Risk factors of failed electrical cardioversion in patients with persistent or long-standing persistent atrial fibrillation.

POSTER PRESENTATIONS

Conversion to sinus rhythm (SR) is rarely attempted in patients with rheumatic atrial fibrillation (AF) because the length of AF duration and the dilation of left atrium (LA) make maintenance of SR difficult. In this study, predictors of the successful maintenance of SR with amiodarone and electrical cardioversion in rheumatic AF patients receiving percutaneous transluminal mitral valvuloplasty (PTMV) were identified. This study included 23 consecutive patients undergoing PTMV for rheumatic AF (6 men, 53+/-11 years; AF duration 25 +/-24 months; LA diameter 44+/-6 mm; mitral valve area (MV) 1.1+/-0.2 cm(2)). Electrical cardioversion was required for the successful conversion to SR in all patients regardless of whether they had received amiodarone (400 mg/day) 2 months before PTMV (n=8) or 2 months after (n=15). After cardioversion, all patients received amiodarone 200 mg/day. With a follow-up period of 35+/-8 months, 14 patients (61%) remained in SR. A greater reduction in LA size (-4+/-3 mm vs 1+/-1 mm; p=0.004) and an greater increase in MV area (0.8+/-0.4 cm(2) vs 0.5+/-0.2 cm(2); p=0.01) by PTMV, not AF duration, were found to be the independent predictors for patients with successful maintenance of SR as compared with patients with recurrence of AF. In rheumatic AF patients receiving PTMV, the successful maintenance of SR with amiodarone and electrical cardioversion can be predicted by the degree to which LA size is reduced and MV area is increased.

ORAL PRESENTATION

Left Atrial Electromechanical Conduction Time Can Predict Six-Month Maintenance of Sinus Rhythm After Electrical Cardioversion in Persistent Atrial Fibrillation by Doppler Tissue Echocardiography

Direct Current Cardioversion of Atrial Fibrillation—The Next 40 Years

Atrial fibrillation (AF) despite the absence of heart failure is related to increased levels of natriuretic peptides (NPs). NPs have not been widely investigated in relation to left atrium (LA) function after sinus rhythm (SR) restoration and duration of AF. The aim of the study was to determine the changes of NPs levels and to define their relation with LA phasic function after electrical cardioversion (ECV). Methods. The study included 48 persistent AF patients with restored SR after ECV. NT-proANP and NT-proBNP were measured for all patients before the ECV. LA phasic function (reservoir, conduit, and pump phases) was assessed using echocardiographic volumetric analysis within the first 24 hours after ECV. Patients were repeatedly tested after 1 month in case of SR maintenance. Results. After 1 month, SR was maintained in 26 (54%) patients. For those patients, NT-proBNP decreased significantly (p=0.0001), whereas NT-proANP tended to decrease (p=0.13). Following 1 month after SR restoration, LA indexed volume decreased (p=0.0001) and all phases of LA function improved (p=<0.01). Patients with AF duration < 3 months had lower NT-proANP compared to patients with AF duration from 6 to 12 months (p = 0.005). Higher NT-proANP concentration before ECV was associated with lower LA reservoir function during the first day after SR restoration (R=-0.456, p=0.005), whereas higher NT-proBNP concentration after 1 month in SR was significantly related to lower LA reservoir function (R=-0.429, p=0.047). Conclusions. LA indexed volume, all phases of LA function, and NT-proBNP levels improved significantly following 1 month of SR restoration. Preliminary results suggest that higher baseline NT-proANP levels and higher NT-proBNP for patients with maintained SR for 1 month are related to lower LA reservoir function. The longer duration of persistent AF is associated with higher NT-proANP concentration.

Research Needs and Priorities for Catheter Ablation of Atrial Fibrillation

This document is a compilation of the current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) practice guideline recommendations for atrial fibrillation (AF) from the “ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation),”* the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)”† and the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Update on Dabigatran).”‡ Updated and new recommendations from 2011 are noted and outdated recommendations have been removed. No new evidence was reviewed, and no recommendations included herein are original to this document. The ACCF/AHA Task Force on Practice Guidelines chooses to republish the recommendations in this format to provide the complete set of practice guideline recommendations in a single resource. ### 1.1. Pharmacological and Nonpharmacological Therapeutic Options #### 1.1.1. Rate Control During AF Class I 1. Measurement of the heart rate at rest and control of the rate using …

The recurrence rate of atrial fibrillation (AF) after elective cardioversion is high. The study aimed to identify clinical predictors for successful electrical cardioversion and maintenance of sinus rhythm after a first electrical cardioversion in patients with persistent AF without concomitant antiarrhythmic drugs of class I and III. Consecutive outpatients (n = 166) with persistent AF for > 1 month, scheduled for elective cardioversion, were prospectively included in the study. A clinical investigation, echocardiographic assay, and Holter electrocardiogram (ECG) before and ECG 4 weeks after cardioversion, were performed in all patients. The mean age of the patients was 68 years (range 45-83) and duration of AF was 5 (1-48) months. Sinus rhythm was established in 124 (75%) patients. In multivariate analysis, only duration of AF < 6 months (p < 0.04, odds ratio [OR] 2.2, 95% confidence interval [CI] 1.1 to 4.7) and patients weight (p < 0.03, OR 2.3, 95% CI 1.1 to 4.8 for weight < 80 kg) were identified as independent predictors of successful cardioversion. At 4 weeks after cardioversion, only 46 (37%) of 124 patients maintained sinus rhythm. Independent factors for maintenance of sinus rhythm, in multivariate analysis, were AF <3 months (p < 0.04, OR 2.5, 95% CI 1.1 to 5.6), treatment with beta blockers (p < 0.00001, OR 7.0, 95% CI 3.0 to 16.3) or verapamil/diltiazem (p < 0.04, OR 3.6, 95% CI 1.1 to 12.1), and right atrial dimension < 37 mm (p < 0.02, OR 5.9, 95% CI 1.4 to 25.4). In patients with persistent AF, the patient's weight and the duration of AF are independent predictors for a successful cardioversion. Short duration of AF, treatment with beta blockers or verapamil/diltiazem, and right atrial area/dimension are independent predictors for maintenance of sinus rhythm.

Effect of Eplerenone on Maintenance of Sinus Rhythm After Catheter Ablation in Patients With Long-Standing Persistent Atrial Fibrillation

The aim of this study was to evaluate the role of matrix metalloproteinases (MMPs) for the prediction of long-term maintenance of sinus rhythm (SR) after cardioversion in atrial fibrillation (AF). The study comprised 102 patients with AF. Pharmacological cardioversion was attempted for a 4-week period with anti-arrhythmic drugs in all patients. Those who failed medication underwent electrical cardioversion. Blood samples for biomarkers and echocardiographic data were obtained at baseline. Thirty-four patients (33.3%) converted to SR by pharmacological (n = 22) and electrical (n = 12) cardioversion and maintained it (SR group). The remaining 68 patients were refractory to the AF (RAF) group including recurrence (n = 22) and unsuccessful treatment (n = 46) after electrical/pharmacological cardioversion. Refractory AF was significantly associated with the duration of AF, hypertension, left atrial diameter, brain natriuretic peptide, MMP-2, and tissue inhibitor of MMP-2. For both multivariable logistic regression analysis and stepwise forward selection procedure, the duration of AF >5 months [odds ratio (OR) 15.32] and MMP-2 >767.0 ng/mL (OR 4.84) were significantly associated with RAF. Our study suggests that elevated MMP-2 and longer AF duration increased the risk for difficulty in restoring SR in AF patients. Stratification of subjects according to the MMP-2 level may therefore be important for the effective management of AF.

Introduction: Radiofrequency catheter ablation has been established as effective therapy for drug-refractory atrial fibrillation (AF). However, a significantly high recurrence rate remains as a problem to be resolved in long-standing persistent AF. It has been accepted that early atrial tachyarrhythmia including recurrence of AF and occurrence of atrial tachycardia (AT) during the first 3 months after catheter ablation, defined as blanking period, may not always lead to late recurrence of AF/AT. The aim of this study was to evaluate the relationship between early recurrence and late recurrence of AF/AT after catheter ablation in patients with long-standing of persistent AF. Methods: This study included 161 patients with long-standing persistent AF (sustained AF duration; 1 to 20 years, with a mean of 3.4±3.8 years) who underwent primary catheter ablation. Recurrence of AF and occurrence of AT within the first 3 months following catheter ablation was defined as early AF/AT recurrence. Results: RFCA was successfully performed in all patients. During the 24-month follow-up period, 86 (53%) patients had AF/AT recurrence and 74 (86%) patients of those had AF recurrence and remaining 12 (14%) patients of those had AT occurrence. During the first 3 months after catheter ablation, 82 (50%) patients had AF/AT recurrence. After transient AAD therapy and/or external cardioversion, 15 (18%) patients converted to and maintained sinus rhythm. In the other 67 (82%) patients, AF/AT continued or recurred during the 24-month follow-up period. By univariate analysis, duration of sustained AF, left atrial diameter, left atrial volume index, and early AF/AT recurrence were significantly associated with late AF/AT recurrence after catheter ablation (p<0.001, p=0.010, p=0.017, p<0.001, respectively). Early AF/AT recurrence was the independent predictor of late AT/AF recurrence after catheter ablation (hazard ratio [HR]=5.97, 95% confidence interval [CI]=3.50-10.16, p<0.001) as well as the sustained AF duration (>3 years, HR=1.93, 95% CI=1.25-2.99, p<0.001) and left atrial diameter (HR=1.03, 95% CI=1.01-1.07, p=0.05) in the cox multivariable analysis. Conclusions: Early AF/AT recurrence was significantly associated with late AF/AT recurrence after catheter ablation in patients with long-standing persistent AF. The prevention of early AF/AT recurrence might be able to reduce the late AF/AT recurrence after catheter ablation of AF.

The aim of this study was to assess the predictive value of the left atrial volume index (LAVI) in electrical cardioversion (ECV) and observe the recurrence rate of atrial fibrillation (AF) after a successful ECV in patients with non-valvular atrial fibrillation. This study was designed as a diagnostic accuracy and prospective cohort study. Eighty patients (mean age 62±12 years; 52.5% female) were enrolled in study. LAVI was measured using the area-length method and the indexed body surface area. Patients in whom the sinus rhythm (SR) was established following the ECV were assessed according to the clinical and electrocardiography (ECG) findings at the first month and grouped as those with continued SR or recurrent AF. The Student's t, Mann-Whitney U, Fisher's exact, Chi-square tests, ROC and logistic regression analyses were used for statistical analysis. Subsequent to the ECV, SR was achieved in 62.5% (n=50) of the patients. In those where SR was established, the AP-Lad (4.32±0.62 vs. 4.77±0.4 cm/p=0.002) and LAVI (35.3±11.5 vs. 53.1±10.1 mL/m2/p<0.001) values were observed to be lower. ECV success was found to be associated only with the LAVI (OR:1.122, 95%CI: 1.058-1.191, p<0.001). The AUC was found as 0.892±0.041 for the LAVI (95% CI:0.075-0.285, p<0.001). During the controls at the end of the 1st month, SR was maintained in 72% (n=36) of the successful ECV group. Among the patients with maintained SR, the antero-posterior left atrial dimension (4.17±0.62 vs. 4.72±0.5 cm/p=0.004) and LAVI (30.8±6.2 vs. 46.8±13.9 mL/m2/p<0.001) values were also observed to be lower. Only the LAVI was found to be associated with the recurrence of the AF (OR:1.355, 95% CI: 1.154-1.591, p<0.001). The AUC was found as 0.950±0.029 for the LAVI (95% CI:0.063-0.313, p=0.003) Lower LAVI values before the ECV are strong and independent predictors of the success of the ECV and the maintenance of SR after a successful ECV.

The velocity of left atrium appendage (LAA) wall motion during atrial fibrillation (AF) is a potential marker of mechanical remodelling. In this study, we investigated whether the velocity of LAA wall motion during AF predicted the success of electrical cardioversion and long-term sinus rhythm maintenance. Standard echocardiographic data were obtained by transthoracic echocardiography, and LAA wall motion velocities were measured by transoesophageal echocardiography. With logistic regression and receiver operating characteristic curve analyses, we related echocardiographic and clinical data to cardioversion outcomes and sinus rhythm maintenance at 12 months. Of 121 patients prospectively included in the study, electrical cardioversion restored sinus rhythm in 97 (81.2%), and 51 (42%) patients maintained sinus rhythm at 12 months. Patients in whom cardioversion restored sinus rhythm had higher LAA wall motion velocities than did the patients with failed cardioversions (p <0.001). Compared to patients with AF at 12 months, patients who maintained sinus rhythm had lower maximum and end-diastolic left atrial volumes (p ≤ 0.01), lower E/e’ ratios (p = 0.005), higher s’ values (p = 0.013), and higher LAA motion velocities (p < 0.001). On multivariate logistic regression, only LAA wall motion velocity and E/e’ ratios remained significant predictors of sinus rhythm maintenance at 12 months (p ≤ 0.04). LAA wall motion velocity was also a significant predictor of sinus rhythm maintenance when corrected for clinical variables (p = 0.039). Conclusion: LAA wall motion velocity, as a marker of mechanical remodelling, can predict short-term and long-term sinus rhythm maintenance after electrical cardioversion in AF.

This study evaluated the response to electrical cardioversion (EC) and the effect on the myocardial performance index (MPI) in patients with persistent and long-standing persistent atrial fibrillation (AF). We enrolled 103 patients (mean age 69.6 ± 8.9 years, 40.7% males) with a diagnosis of persistent and long-standing persistent AF. EC was applied to all patients after one g of amiodarone administration. Echocardiographic findings before EC were compared in patients with successful versus unsuccessful cardioversions and in patients with maintained sinus rhythm (SR) versus those with AF recurrence at the end of the first month. We also compared echocardiographic data before EC versus at the end of the first month in the same patients with maintained SR. SR was achieved in 72.8% of patients and was continued at the end of the first month in 69.3% of the patients. The MPI value of all patients was found to be 0.73 ± 0.21. The size of the left atrium was determined to be an independent predictor of the maintenance of SR at 1 month. In subgroup analyses, when we compared echocardiographic findings before EC and at the end of the first month in patients with maintained SR, the MPI (0.66 ± 0.14 vs 0.56 ± 0.09, p < 0.001) values were significantly decreased. Our study is the first to show impairment of the MPI, which is an indicator of systolic and diastolic function, in patients with persistent and long-standing persistent AF and improvement of the MPI after successful EC.