.00] p=0.003, I2=63%]), and ECV (MD=2.07 (95% CI [1.66, 2.49] p&lt;0.ehab724.0361, I2=12%), with an odds ratio of 1.88 (95% CI [1.04, 3.37] p=0.04, I2=52%) among those with dichotomous data. Subgroup analyses were done to reduce heterogeneity. E/e' ratio was not significantly different in the population of paroxysmal AF undergoing ablation (MD=0.64, 95% CI [−0.55, 1.83], p=0.29, I2=76%) but significantly different in patients with non-paroxysmal AF undergoing ECV (MD=2.19, 95% CI [1.82, 2.56], I2=0%). Conclusion This analysis suggests that a higher E/e' ratio may be used to predict recurrence of AF after ablation or ECV, especially in patients undergoing ECV. The heterogeneity of the data for E/e' ratio in AF ablation and the variety of co-morbid conditions to atrial fibrillation limits its clinical applicability. Further studies are recommended to determine the optimal cutoff of this ratio that would predict AF recurrence. FUNDunding Acknowledgement Type of funding sources: None. Forest plot for studies on Ablation Forest plot for studies on ECV