Atrial Fibrillation In Setting Research Articles

Intraprocedural and outcome findings in repeat left atrial procedures after pulsed field ablation for pulmonary vein isolation in paroxysmal and persistent atrial fibrillation

Abstract Background Pulsed Field Ablation (PFA) has emerged as a promising novel technique for pulmonary vein isolation (PVI) in the setting of atrial fibrillation. First outcome data revealed comparable success rates to radiofrequency and cryoablation. However, data on lesion dimensions and reconnection of PV after PFA potentially causing recurrence of AF is sparse. We, therefore report on pivotal reconnection sites and ablation extend after PFA-PVI. Methods All patients after PFA-PVI for paroxysmal or persistent AF at our center between September 2021 and October 2023 were included in this retrospective analysis. Baseline characteristics, procedural and outcome data were obtained. Furthermore, in all redo procedures of these patients lesion dimensions and the occurrence and location of PV gaps were evaluated. Results A total of 123 patients with atrial fibrillation underwent successful PFA-PVI during index procedure. The study cohort comprised [n= 52; 42%] paroxysmal and [n= 71; 58%] persistent atrial fibrillation cases. After a median follow-up of 123 (IQR 93-150) days recurrence of atrial arrhythmia (all AF) occurred in 9 [14. 5%] patients. Of these, 6 [9.6%] patients underwent a redo procedure due to recurrence of atrial fibrillation (3 PAF and 3 persAF [50%]; p=1). All left atrial maps and 24 PVs were analyzed. All 6 [100%] patients exhibited electrical reconnection of one or more pulmonary vein. Analysis of redo procedures revealed that the dimensions of PFA-induced lesions varied among patients: The right inferior pulmonary vein (RIPV) showed reconnection in all redo-patients (100%). Also frequent reconnection was observed for the RSPV (3 pts [50%]) and LIPV (2 pts [33%]). The gap size was 66±40% of the circumference in the reconnected RPVs and 61±31% in the reconnected LPVs. A roof-line lesion set was performed in 4 out of 6 pts (67%) due to the initially antral PV lesions affecting the posterior wall and LA roof potentially creating an isthmus for roof-dependent atrial tachycardia (AT). Conclusion Outcome data for PFA-PVI are comparable to other energy sources used for PVI. However, reconnection of PV also occurs after PFA-PVI. This retrospective analysis of redo procedures after initially successful PVI identified the RIPV as pivotal for reconnection. Furthermore, map analysis revealed that reconnection gaps extend to up to 2/3 of the initial circumferential PV ablation area. Furthermore, PFA seems to create new critical isthmuses potentially causing AT. No difference in reconnection was seen comparing PAF and persAF.

Aggressive Rhythm Control Strategy in Atrial Fibrillation Patients Presenting at the Emergency Department: The HEROMEDICUS Study Design and Initial Results.

Atrial fibrillation has progressively become a more common reason for emergency department visits, representing 0.5% of presenting reasons. Registry data have indicated that about 60% of atrial fibrillation patients who present to the emergency department are admitted, emphasizing the need for more efficient management of atrial fibrillation in the acute phase. Management of atrial fibrillation in the setting of the emergency department varies between countries and healthcare systems. The most plausible reason to justify a conservative rather than an aggressive strategy in the management of atrial fibrillation is the absence of specific guidelines from diverse societies. Several trials of atrial fibrillation treatment strategies, including cardioversion, have demonstrated that atrial fibrillation in the emergency department can be treated safely and effectively, avoiding admission. In the present study, we present the epidemiology and characteristics of atrial fibrillation patients presenting to the emergency department, as well as the impact of diverse management strategies on atrial-fibrillation-related hospital admissions. Lastly, the design and initial data of the HEROMEDICUS protocol will be presented, which constitutes an electrophysiology-based aggressive rhythm control strategy in patients with atrial fibrillation in the emergency department setting.

Mitral regurgitation in atrial fibrillation: Is a simple repair enough to tackle a complex problem?

BackgroundClinical and echocardiographic results of valve repair for mitral regurgitation in the setting of atrial fibrillation are poorly studied. MethodsBetween January 2008 and December 2020, 89 patients underwent valve repair for mitral regurgitation in the setting of atrial fibrillation. Clinical and echocardiographic follow-up data were collected and studied. The primary composite endpoint consisted of all-cause mortality or hospitalization for heart failure. ResultsValve repair with true-sized annuloplasty was performed in 83 (93 %) and restrictive annuloplasty in 6 (7 %) patients. Early mortality occurred in 3 (3 %) and residual mitral regurgitation in 1 (1 %) patient. During a median follow-up of 5.4 years (interquartile range 3.4–9.5), 25 patients died, 6 due to end-stage heart failure. Ten patients were hospitalized for heart failure. The estimated event-free survival rate at 10 years was 48.2 % (95 % CI 33.5 %–62.9 %). Recurrent mitral regurgitation was observed in 14 patients and most often caused by leaflet tethering. When analyzed as a time-dependent variable, recurrent regurgitation was related to the occurrence of the primary endpoint (hazard ratio 3.192, 95 % CI 1.219–8.359, p = 0.018). On exploratory sub-analyses, no recurrent regurgitation was observed after restrictive annuloplasty or in patients with paroxysmal atrial fibrillation. Moreover, recurrent regurgitation was observed more often when signs of left ventricular impairment were present preoperatively. ConclusionsDespite good initial results, recurrent regurgitation was a frequent observation after valve repair for mitral regurgitation in atrial fibrillation and had an effect on heart failure related morbidity and mortality. Refinements in the timing of surgery and surgical technique might help improve outcomes.

Perioperative atrial fibrillation in relation to major emergency abdominal surgery and non-perioperative new onset atrial fibrillation: is there a difference in outcome?

Abstract Background Major emergency abdominal surgery (e.g. ileus, perforation) is relatively common and associated with postoperative complications and mortality. Long-term management of patients with atrial fibrillation (AF) associated with a secondary precipitant has recently received increased attention. It is further unknown whether the conflicting results regarding long-term outcomes in patients with new onset AF depends on surgical subtype or the arrhythmia itself. Purpose The aim of this study was to compare long-term clinical outcomes (AF related hospitalization, stroke, and mortality) in patients with perioperative new onset AF in relation to major emergency abdominal surgery and patients with non-perioperative new onset AF. Methods We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000-2018) and were diagnosed with new onset AF perioperatively, and patients who developed new onset AF in a non-perioperative setting. Patients with new onset perioperative AF were matched in a 1:5 ratio on age, sex and year of AF diagnosis with patients with non-perioperative new onset AF. From discharge, we examined unadjusted rates of outcomes and adjusted hazard ratios of outcomes were assessed using multivariable Cox regression analysis. Results The study population comprised 794 (out of 42,021) patients with perioperative new onset AF and 3970 patients with non-perioperative new onset AF (median age of 78 years [interquartile range: 70-83] and 57.3% women in both groups). In general, patients with new-onset perioperative AF had lower comorbid burden compared with patients with non-perioperative new onset AF. During the first month after the hospital admission, 15.0% of the patients with perioperative AF and 36.1% of the patients with new onset AF initiated oral anticoagulation therapy (after 2010, 19.7% and 41.2%, respectively). Two years after discharge, 3.9% of patients with perioperative AF and 5.8% of patients with new onset AF (p = 0.031) had had a stroke, while 32.9% and 40.1% (p = 0.002) had had a new hospitalization with AF. Cumulative incidences of stroke and AF related hospitalization are depicted in the Figure. In the multivariable models, perioperative AF was associated with a similar rate of stroke and lower rate of AF related hospitalization compared with non-perioperative new onset AF (HR 1.03, 95% confidence interval, CI: 0.54-1.96 for stroke and HR 0.68, 95% CI: 0.50-0.92 for AF related hospitalization, respectively). Conclusion Perioperative new onset atrial fibrillation in relation to major emergency abdominal surgery was associated with long-term similar rates of stroke and lower rates of AF related hospitalization compared with new onset atrial fibrillation in the non-perioperative setting. This study demonstrates a need for more knowledge about the progress of atrial fibrillation in the setting of non-cardiac surgery.Cumulative Incidence - strokeCumulative Incidence - AF_re

First long-term outcome data for the MicraVR™ transcatheter pacing system: data from the largest prospective German cohort.

The MicraVR™ transcatheter pacing system (TPS) has been implemented into clinical routine for several years. The primary recipients are patients in need for VVI pacing due to bradycardia in the setting of atrial fibrillation (AF). Implantation safety and acute success have been proven in controlled studies and registries. So far only few long-term real-life data on TPS exist. We report indication, procedure and outcome data from two high-volume implanting German centers. Between 2016 and 2019, 188 (of 303) patients were included. During follow-up (FU), TPS interrogation was performed after 4 weeks and thereafter every 6 months. Indication for TPS implantation in 159/188 (85%) patients was permanent or intermittent AV block III° in the setting of atrial fibrillation. The mean procedure duration was 50 min [35.0-70.0]. The average acute values after system release were: thresholds: 0.5V [0.38-0.74]/0.24ms; R-wave sensing: 10.0mV [8.1-13.5]; impedance: 650 Ohm [550-783]; RV-pacing demand: 16.9% [0.9-75.9]; and battery status: 3.15 V [3.12-3.16]. During FU of 723.4 ± 597.9 days, neither pacemaker failure nor infections were reported. Long-term FU revealed: thresholds: 0.5V [0.38-0.63]/0.24 ms; sensing: 12.3mV [8.9-17.2]; impedance: 570 Ohm [488-633]; RV-pacing demand: 87.1% [29.5-98.6]; and battery status 3.02 V [3.0-3.1]. Forty-three patients died from not-device-related causes. This to date largest German long-term dataset for MicraVR™ TPS implantation revealed stable device parameter. Foremost, battery longevity seems to fulfill predicted values despite a significant increase in RV-pacing demand over time and even in patients with consecutive AV-node ablation. Of note, no infections or system failure were observed.

Abstract P2010: Relationship between echocardiographic parameters and invasively measured left ventricular filling pressure in the persistent atrial fibrillation with preserved left ventricular systolic function

Background: Among patients with normal systolic function, elevated left ventricular end diastolic pressure (LVEDP) could represent early diastolic dysfunction or could be the main physiological consequence of diastolic dysfunction. However, the evaluation of LVEDP using classic echocardiographic assessment has been challenging in the setting of atrial fibrillation (AF). The aim of this study was to investigate the methods for predicting LVEPD in patients with persistent AF. Methods: Clinical data, laboratory data, and echocardiography findings were assessed in 90 patients with chronic AF who were undergoing diagnostic left-heart catheterization. LVEDP and standard echocardiographic measurements including pulmonary arterial systolic pressure (PASP) were evaluated. Results: E/e’ (r=0.448, p<0.001), E/Vp (r=0.471, p<0.001) and PASP (r=0.421, p<0.001) correlated well with LVEDP (figure 1). Using receiver operating characteristic analysis, the optimal cut-off for E/e’ was 13 (sensitivity, 88%; specificity, 65%) to predict LVEDP of >15 mmHg (figure ). Conclusion: E/e’, E/Vp and PASP were well correlated with LVEDP in patients with AF with preserved EF. E/e’ greater than 13 may suggest elevated LVEDP (>15 mmHg) in patients with persistent AF.

PO-01-069 HEART FAILURE INCIDENCE AMONG PATIENTS WITH ATRIAL FIBRILLATION TREATED WITH ANTI-ARRHYTHMIC DRUGS VERSUS CATHETER ABLATION: RETROSPECTIVE ANALYSIS OF AN ADMINISTRATIVE CLAIMS DATABASE OF COMMERCIALLY INSURED POPULATION IN THE UNITED STATES

Atrial fibrillation (AF) considerably increases the risk of heart failure (HF). While the risk of hospitalization of heart failure and mortality are known in the setting of atrial fibrillation, effective treatment of AF could potentially alleviate the risk of HF development. We compared the incidence of heart failure among patients with AF treated with catheter ablation (CA) versus anti-arrhythmic drugs (AAD). 2014-2022 Optum Clinformatics database for commercially insured and Medicare Advantage beneficiaries in the United States was utilized for patients (aged 19 years and above) with AF and history of one AAD usage. Patients were then classified into two cohorts – those who had CA (CA cohort) versus those who had a different AAD prescription (AAD cohort) between 2014 and 2022. Exclusion criteria included history of HF, prior valvular procedure, pacemaker or implantable cardioverter defibrillator, surgical ablation, or left atrial appendage occlusion. The two study cohorts were matched on socio-demographic and clinical covariates using a propensity score technique. Cox regression model was used to examine the differential risk of incident HF in the two cohorts. Sub-analyses were performed by race/ethnicity and sex, respectively. After propensity matching, 10,462 patients were identified in each of the two study cohorts (AAD and CA). Patients treated with CA had 56% lower risk of incident HF as compared to those treated with AADs (hazard ratio [HR] 0.44; 95% CI 0.41-0.47). Sub-analysis by race/ethnicity depicted similarly consistent results, with White (HR 0.43; 95% CI 0.40-0.46), Black (HR 0.42; 95% CI 0.33-0.54), Hispanic (HR 0.49; 95% CI 0.38-0.63), and Asian (HR 0.29; 95% CI 0.15-0.55) patients, respectively. When examining by sex, female patients treated with CA (HR 0.46; 95% CI 0.42-0.50) and male patients treated with CA (HR 0.40; 95% CI 0.36-0.44) had significantly lower risk of incident HF compared to female and male patients, respectively, treated with AAD. Patients with AF treated with CA were observed to have significantly lower risk of development of HF as compared to those treated with AAD, with a 56% overall reduction in incidence of HF. The lower risk of HF associated with CA versus AAD was consistent across different race/ethnic and sex categories.

The relationship between leukocyte to albumin ratio and atrial fibrillation severity

BackgroundAn increased leukocyte count is a sign of inflammation and has been demonstrated to be a predisposing factor and complication of atrial fibrillation. Similarly, albumin, the major protein in the serum, is also considered an acute phase reactant protein that has osmotic and anti-inflammatory properties, and a low albumin level is a known factor associated with severity in many pathologies, including atrial fibrillation. The neutrophil percentage-to-albumin ratio (NPAR) and other emerging leukocyte counts/albumin ratios have been reliable systemic inflammation-based predictors of mortality and complications in various diseases, but they have not yet been used with atrial fibrillation. This study’s aim was to explore whether the leukocyte to albumin ratio could also serve as a useful index in estimating atrial fibrillation severity, including the severity of atrial fibrillation secondary to stroke, to provide a new and more objective tool than the conventional and medical history-based CHA2DS2–VASc score.Materials and methodsData were retrospectively collected from the Wuhan University Zhongnan Hospital database from January 1st to December 31st, 2021. The patients were classified into 2 groups: Group 1-low severity and Group 2- moderate to high severity, and diverse statistical analyses were conducted to evaluate the relationship between the leukocyte-to-albumin ratio and AF severity.ResultsOnly 2329 test subjects met the inclusion criteria. We had 727 test subjects (381 males and 346 females) categorized into the low severity cohort and 1601 test subjects (932 males and 670 females) in the moderate to high severity group. The difference in mean age between the two groups was significant (95% CI [−2.682 to −0.154] p = 0.028), and the difference in the LAR mean rank between the two groups was significant (p = 0.00). The Chi-square test of association yielded the following results: the relationship between the LAR level and category of severity was statistically significant (p = 0.00), and the Mantel‒Haenszel statistic association odds ratio was OR = 0.657. 95% CI OR [0.549–0.787] p = 0.000. The association between sex and atrial fibrillation severity also reached statistical significance. However, sex and LAR were found to be independent factors in atrial fibrillation (Chi-square p value = 0.564).ConclusionIt has been demonstrated throughout this investigation that the leukocyte to albumin ratio could provide key clues in clinical practice and contribute to thromboembolism risk assessment in the setting of atrial fibrillation.

213: ONE SHOCK TREATED WITH ANOTHER: NEW-ONSET ATRIAL FIBRILLATION AFTER HIGH-VOLTAGE ELECTRICAL INJURY

Introduction: Development of atrial fibrillation following electrical injury has been rarely reported in literature. This can place medical providers in a situation where they are uncertain on how to manage such event. We present a case of high voltage electrical injury (7200V) resulting in new onset atrial fibrillation. Description: A 38-year-old electric line worker with no previous medical history came in with complaint of new onset palpitations and lightheadedness that started an hour prior to arrival. Patient stated he was standing on a boom lift, pressure-washing a church’s tower when his lance touched an electrical wire overhead. The lines were coming from a main electric pole estimated to be 7200V that connected to the transformer. Patient felt a shock pass through his right hand down to the rest of his body for a few seconds, and then he fell. He was not wearing any gloves. He denied any loss of consciousness, alcohol use, chest pain or any previous heart condition. In the ED, he was found to be in atrial fibrillation with heart rate ranging from 110-150. His CPK was 295 units/L and troponin was < 6 ng/L. Patient received IV diltiazem 15mg and IV amiodarone 150mg. He was started on amiodarone drip, admitted to ICU for monitoring and transitioned to Metoprolol 25mg BID and Xarelto 15mg daily the next day before discharge. Three weeks later, he underwent transesophageal echocardiogram (TEE) guided electrical cardioversion for persistent atrial fibrillation. Discussion: Electrical injury can induce cardiac arrhythmias via different mechanisms. The sheer energy of the electric current could directly stimulate the myocytes. It could also impair the sodium-potassium adenosine triphosphatase transporter which plays a major role in electrical-mechanical activity of cardiac muscle. Myocardial necrosis can also lead to production of new arrhythmogenic foci. Troponin and CPK are not always strong indicators of myocardial injury, however, high CK levels >400 units/L may be associated with longer hospitalization, and a greater risk of skin grafting or amputation. Atrial fibrillation in setting of electrical injury is managed with the use of beta blockers, anti-arrhythmics and in some cases, electrical cardioversion.

High-power short-duration versus low-power long-duration ablation guided by the ablation index

AimsTo compare the two different ablation strategies, both guided by the Ablation Index (AI), in the setting of atrial fibrillation (AF) ablation: high-power short-duration (HPSD) ablation using 40 W on the posterior wall and 50 W elsewhere versus low-power long-duration (LPLD) using 25 W posteriorly and 35 W elsewhere. MethodsProspective, multicenter nonrandomized, noninferiority study of consecutive patients referred for paroxysmal AF ablation from January 2018 to July 2019. Ablation was guided by the AI (≥500 for anterior segments, ≥450 for the roof and inferior segments and 400 posteriorly) and an interlesion distance (ILD) ≤ 6 mm. Patients were separated into two groups: HPSD vs LPLD. Acute reconnection (after adenosine trial) and 2-year outcomes were assessed. Results160 patients (61% males, median age of 62 [IQR 51–69] years), fulfilled the study inclusion criteria – 80 patients (316 pulmonary veins [PV]) in the HPSD group and 80 patients (314 PV) in the LPLD. The probability of acute PV reconnection was similar between both groups: 2.2% in HPSD, 95%CI 0.6% to 3.8% vs. 3.4% in LPLD, 95%CI 1.4% to 5.4%; p < 0.001 for noninferiority. Median PV ablation time (20 min vs 30 min, p < 0.01) and procedure duration (80 min vs 100 min, p < 0.001) were shorter in the HPSD group. After a median follow-up of 26 months, arrhythmia recurrence was similar between groups (17.5% in HPSD group vs. 18.8% in LPLD group, p = 0.79). ConclusionsIn paroxysmal AF patients treated with the Ablation Index, a HPSD strategy is noninferior to the more standard LPLD ablation, while allowing for quicker procedures with shorter ablation times.

Delayed Release of Amiodarone Causing Late-Onset Thyrotoxicosis

Introduction: Amiodarone is an antiarrhythmic medication associated with a wide range of adverse effects, including thyroid dysfunction.1 Thyrotoxicosis without underlying Graves' disease or nodules is classified as Type II, or destructive, amiodarone-induced thyrotoxicosis (AIT).2 However, few cases have been reported in whom AIT occurs months after cessation of medication use. We describe a case of late-onset Type II AIT, diagnosed in the setting of atrial fibrillation (AF), 10 months after last known dose of amiodarone. Description of the Case: A 51-year-old man presented with palpitations and an electrocardiogram showing AF with rapid ventricular response. His history was notable for a diagnosis of AF, treated with ablation and multiple courses of amiodarone, most recently 1 year prior with a cumulative dose of 22.4 g for 12 weeks. Serum laboratory tests showed newly suppressed thyroid-stimulating hormone <0.02 (0.3–4.7 mcIU/mL) and elevated free thyroxine 1.9 (0.8–1.7 ng/dL). Thyroid autoantibodies to thyroid peroxidase and thyrotropin receptor and thyroid-stimulating immunoglobulins were absent. He had no recent exposure to biotin or iodinated contrast and reported no recent viral illness or neck pain. He had a 9 kg weight loss in the preceding few months secondary to decreased appetite. Family history was significant for mother and nephew with autoimmune thyroid disease. Thyroid ultrasonography showed no nodules. An iodine-123 uptake scan showed homogeneous bilateral decreased uptake most consistent with destructive thyroiditis. Methimazole treatment, started empirically at presentation, was discontinued. Thyroid function tests normalized within 3 months with no therapy needed. Discussion: Delayed-onset AIT may occur after cessation of amiodarone therapy. To our knowledge, only one case series of eight patients has been reported in whom late-onset thyrotoxicosis occurred after amiodarone cessation.3 Amiodarone contains a significant amount of iodine and releases about 100 to 300 times of the recommended daily intake. It is a lipophilic complex primarily stored within adipose tissue, with a long half-life of up to 100 days. Our patient's rapid weight loss may have contributed to a delayed release of amiodarone from lipid stores, thereby triggering Type II AIT. This case emphasizes the importance of considering AIT in all patients with history of amiodarone use, even months after cessation of therapy, when supported by presentation and diagnostic tests. Patient Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No competing financial interests exist for any of the authors. Runtime of video: 4 mins 12 secs

Anticoagulation use in the setting of atrial fibrillation in a typical outpatient cardiology population

Abstract Funding Acknowledgements Type of funding sources: None. Background The risk of cerebrovascular events has been greatly reduced with the guideline recommendation of anticoagulation in the presence of atrial fibrillation (AF). Based on current epidemiological evidence, over ⅓ of patients with known AF who are eligible for anticoagulation, do not receive them. The elderly population are especially susceptible to this disparity. The CHA2DS2-VASC score is currently being used to assess for need for anticoagulation in patients with AF. More recently, the HAS-BLED score has been developed to assess for bleeding risk. Weighing the bleeding risk using HAS-BLED score with stroke risk using CHA2DS2-VASC score, we assessed if a segment of the Canadian population with AF were appropriately anti-coagulated. Purpose Assess the concordance of one outpatient cardiology practice with anticoagulation guidelines for atrial fibrillation. Materials &amp; Methods Patients were randomly selected from a single centre outpatient Cardiology practice between January and May 2021. The patients were selected by 1 researcher. The patients selected must have been diagnosed with atrial fibrillation by ECG and Holter analysis. The HAS-BLED and CHA2DS2-VASC scores were calculated for each individual. Results 101 patients were selected for this study. 66 were male and 35 were female with ages ranging from 33 to 91 years old. Patients with a CHA2DS2-VASC score greater than 1, were anti-coagulated with direct oral anticoagulation (DOAC) unless they were in severe renal failure (creatinine clearance &amp;lt;30ml/min) in which case Warfarin was used. In the age group of 65 and under, 12 patients had a CHA2DS2-VASC score greater than 1 and were anti-coagulated. In the age group 65 and over, 72 had a CHA2DS2-VASC score greater than 1. Of the 72 individuals, 71 were appropriately anti-coagulated. In the age group 80 and over, 29 individuals had a CHA2DS2-VASC score greater than 1 and were anti-coagulated. For the individuals on anticoagulants, the HAS-BLED score was less than or equal to the CHA2DS2-VASC score. Only one of the patients in the study with a CHA2DS2-VASC score greater than 1, was not anti-coagulated. There were no reported major bleeding risks in the patients reviewed. Conclusion In a sample of the typical Canadian population, based on risk factor assessments using both the CHA2DS2-VASC and HAS-BLED scores, 99% of patients were appropriately anti-coagulated in the presence of AF. This shows a significant increase in appropriate management of AF patients compared to the current national and global averages. There were no major bleeding events reported in any of the patients receiving full anticoagulation. This supports the recommendation that the benefit of anticoagulation in stroke reduction from thromboembolism outweighs the risk of major bleeding events.

Outcomes of cardiac surgery with left atrial appendage occlusion versus no Occlusion, direct oral Anticoagulants, and vitamin K Antagonists: A systematic review with Meta-analysis.

Surgical left atrial appendage occlusion (LAAO) is being used increasingly in the setting of atrial fibrillation but has been associated with procedural complications. This systematic review and meta-analysis compared the outcomes of surgical LAAO with those of no LAAO and the use of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) using the PRISMA guidelines. A literature search was undertaken for relevant studies published between January 1, 2003, and August 15, 2021. Primary clinical outcomes were all-cause mortality, embolic events, and stroke. Secondary clinical outcomes included major adverse cardiac events (MACE), postoperative atrial fibrillation, postoperative complications, reoperation for bleeding, and major bleeding. There was a statistically significant 34% reduction in incidence of embolic events (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.57-0.77, p<0.001) and a significant 42% reduction in risk of MACE (OR 0.58, 95% CI 0.38-0.88, p=0.01) in patients who underwent LAAO.Surgical LAAO has the potential to reduce embolic events and MACE in patients undergoing cardiac surgery for atrial fibrillation. However, complete replacement of DOACs and warfarin therapy with surgical LAAO is unlikely despite its non-inferiority in terms of minimizing all-cause mortality, embolic events, MACE, major bleeding, and stroke in patients on oral anticoagulation therapies.

Prevalence and factors associated with atrial mitral and tricuspid regurgitation in patients with atrial fibrillation

This study aimed to examine the prevalence of atrial tricuspid regurgitation (ATR) and atrial mitral regurgitation(AMR) in the setting of atrial fibrillation (AFib) and identify variables related to the severity of both types of regurgitation. Cross-sectional study evaluating data from transthoracic echocardiograms performed during 2019. We included patients with AFib during the examination, and without primary valve disease or other significant heart disease. Four-hundred and thirty-two patients fulfilled the inclusion criteria (mean age 77.5±9.2 years, 49.1% women). We observed significant ATR in 14.8%, and significant AMR in 1.4% of patients. ATR and AMR severities were equal in 49.3% of patients, and 41% displayed greater ATR severity. ATR prevalence was significantly greater among women (23.1%vs 6.8%, p<0.001), but AMR prevalence was similar between genders (1.9%vs .9%, p=0.443). Variables related to greater ATR severity were: female sex (OR: 2.61, 95%CI: 1.60-4.24), left atrial (LA) volume (OR: 3.58, 95%CI: 1.50-8.55), systolic pulmonary artery pressure (OR: 1.10, 95%CI: 1.07-1.13), and moderate AMR (OR: 2.21, 95%CI: 1.22-4.00). Variables related to greater AMR severity were female sex (OR: 1.96, 95%CI: 1.24-3.09), LA volume (OR: 11.68, 95%CI: 5.29-25.80), and body mass index (OR: .94, 95%CI: .90-.98). In the context of AFib, ATR was more prevalent than AMR and prevailed in women. LA enlargement was associated with higher degrees of both AMR and ATR. Pulmonary hypertension was also independently associated with ATR, as well as greater AMR severity, suggesting possible adaptive changes in leaflets that might modify the atrial regurgitation incidence.

Contemporary review on the management of oral anticoagulation and anti-platelet therapies in patients undergoing percutaneous coronary intervention with concurrent atrial fibrillation

: Management of coronary artery disease (CAD) with percutaneous coronary intervention (PCI) in the setting of atrial fibrillation (AF) presents clinicians with the challenge of balancing thrombosis risk with bleeding risk. Major societies including American College of Cardiology (ACC)/American Heart Association (AHA), Heart Rhythm Society (HRS) and European Society of Cardiology (ESC) guideline recommendations include the necessity to use antiplatelet therapy and anticoagulation for the prevention of thromboembolism in patients who undergo intervention with PCI who have concurrent AF. Dual antiplatelet therapy (DAPT) is the standard of care for patients post PCI, and anticoagulation with vitamin K antagonists (VKA) or direct acting oral anticoagulants (DOAC) is the standard of care, with DOACS being recommended by ACC/AHA and ESC as preferred, for patients with AF and elevated ischemic stroke risk. Here, we review the contemporary major society guideline recommendations applicable for the use of triple therapy with dual anti-platelet agents and oral anticoagulant, in patients undergoing PCI who have concurrent AF. We also review and summarize the relevant historical primary literature related to the approval of antiplatelet and anticoagulant therapy in PCI and AF respectively. Using a case description as a basis to illustrate this difficult clinical scenario, we review the contemporary literature, and present proposed management algorithms.

Influence of Atrial Fibrillation on the Diagnosis of Severe Low-Flow Aortic Stenosis

Low-flow severe aortic stenosis (AS) can be difficult to diagnose, particularly in the setting of atrial fibrillation (AF) in which multiple beats (5

Improved Thrombus Assessment by Transesophageal Echocardiography: The DOLOP (Detection of Left Atrial Appendage Thrombosis Utilizing Optison) Study

Transesophageal echocardiography (TEE) to assess for thrombus in the left atrial appendage (LAA) is an essential clinical tool prior to cardioversion or ablation in the setting of atrial fibrillation (AF) or flutter. While TEE is superior to transthoracic echo for LAA evaluation, noncontrast images can be limited by artifact and reverberation as well as spontaneous echo contrast (SEC).1 Use of ultrasound-enhancing agents (UEAs) can improve diagnostic accuracy;2 however, the only Food and Drug Administration–approved use of UEAs is left ventricle opacification.

Electroanatomic guidance versus conventional fluoroscopy during transseptal puncture for atrial fibrillation ablation.

Technological advancement in the setting of atrial fibrillation (AF) ablation has decreased radiation exposure and complications associated with the procedure. Yet, transseptal puncture (TSP) remains a challenging step that necessitates accurate guidance. We describe our experience performing TSP under electroanatomic (EA) guidance. The analysis included 145 consecutive EA-guided ablation procedures performed between June 2018 and April 2019 and 145 consecutive standard ablations performed before June 2018. EA guidance utilized the CARTO 3 three-dimensional mapping system to reconstruct anatomic and electrical characteristics of the right atrium and fossa ovalis. Patients with a history of previous cardiac surgery were excluded. For EA-guided procedures, the mean patient age was 60 ± 10 years, 75.2% were male, and 69.0% had paroxysmal AF. Similarly, the mean age for conventional procedures was 60 ± 11 years, 71.0% were male, and 71.7% had paroxysmal AF. The fossa ovalis was detected as a region of low voltage, <0.75 mV. EA guidance yielded shorter fluoroscopy times (EA vs. conventional, 3.6 ± 2.5 vs. 13.5 ± 10.5 min; p < .001) and a lower dose area product than conventional guidance (13 ± 11 Gy* cm2 vs. 28 ± 27 Gy* cm2 ; p < .001).The total procedure duration was similar between groups (146 ± 48vs. 148 ± 54 min). There were no significant complications related to TSP. During AF ablation, TSP with EA guidance facilitated safe access to the left atrium while reducing radiation risk to both patients and operators.

P1087Prevalence and significance of mitral regurgitation in atrial fibrillation coexisting with HFpEF and HFmEF

Abstract Background Recent data has acknowledged atrial induced functional mitral valve regurgitation (MR) in the setting of atrial fibrillation (AF) and/or heart failure with preserved ejection fraction (HFpEF) as a distinct type of secondary MR, holding prognostic significance. However, evidence on its prevalence is still scarce, especially in the phenotype of mid-range ejection fraction heart failure (HFmEF). Purpose The aim of this study is to evaluate the occurrence of left atrial (LA) enlargement and MR in AF patients with or without heart failure with preserved or mid-range ejection fraction. Methods This retrospective study included 750 consecutive patients with AF admitted to a tertiary hospital from January 2018 to June 2019. We excluded patients with primary valvular disease and HF with reduced EF. MR presence and severity were assessed by evaluating the valve morphology, colour flow imaging and, when feasible, vena contracta and PISA methods. We measured LA anteroposterior diameter and used LA dilatation as a surrogate marker for mitral annulus dilatation. Results We evaluated 584 AF patients: mean age 72.22 ± 10.10 years; 58,73% females; 79.75% had HF: 73.13% of them had HFpEF and 26.87% had HFmEF. Compared to those without HF, patients with HF had a relative risk (RR) of associating LA enlargement of 5.37 (95%CI = 3.05-9.48, p &amp;lt; 0.001) and a RR of associating MR of 1.47 (95%CI 1.08-2.00, p = 0.01). Mean LA diameter was higher in the HF group, compared to non-HF (47.06 ± 7.26 mm vs 40.91 ± 7.10 mm, p &amp;lt; 0.001). MR severity was more likely associated with HF (RR = 1.68, 95%CI = 1.46-1.94, p &amp;lt; 0.001). When comparing results between the two HF subgroups, patients with HFmEF had a higher mean LA diameter than those with HFpEF (48.52 ± 5.68 mm vs 46.36 ± 7.57 mm, p = 0.011), without associating a significant difference in the MR prevalence (72.97% vs 73.98%, p = 0.94). The presence of a dilated LA was directly correlated with MR in the HF group (RR = 1.94, 95%CI = 1.18-3.20, p = 0.023), but not in those without HF (RR = 1.04, 95%CI = 0.57-1.90, p = 0.89). In HF patients, permanent AF associated the highest prevalence of LA dilatation (96.67%) and MR (81.73%) in contrast to paroxysmal AF (81.10%, p &amp;lt; 0.01, respectively 63.43%, p = 0.0002). Conclusions LA dilatation, the presence and severity of MR correlated with AF and HF, especially in permanent AF patients. In patients without HF, LA dilatation did not correlate with the presence of MR. MR prevalence was similar in patients with HFmEF and HFpEF, irrespective of a higher degree of LA dilatation in HFmEF. Our results suggest that the pathophysiological mechanisms involved in LA enlargement and MR are different for different phenotypes of AF in patients with or without HF.

How, When, and Why: High-Density Mapping of Atrial Fibrillation.

High-density (HD) mapping presents opportunities to enhance delineation of atrial fibrillation (AF) substrate, improve efficiency of the mapping procedure without sacrificing safety, and afford new mechanistic insights regarding AF. Innovations in hardware, software algorithms, and development of novel multielectrode catheters have allowed HD mapping to be feasible and reliable. Patients to particularly benefit from this technology are those with paroxysmal AF in setting of preexisting atrial scar, persistent AF, and AF in the setting of complex congenital heart disease. The future will bring refinements in automated HD mapping including evolution of noncontact methodologies and artificial intelligence to supplant current techniques.