Circulating microRNAs in atrial fibrillation with HFpEF: a pilot study exploring short-term variability and clinical feasibility

We previously reported the feasibility and efficacy of a simulation-guided clinical catheter ablation of atrial fibrillation (AF) in an in-silico AF model. We developed a highly efficient realistic AF model reflecting the patient endocardial voltage and local conduction and tested its clinical feasibility. We acquired > 500 endocardial bipolar electrograms during right atrial pacing at the beginning of the AF ablation procedures. Based on the clinical bipolar electrograms, we generated simulated voltage maps by applying fibrosis and local activation maps adjusted for the fiber orientation. The software’s accuracy (CUVIA2.5) was retrospectively tested in 17 patients and feasibility prospectively in 10 during clinical AF ablation. Results: We found excellent correlations between the clinical and simulated voltage maps (R = 0.933, p < 0.001) and clinical and virtual local conduction (R = 0.958, p < 0.001). The proportion of virtual local fibrosis was 15.4, 22.2, and 36.9% in the paroxysmal AF, persistent AF, and post-pulmonary vein isolation (PVI) states, respectively. The reconstructed virtual bipolar electrogram exhibited a relatively good similarities of morphology to the local clinical bipolar electrogram (R = 0.60 ± 0.08, p < 0.001). Feasibility testing revealed an in situ procedural computing time from the clinical data acquisition to wave-dynamics analyses of 48.2 ± 4.9 min. All virtual analyses were successfully achieved during clinical PVI procedures. We developed a highly efficient, realistic, in situ procedural simulation model reflective of individual anatomy, fiber orientation, fibrosis, and electrophysiology that can be applied during AF ablation.

SCREENING FOR ATRIAL FIBRILLATION VIA MOBILE ECG IN CANADIAN PRIMARY CARE PRACTICE: A FEASIBILITY EVALUATION

Utilization and Clinical Feasibility of a Handheld Remote Electrocardiography Recording Device in Cardiac Arrhythmias and Atrial Fibrillation: A Pilot Study

Aim: This study aims to evaluate the effectiveness of prolonged Holter monitoring in detecting atrial fibrillation (AF) and other arrhythmias in patients following ischemic stroke. We seek to establish the optimal duration of monitoring that maximizes detection rates while considering clinical feasibility and cost-effectiveness. Materials and Methods: We conducted a systematic review of recent literature, analyzing data from randomized clinical trials and observational studies that assessed the yield of AF detection through various durations of Holter monitoring. Key metrics included detection rates of AF and other relevant arrhythmias, along with patient outcomes related to therapeutic interventions initiated based on monitoring results. Conclusions: This review highlights the crucial role of prolonged Holter monitoring, particularly 7-day monitoring, in detecting paroxysmal atrial fibrillation (AF) among ischemic stroke survivors, especially those with cryptogenic strokes. Extended monitoring significantly improves AF detection, enabling timely anticoagulation therapy and better stroke prevention. While challenges like patient compliance and cost-effectiveness remain, integrating prolonged Holter monitoring into standard care could enhance diagnostic accuracy and reduce recurrent stroke risk.

Background: Pulmonary vein isolation (PVI) is the cornerstone therapy during catheter ablation of atrial fibrillation (AF) isolation. 30% of patients continue to have recurrent AF despite pulmonary vein (PV) isolation. Defining targets for catheter ablation in PV non responder subgroup continues to be challenging despite technological advances. Volta AF-Xplorer™ (VX) is an artificial intelligence (AI) system that analyzes intracardiac signals using electrocardiograms to recognize regions of spatial temporal dispersion and generate sequential maps as targets for ablation. Objective: We aim to assess the clinical feasibility and outcomes of the VX AI mapping algorithm during RF catheter ablations to treat recurrent persistent AF in PV non responders. Methods: A single center prospective analysis of patients undergoing repeat ablation for recurrent persistent AF using VX mapping software was performed. All patients had previous PVIs, with recurrence of AF and failed at least 2 antiarrhythmic drugs. Patients underwent 3D mapping using Carto and Ensite X mapping systems with real time detection and annotation of spatial temporal dispersion using the Volta technology. The identified targets were ablated until endpoints of termination and non inducibility was achieved and intraprocedural data points were recorded. Results: 19 patients with a mean age of 67±10.15 years 63.2% male were included in this analysis. Average total procedure time was 68±33 min and average mapping time was 17±10 min. Ablations were performed under zero fluoroscopy. PVI was confirmed in all cases. Ablation was performed at dispersion points identified using the AI mapping system. Termination was achieved in 18 out of the 19 cases (94.7%). 16 patients converted directly to normal sinus rhythm (NSR) and 2 patients to atrial flutter and then to NSR. The one patient that did not terminate required cardioversion but was not inducible with pacing maneuvers. Conclusion: This experience highlights the clinical safety, utility, feasibility, and outcomes of the Volta AF-Xplorer AI mapping software during catheter ablation of PV non responders for recurrent persistent AF.

Risk-benefit ratio assessment for stroke prevention in intermediate risk atrial fibrillation patients: will TEE-based aspirin treatment fill the gap?

Background and Aims Hemodialysis (HD) patients (Pts) with nonvalvular atrial fibrillation (AF) on anti-vitamin-K oral anticoagulation (VK-OAC) are at high risk for cardio-vascular events, major bleeding and rapid vascular/valvular calcification. Thus, current VK-OAC is debated since prospective studies are missing, but all direct oral anticoagulation drugs (DOACs) are not labeled for ESRD. We studied the clinical feasibility of long-term DOAC treatment in HD-pts using individual dosing by regular anticoagulant drug-effect monitoring. Method We analysed 9 HD-patients with AF (median age 77 yrs; range=R: 59-86; 7 Male) on DOAC therapy for at least 6 months (n=1 rivaroxaban=Riva, n=8 apixaban=Apix) initiated by cardiologist with patients informed consent with lower dose as in CKD-4 under regular (weekly) anti-Xa drug-effect monitoring (prior HD) using available routine laboratory test validated for low-molecular heparin: Target trough range (12-24h after drug) was 0.1-1.0 U/ml (=prophylactic to therapeutic anti-Xa levels; test range &amp;lt;0.1, &amp;gt;1.6 U/ml). Bleeding caused drug stop/reduction until anti-Xa control. Results Median study time was 14 months (R: 6-24). We analysed 310 anti-Xa levels on Apix and 83 levels on Riva. After dose adjustment finally 2 Apix-Pts (22%) received full CKD-4 dose (35 mg/week=wk) and 7 patients (78%) had median dose of 10 mg/wk (10-27 mg; 6x Apix) or 40 mg/wk Riva, i.e. 29% and 38% of usual CKD-4 dose. Two Pts with higher dose had clinical reasons: short-bowl-syndrome (less resorption) or high grade (3-4) left atrial sludge (therapeutic goal). Overall, median anti-Xa level was 0.47 U/ml (R: &amp;lt;0.1-&amp;gt;1.6) and 80% were in center-accepted targets: 0.1-1.2 U/ml. Lower dose Pts had higher in-target-rate (83%) than the 2 high dose Pts (70%) by more exceeding the upper limit. During our study we saw no cerebral/systemic thrombo-embolic event or major bleeding, but 2 pts had epistaxis (need out-patient intervention), 1x persistent macrohematuria (need catheterization) and 3 pts. had multiple subcutaneous hematoma, none needed event-related transfusion. We saw two non-cardiovascular deaths (22%; 2/9): 1x pneumonic sepsis, 1x advanced cancer. Conclusion We provide new clinical feasibility data on long-term DOACs therapy in HD-patients. Since DOACs are not labelled for ESRD we recommend strict indication plus regular anti-Xa drug-effect monitoring for adequate individual dosing. Our data support initial doses as for CKD-4 but applied only on HD-free days (4x/wk; =57% of usual) and adjustment in steady-state (1-2 wks): final individual doses were increased up to 100% in some patients, but mostly were reduced to 30-40% of usual CKD-4 doses. Overall, this individual dosing approach for DOACs provided adequate anti-Xa levels to prevent thrombo-embolic as well as major bleeding events. This initial data need to be confirmed in larger studies to improve evidence-based management of HD-patients with nonvalvular AF.

We aimed to evaluate the feasibility of an oral direct thrombin inhibitor, dabigatran, as a periprocedural anticoagulant for use with ablation of atrial fibrillation (AF). Consecutive patients scheduled to undergo an AF ablation were randomly assigned to receive dabigatran (n = 45) or warfarin (n = 45) to compare their clinical feasibility. Both of those oral anticoagulants were discontinued the day before the ablation and were resumed after confirming hemostasis of the venipuncture site. A bridging therapy with heparin was not used in either of the patient groups. Dabigatran was switched to warfarin before the ablation because of dyspepsia in three patients. An occurrence of rebleeding from the venipuncture site was less common in dabigatran-allocated patients than in warfarin-allocated patients (20% vs 44%; P = 0.013). The reduction in the D-dimer level after the initiation of oral anticoagulants was greater in the dabigatran-allocated patients than in the warfarin-allocated patients. The time from the initiation of the anticoagulants to the ablation was significantly shorter in the dabigatran-allocated patients than in the warfarin-allocated patients (43 ± 7 vs 63 ± 13 days; P < 0.0001). There was only one fatal periprocedural complication in a patient receiving warfarin, who had a mesenteric arterial thrombosis after the ablation. An anticoagulation strategy with dabigatran may surpass that with warfarin in reducing both the periprocedural risk of minor bleeding and a hypercoagulable state, and the time to ablation in patients undergoing ablation of AF.

We develop a hybrid two-stage approach for paroxysmal atrial fibrillation (PAF) prognosis based on features extracted from short-term heart rate variability (HRV) sequences. At the first stage, a data-mining-based approach is used to identify crucial medical-oriented features that can distinguish PAF HRV sequences from non-PAF HRV ones. However, PAF patients can experience PAF without exhibiting the medical-oriented features. To detect this type of patients, at the second stage, we employ a machine-learning-based approach to select certain nonlinear features that can classify HRV sequences into classes of PAF or non-PAF The developed approach was trained on the PAF Prediction Challenge Database and was tested on the dataset consisting of minute HRV episodes extracted from MIT-BIH Atrial Fibrillation Database and the MIT-BIH Normal Sinus Rhythm Database. It was obtained from the numerical evaluation that the developed approach achieved about 85% of accuracy in short-term prognosis of PAF by using the first stage approach alone and around 90% of accuracy with the combination of both stages. Furthermore, the developed medical-oriented features can be clinically valuable to the cardiologists for providing insights to the initiation of PAF.

Autonomic nervous system and paroxysmal atrial fibrillation: A study based on the analysis of RR interval changes before, during and after paroxysmal atrial fibrillation

Objective: to assess the clinical and economic feasibility of ticagrelor in combination with acetylsalicylic acid (ASA) in comparison with clopidogrel in combination with ASA in patients with acute coronary syndrome (ACS), including both those who underwent, and those who did not undergo percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG); and new oral anticoagulants (NOACs) in combination with clopidogrel in comparison with warfarin in combination with clopidogrel and ASA in patients with atrial fibrillation (AF) who underwent PCI; to identify the impact of the above strategies of antithrombotic therapy on the targets of the State Health Care Program of the Russian Federation (RF) “Development of Health Care” and the Federal Project “Cardiovascular Diseases Control”.Material and methods. The clinical and economic study (CES) of ticagrelor in combination with ASA in ACS patients was based on a costbenefit analysis. A combined model, including a decision tree and Markov model was developed. The horizon period of the analysis was 5 years. Quality-adjusted life year (QALY) was used as an efficiency criterion and only the direct medical costs associated with the conditions identified in the modeling were taken into account. A discount rate of 5% was taken into account during the CES. The application of NOACs in combination with clopidogrel was studied in the CES using a cost minimization analysis considering the costs per patient characterized by the presence of AF regardless of the presence of ACS and a history of PCI.Results. We used a decision tree and Markov modeling in adult patients with ACS, who had or had not undergone PCI or CABG, in the horizon period of 5 years considering the discount rate of the added quality-adjusted life year (incremental cost-effectiveness ratio (ICER) per QALY). The result for ticagrelor in combination with ASA compared to clopidogrel in combination with ASA was 605,199 rubles, which was significantly lower than the willingness-to-pay threshold (2,235,201 rubles). Assessment of the impact of the therapy regimen including ticagrelor in combination with ASA on the target indicators of the State Health Care Program of the RF “Development of Healthcare” and the Federal Project “Cardiovascular Diseases Control” showed that the use of this therapy regimen will reduce mortality from myocardial infarction (MI) and cardiovascular causes by 2.45 cases per 100 thousand population provided that 100% of patients with MI and unstable angina in the RF are transferred from clopidogrel + ASA scheme to ticagrelor + ASA. The potential contribution of ticagrelor in combination with ASA compared to clopidogrel in combination with ASA in patients with ACS in achieving the target reduction of mortality from circulatory diseases will be 6.48% by 2023. In all simulated scenarios, in the group of patients with AF who had undergone PCI, pharmacotherapy regimens containing NOACs (dabigatran etexilate, rivaroxaban, apixaban) were more costly than therapy regimens containing warfarin (with not significantly different effectiveness).Conclusion. The results of the evaluation of clinical and economic feasibility of antiplatelet therapy strategies demonstrated the costeffectiveness of ticagrelor in combination with ASA compared to clopidogrel in combination with ASA in patients with ACS, including those who had undergone PCI or CABG and those who had not. The strategy of ticagrelor + ASA showed a favorable effect on the rates of mortality from MI, as well as from circulatory diseases. The results of the clinical and economic evaluation of the four strategies of antithrombotic drug therapy in patients with AF who had undergone PCI showed higher costs of the regimens containing NOACs with a presumed zero effect on the mortality from circulatory diseases.

ABSTRACTBackgroundHigh‐power short‐duration (HPSD) ablation is an established therapy for pulmonary vein (PV) isolation (PVI) in atrial fibrillation (AF), aiming to form efficient transmural lesions. Very HPSD (vHPSD) can further shorten ablation time but may increase the risk of acute PVI failure compared with HPSD. A combined HPSD and vHPSD strategy (90 W/50 W combination workflow) potentially balances efficiency and durability, though its clinical feasibility remains unknown. Therefore, this multicenter registry evaluated the acute and long‐term efficacy of a 90 W/50 W combination workflow for PVI in patients with paroxysmal AF.MethodsIn this prospective study, a total of 101 consecutive patients with paroxysmal AF underwent PVI using radiofrequency ablation with a 90 W/50 W combination workflow. We evaluated acute outcomes, including first‐pass isolation and acute PV reconnection, and monitored atrial tachyarrhythmia recurrences over 12 months.ResultsMedian PVI procedure time was 35 min, with total procedure time at 105 min. First‐pass PVI was achieved in 58.4% of patients, including 74.3% in the right PV and 72.3% in the left PV. Acute PV reconnection occurred in 31.7% (32/101). In multivariate analysis, carina sites independently predicted acute PVI failure in both HPSD and vHPSD groups, while contact force also predicted failure in the HPSD group. After 1 year, 89.9% of patients remained free from documented atrial tachyarrhythmias.ConclusionThe 90 W/50 W combination workflow did not notably shorten procedure time or enhance first‐pass success. More standardized strategies, particularly in carina segments with higher contact force and ablation index under HPSD, may be required to ensure optimal lesion durability and favorable outcomes.

Autonomic nervous system and paroxysmal atrial fibrillation: a study based on the analysis of RR interval changes before, during and after paroxysmal atrial fibrillation.

Polysomnographic Heart Rate Variability Indices and Atrial Ectopy Associated with Incident Atrial Fibrillation Risk in Older Community-dwelling Men.

Feasibility and determinants of short-term heart rate variability in patients using photoplethysmography-based wearable devices - data derived from TeleCheck-AF