Atrial Fibrillation Relapse Research Articles

Echocardiographic Assessment of Left Atrial Mechanics in Patients with Atrial Fibrillation Undergoing Electrical Cardioversion: A Systematic Review.

Background: To date, only a few studies have evaluated left atrial (LA) mechanics in patients with atrial fibrillation (AF) scheduled for electrical cardioversion (ECV). The present systematic review has been primarily designed to summarize the main findings of these studies and to examine the overall effect of AF on left atrial reservoir strain (LASr) in patients undergoing ECV. Methods: All the echocardiographic studies evaluating the effect of AF on LA mechanics in patients scheduled for ECV, selected from the PubMed and EMBASE databases, were included. There was no limitation of time period. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: The full texts of 12 studies with 880 AF patients were analyzed. The pooled ECV success rate was 91.5% (range 65.8-100%). Over a median follow-up of 5.4 months (range 0.3-12 months), 35.2% of the patients (range 5-68.8%) experienced AF recurrence. At baseline, the average LASr was 11.4% (range 6.2-17.7%). A reduced LASr before ECV was strongly correlated with reduced left atrial appendage (LAA) flow velocities and/or thrombosis. The main independent predictors of cardioversion failure were impaired LASr and previous AF history. A severe LASr deterioration was independently correlated with AF recurrence after ECV. The other independent predictors of AR relapses were LA asynchrony, reduced difference between post- and pre-ECV LASr, and reduced right atrial reservoir strain. Conclusions: LASr assessment before ECV may provide useful prognostic information about AF relapses and improve the refinement of the thromboembolic risk of AF patients scheduled for ECV.

DC cardioversion of atrial fibrillation

Direct current (DC) cardioversion is an everyday clinical procedure used to restore sinus rhythm from atrial fibrillation. This review summarises the current state of art in Denmark. Sufficient anticoagulation must be ensured before DC cardioversion to reduce the risk of thromboembolism. Biphasic maximum energy shocks delivered via anterolateral electrodes are recommended. Overall success is high, and the complication rate is low. Relapse of atrial fibrillation is common, and a long-term treatment strategy which may include antiarrhythmics, ablation and lifestyle change should be established in collaboration with the patient.

Catheter ablation for atrial fibrillation and impact on clinical outcomes.

Catheter ablation is the most effective rhythm-control option in patients with atrial fibrillation (AF) and is currently considered an option mainly for improving symptoms. We aimed to assess the impact of catheter ablation on hard clinical outcomes. We performed a systematic review of randomized controlled trials (RCTs) comparing catheter ablation vs. optimized medical treatment. We searched MEDLINE, EMBASE, and CENTRAL on 8 January 2024, for trials published ≤10 years. We pooled data through risk ratio (RR) and mean differences (MDs), with 95% confidence interval (CI), and calculated the number needed to treat (NNT). Sub-group and sensitivity analyses were performed for the presence/absence of heart failure (HF), paroxysmal/persistent AF, early ablation, higher/lower quality, and published ≤5 vs. >5 years. Twenty-two RCTs were identified, including 6400 patients followed for 6-52 months. All primary endpoints were significantly reduced by catheter ablation vs. medical management: all-cause hospitalization (RR = 0.57, 95% CI 0.39-0.85, P = 0.006), AF relapse (RR = 0.48, 95% CI 0.39-0.58, P < 0.00001), and all-cause mortality (RR = 0.69, 95% CI 0.56-0.86, P = 0.0007, NNT = 44.7, driven by trials with HF patients). A benefit was also demonstrated for all secondary endpoints: cardiovascular mortality (RR = 0.55, 95% CI 0.34-0.87), cardiovascular (RR = 0.83, 95% CI 0.71-0.96), and HF hospitalizations (RR = 0.71, 95% CI 0.56-0.89), AF burden (MD = 20.6%, 95% CI 5.6-35.5), left ventricular ejection fraction (LVEF) recovery (MD = 5.7%, 95% CI 3.5-7.9), and quality of life (MLHFQ, AFEQT, and SF-36 scales). Catheter ablation significantly reduced hospitalizations, AF burden, and relapse, and improved quality of life. An impact on hard clinical outcomes, with an important mortality reduction and improvement in LVEF, was seen for patients with AF and HF.

Association of iron deficiency anemia with the development of paroxysms of atrial fibrillation within a year after pharmacological cardioversion with amiodarone

BACKGROUND: Anemia is a common problem with atrial fibrillation. There is a limited number of studies examining the role of iron deficiency anemia in the course of atrial fibrillation. AIM: To evaluate the association of iron deficiency anemia with the development of recurrent atrial fibrillation within 12 months in patients after pharmacological cardioversion with amiodarone. MATERIAL AND METHODS: The study included 198 patients over 18 years of age [120 (60.6%) men and 78 (39.4%) women, median age 71 (63.2; 77) years] with paroxysmal non-valvular atrial fibrillation and duration of paroxysm 48 h, after successful pharmacological cardioversion with amiodarone. The group with anemia included 99 patients (all had iron deficiency anemia), the group without anemia included 99 people. Patients with anemia were older; the groups were comparable in other main indicators. The development of recurrent atrial fibrillation over 1 year of follow-up was assessed by the Kaplan–Meier method and the Cox proportional hazards model. Differences were considered statistically significant at a p value 0.05. RESULTS: In the iron deficiency anemia group, symptomatic relapses of atrial fibrillation developed in 40.4% of patients during 1 year of observation; in the group without anemia — in 25.3% of patients (p=0.003). Kaplan–Meier analysis showed that iron deficiency anemia is associated with an increased risk of developing recurrent atrial fibrillation within 1 year after pharmacological cardioversion with amiodarone, relative risk 1.87 (p=0.014). Comparison of the risks associated with iron deficiency anemia and iron deficiency (regardless of the presence of anemia) showed a greater risk of recurrent atrial fibrillation associated with iron deficiency than with anemia (for interaction p=0.014). CONCLUSION: A comparison of the risks of developing recurrent atrial fibrillation in patients with iron deficiency itself and in patients with iron deficiency anemia showed a greater influence on the prognosis of recurrent atrial fibrillation by the presence of iron deficiency.

Left atrial wall thickness measured by a machine learning method predicts AF recurrence after pulmonary vein isolation

Abstract Background Left atrial (LA) remodeling plays a significant role in the progression of atrial fibrillation (AF). Although LA wall thickness (LAWT) has emerged as an indicator of structural remodeling, its impact on AF outcomes remains unclear. We aimed to determine the association between LAWT and AF recurrence after pulmonary vein isolation (PVI). Methods Single-center registry of patients enrolled for radiofrequency PVI from 2016 to 2018. In all cases, a pre-ablation CT scan was performed within less than 48 hours. Mean LAWT was retrospectively determined by a semi-automated machine learning method with minimal human intervention (ADAS 3D®). Additionally, regional tissue thickness was assessed in four locations: roof and inferior, posterior, and anterior walls. In a subgroup of patients, a pre-ablation cardiac magnetic resonance (CMR) was also performed within the same week. LA functional parameters and fibrosis, using 3D delayed gadolinium enhancement, were analyzed. The primary endpoint was AF recurrence after a 3-month blanking period. Results A total of 439 patients (mean age 61±12years, 62% male, 78% with paroxysmal AF) were included. The mean LAWT was 1.4±0.2mm (ranging from 0.9 to 1.9mm). Software processing duration was 8.2±0.4 min, and the mean human input time was 1.3±0.1 min. There was no correlation between LAWT and CT-derived LA-indexed volume (Spearman –0.01, p=0.845). During a median follow-up of 5.8 (IQR 4.9–6.6) years, 238 patients (54%) had an AF relapse. LAWT was an independent predictor of recurrence, after adjusting for known confounders including age, non-paroxysmal AF, LA-indexed volume, and chronic kidney disease (adjusted HR 6.49 [95% CI 2.70-15.49], p&amp;lt;0.001). AF recurrence rates were 11%, 15%, and 21%/year across terciles of increasing LAWT (log-rank p&amp;lt;0.001) – Figure. The posterior LAWT revealed the strongest association with the study endpoint (HR 1.93 [95% CI 1.24-3.02], p=0.004). In the cohort of 62 patients with both CT and CMR, LAWT showed weak correlations with LA ejection fraction and LA coupling index (Spearman &amp;lt;0.25; p=0.054 and p=0.093, respectively), and a moderate correlation with LA fibrosis (Spearman 0.468; p&amp;lt;0.001). Conclusions Mean LAWT, easily assessed by commercially available machine learning software, is an independent predictor of AF recurrence after PVI in the long-term follow-up. This association is mainly driven by the posterior LAWT. Whether patients with increased LAWT should receive tailored therapy deserves further investigation.Figure

Pulmonary Vein Isolation in Elderly Patients ≥ 75 Years: A Propensity Score-Matched Analysis With Focus on Differences Among Atrial Fibrillation Types

BackgroundAge is a major risk factor for development of atrial fibrillation (AF) and associated with increased recurrence rates in the setting of rhythm control. Current data tend to support catheter ablation in elderly patients, but uncertainties exist regarding efficacy and safety of ablation in elderly patients. MethodsThis was a prospective single-centre observational study with propensity score matching (PSM) to investigate the influence of age on efficacy and safety of cryoballoon ablation (CBA) stratified by age (< 75 years vs ≥ 75 years) and AF phenotype (paroxysmal vs persistent). Primary efficacy endpoint was recurrence of atrial arrhythmia after a 90-day blanking period. Safety endpoints were death, stroke, or procedure-associated complications. ResultsConsecutive patients (n = 953) underwent CBA for first-time AF ablation. Median follow-up was 18 months. By means of PSM, 268 matches were formed. At 1 year, primary efficacy endpoint occurred in 22.4% of young vs 33.2% of elderly patients, including both AF phenotypes (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.47-0.90; P = 0.01). AF relapse occurred in 19.7% of young vs 28.5% of elderly patients with paroxysmal (HR, 0.63; 95% CI, 0.40-0.99; P = 0.046) compared with 25.9% (30 of 116, young) vs 38.8% (45 of 116, elderly) patients with persistent AF (HR, 0.62; 95% CI, 0.39-0.97; P = 0.038). No difference was observed regarding the incidence of safety endpoints between young and elderly patients (P = 0.38). ConclusionsCBA is associated with higher recurrence rates in elderly (≥ 75 years) than in younger patients, with highest recurrence rates in elderly patients with persistent AF.

Вопросы безопасности антиаритмической терапии при фибрилляции предсердий

The article discusses the safety of antiarrhythmic therapy for atrial fibrillation in the light of the development of cardiac and non-cardiac side effects, the presence of drug-drug interactions of antiarrhythmic drugs in the near (with anticoagulants) and far circle. The features of the choice of antiarrhythmic therapy for the prevention of relapses of atrial fibrillation, restoration of sinus rhythm, as well as heart rate control are presented, and aspects of the tactics of managing these patients are highlighted.

Amiodarone prevention for atrial fibrillation relapse after surgical ablation

Background: Atrial fibrillation (AF) is the most common heart rhythm disorder. AF ablation based on endovascular or surgical techniques is a standard of care in everyday practice. Early recurrence of atrial arrhythmias is a significant problem after ablative procedures. Prophylactic use of antiarrhythmic drugs has become a possible solution. Materials and methods: We performed a retrospective observational cohort study of 59 patients with heart disease requiring surgery under extracorporeal circulation (ECC) and have received radiofrequency ablation (RFA) for chronic or persistent AF with a successful conversion to sinus rhythm. Patients were divided into two groups: 36 were treated with amiodarone for three months postoperatively (treatment group), and 23 had no concomitant amiodarone therapy (control group). We compared the groups regarding freedom from recurrent atrial arrhythmia and the frequency of conduction disorders requiring permanent pacemaker implantation. Results: No differences between the groups were found regarding demographic characteristics, risk profile, and heart diseases indicating cardiac surgery. During follow-up, a significantly higher proportion of patients with sinus rhythm in the group receiving amiodarone was found (80.56% vs. 52.17%; p &amp;lt; 0.041). No cases of premature discontinuation of amiodarone for side effects or noncompliance were registered in the treatment group. Conclusion: Three months of amiodarone therapy post-surgical RFA of AF is an effective and safe strategy for relapse prevention.

Quantification of epicardial adipose tissue by computed tomographic scanning as a prognostic criterion of atrial fibrillation recurrence after catheter ablation.

Aim This study focused on a systematic review and meta-analysis on the predictive role of quantifying the epicardial adipose tissue (EAT) volume using data of computed tomography (CT) in patients after catheter ablation for atrial fibrillation (AF).Material and methods We performed a search in PubMed and Google Scholar for studies that examined the predictive value of EAT volume measured by CT for AF recurrence in patients after undergoing pulmonary venous isolation. Risk ratio (RR) values from studies, where similar scoring criteria were available, were pooled for the meta-analysis.Results Eighteen studies were selected from 901 publications for these systematic review and meta-analysis. In total, 4087 patients were included in this analysis (mean age, 59.0 years; mean follow-up duration, 14.9 mos). Patients with recurrent AF after ablation had higher left atrial EAT volume compared to patients without relapse (weighted mean difference, 5.99 ml; 95% CI: -10.04 to -1.94; p = 0.004). An increase in left atrial EAT volume per ml was significantly associated with the development of AF recurrence after ablation (RR 1.08; 95% CI: 1.01 to 1.16; p=0.03). Patients with recurrent AF after ablation also had higher total EAT values than patients without relapse (difference in weighted values, 11.67 ml; 95% CI: -19.81 to -3.54; p = 0.005). However, no significant association was found between the total EAT volume and the risk of AF relapse (RR 1.00; 95% CI: 1.00 to 1.01; p=0.06).Conclusions The volume of left atrial EAT measured by CT has a significant predictive value in AF patients after catheter ablation and can be used for stratification of the risk for recurrent AF.

Efficacy of different variants of endocardial balloon cryoablation in patients with persistent atrial fibrillation

Aim. To study the effectiveness of “extended” cryoballon ablation in patients with a persistent form of atrial fibrillation (AF) and to determine the risk factors for AF recurrence after cryoablation.Methods. The study included 89 patients (62±10 years, 24 [27%] men) with a persistent form of AF. The patients were randomized into two groups: in the 1st, the pulmonary veins (PV) cryoablation was performed (n=48 [53.9%]); in the 2nd, the PV cryoablation was performed in combination with cryoablation of the posterior wall of the left atrium (n=41 [46.1%]). The number of patients at high risk of thromboembolic events predominated in Group 2 (p=0,03). There is a high frequency of taking antiarrhythmic drugs of class III in this group (p=0.018). The follow-up period was 12 months. Clinical efficacy was assessed during a survey and daily ECG monitoring at face-to-face visits after 3, 6 and 12 months.Results. Antral isolation of PV was achieved in all 89 (100%) patients in both groups. In group 2, the average number of applications in the posterior wall of the PV was 10 [9; 13]. The effectiveness of cryoablation in group 1 by the end of the 12-month follow-up period was 54.2%, in group 2 - 56.1%. The complication rate (6.7%) in both groups did not differ statistically (p=0.683). The risk of arrhythmia recurrence didn’t depend on the strategy of cryoablation in postablation period (p=0.834). When conducting a single-factor analysis, a statistically significant effect on the probability of AF recurrence in the period of 3-12 months in group 1 was caused by AF recurrence in the blind period (95% confidence interval (CI): 1.5-27.7, p=0.013), in group 2 belonging to the female sex (95% CI: 1.2-24.6, p=0.032) and AF relapse in the blind period (95% CI: 1.5-128.5, p=0.020). During multivariate analysis in group 2, a statistically significant influence on the risk of AF recurrence in the period of 3-12 months was exerted by belonging to the female sex (hazard ratio (HR) 7.84; 95% CI 1478-42,23; p=0.016) and the presence of early AF recurrence (HR 20.36; 95% CI 1.99-208.23; p=0.011).Conclusion. Extended cryoablation in terms of efficiency and safety was comparable with the standard cryoablation. Early recurrence of AF (in the first 3 months after the intervention) turned out to be an independent risk factor for AF recurrence in the long-term period up to 12 months after cryoablation in both groups.

Long-Term Follow-Up In Paroxysmal Atrial Fibrillation Patients With Documented Isolated Trigger.

Supraventricular tachycardias may trigger atrial fibrillation (AF). The aim of the study was to evaluate the prevalence of supraventricular tachycardia (SVT) inducibility in patients referred for AF ablation and to evaluate the effects of SVT ablation on AF recurrences. 249 patients (mean age: 54 ± 14 years) referred for paroxysmal AF ablation were studied. In all patients, only AF relapses had been documented in the clinical history. 47 patients (19%; mean age: 42 ± 11 years) had inducible SVT during the electrophysiological study and underwent an ablation targeted only at SVT suppression. Ablation was successful in all 47 patients. The ablative procedures were: 11 slow-pathway ablations for atrioventricular nodal re-entrant tachycardia; 6 concealed accessory pathway ablations for atrioventricular re-entrant tachycardia; 17 focal ectopic atrial tachycardia ablations; 13 with only one arrhythmogenic pulmonary vein. No recurrences of SVT were observed during the follow-up (32 ± 18 months). 4 patients (8.5%) showed recurrence of at least one episode of AF. Patients with inducible SVT had less structural heart disease and were younger than those without inducible SVT. A significant proportion of candidates for AF ablation are inducible for an SVT. SVT ablation showed a preventive effect on AF recurrences. Those patients should be selected for simpler ablation procedures tailored only to the triggering arrhythmia suppression.

Comparative Efficacy and Safety Profiles of High-power, Short-duration and Low-power, Long-duration Radiofrequency Ablation in Atrial Fibrillation: A Systematic Review and Meta-analysis.

High-power, short-duration (HPSD) radiofrequency (RF) ablation is expected to be more effective and safer than low-power, long-duration (LPLD) RF ablation in treating atrial fibrillation (AF). Given the limited data available, the findings are controversial. This meta-analysis evaluated whether the clinical effects of HPSD outweigh those of LPLD. A systematic search of PubMed, Embase, and Google Scholar databases identified studies comparing HPSD to LPLD ablation. All the analyses used the random-effects model. This analysis included 21 studies with a total of 4,169 patients. Pooled analyses revealed that HPSD was associated with a lower recurrence of atrial tachyarrhythmias (ATAs) at 1 year (relative risk [RR], 0.62; 95% confidence interval [CI], 0.50-0.78; P = .00001; I2 = 0%). Furthermore, the HPSD approach reduced the risk of AF recurrence (RR, 0.64; 95% CI, 0.40-1.01; P = .06; I2 = 86%). The HPSD approach was associated with a lower risk of esophageal thermal injury (ETI) (RR, 0.78; 95% CI, 0.58-1.04; P = .09; I2 = 73%). The HPSD strategy increased first-pass pulmonary vein (PV) isolation (PVI) and decreased acute PV reconnection (PVR), both of which were predominantly manifested in bilateral and left PVs. HPSD facilitated a reduction in procedural time, number of lesions created during PVI, and fluoroscopy time. The HPSD method reduces ETI, PVR, and recurrent AF. The HPSD approach also reduced the procedural time, number of lesions created during PVI, fluoroscopy time, and post-ablation AF relapse in 1 year, improving patient outcomes and safety.

Right ventricular to pulmonary artery coupling change after catheter ablation of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Right ventricular (RV) to pulmonary artery (PA) coupling can be assessed using the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP). Although its use has been widely adopted in clinical practice, less is known about its role in patients with atrial fibrillation (AF) and its change after catheter ablation. Purpose The aim of this study is to assess the changes and the clinical impact of RV-PA coupling in patients with AF who underwent catheter ablation. Methods This is a prospective study that enrolled patients undergoing catheter ablation for AF between March 2021 and September 2022 in three tertiary centers in Italy. We evaluated the changes in RV structure and function and TAPSE/PASP between baseline and the 3-month follow-up and their relation with AF relapse after procedure. Results A total of 135 patients were included (mean age 65.2 ± 9.1 years; 68% males, mean left ventricular ejection fraction [LVEF] 56.9 ± 7.9%). Patients in the lowest tertile (TAPSE/PASP &amp;lt; 0.67 mm/mmHg) were older, with and LVEF and LV global longitudinal strain (LVGLS). They also showed lower TAPSE, S’ wave at Tissue Doppler and RV global strain and higher PASP. In the overall population, after 3 months from the ablation procedure, we observed a significant increase of TAPSE (from 22.4 ± 4.1 to 24.0 ± 3.8, p &amp;lt; 0.001), a reduction of PASP (from 29.5 ± 6.6 to 27.9 ± 7.7, p = 0.030) and an increase in TAPSE/PASP from 0.81 ± 0.27 to 0.93 ± 0.29 (p &amp;lt; 0.001). The latter improved both in the patients who were in sinus rhythm (p = 0.031) and with AF (p = 0.003) at baseline. Compared to patients in the highest TAPSE/PASP tertile, those in the lowest one (TAPSE/PASP &amp;lt; 0.67 mm/mmHg) showed an increased risk of AF relapse after catheter ablation (OR 4.33, 95% confidence interval 1.25 – 14.96, p = 0.020). Moreover, the increase of TAPSE/PASP ratio during the follow-up period was associated with a reduced probability of AF relapse, after adjustment for covariates (OR 0.70, 95% confidence interval 0.49 – 0.99, p = 0.046). Conclusion In a multicenter cohort of patients with AF undergoing catheter ablation, a significant improvement of RV-PA coupling, assessed by the TAPSE/PASP ratio, has been observed, regardless of rhythm at admission. Moreover, TAPSE/PASP at baseline, and its change, may represent a useful parameter to predict AF relapse after the procedure.

Incremental Value of Right Atrial Strain Analysis to Predict Atrial Fibrillation Recurrence After Electrical Cardioversion

Although the assessment of left atrial (LA) mechanics has been reported to refine atrial fibrillation (AF) risk prediction, it doesn't completely predict AF recurrence. The potential added role of right atrial (RA) function in this setting is unknown. Accordingly, this study sought to evaluate the added value of RA longitudinal reservoir strain (RASr) for the prediction of AF recurrence after electrical cardioversion (ECV). We retrospectively studied 132 consecutive patients with persistent AF who underwent elective ECV. Complete two-dimensional and speckle-tracking echocardiography analyses of LA and RA size and function were obtained in all patients before ECV. The end point was AF recurrence. During a 12-month follow-up, 63 patients (48%) showed AF recurrence. Both LASr and RASr were significantly lower in patients experiencing AF recurrence than in patients with persistent sinus rhythm (LASr, 10%±6% vs 13%±7%; RASr, 14%±10% vs 20%±9%, respectively; P<.001 for both). Right atrial longitudinal reservoir strain (area under the curve=0.77; 95% CI, 0.69-0.84; P<.0001) was more strongly associated with the recurrence of AF after ECV than LASr (area under the curve=0.69; 95% CI, 0.60-0.77; P<.0001). Kaplan-Meier curves showed that patients with both LASr ≤ 10% and RASr ≤ 15% had a significantly increased risk for AF recurrence (log-rank, P<.001). However, at multivariable Cox regression, RASr (hazard ratio, 3.26; 95% CI, 1.73-6.13; P<.001) was the only parameter independently associated with AF recurrence. Right atrial longitudinal reservoir strain was more strongly associated with the occurrence of AF relapse after ECV than LASr, and LA and RA volumes. Right atrial longitudinal reservoir strain was independently and more strongly associated than LASr with AF recurrence after elective ECV. This study highlights the importance of assessing the functional remodeling of both the RA and LA in patients with persistent AF.

Role of the implantable loop recorder in clinical practice: insights on indications, diagnostic yield and therapeutic implications from a single, high volume, tertiary care centre experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Besides the established class I indication for the evaluation of patients with recurrent syncope of uncertain origin, implantable loop recorders (ILRs) have been increasingly used for other diagnostic purposes (e.g. detection of atrial fibrillation (AF) following cryptogenic stroke). Purpose To describe the main indications to ILR and to investigate procedural parameters, outcomes and diagnostic yield of ILR in a single, high-volume tertiary care centre. Methods All patients undergoing ILR implantation between November 2007 and April 2022 were consecutively enrolled in this study. Clinical characteristics of patients, procedural data and outcomes were collected. The indications to ILR implantation were divided into four categories: 1) AF detection in patients with recent cryptogenic stroke or peripheral thromboembolism [CRYSP], 2) recurrent syncope of uncertain origin [RSUO], 3) monitoring of ventricular arrhythmic events [VAE] in patients with predisposing cardiomyopathy/channelopathy, 4) monitoring of AF burden or relapse [AFB]. The main endpoint of the study was the diagnostic yield (number of definitive diagnoses made) and the time to diagnosis following ILR implantation. The occurrence of acute or subacute complications was used as a secondary safety endpoint. Results Overall, 1442 patients underwent ILR implantation (mean age 65 years, 43% female). The two main indications to ILR were AF detection following CRYSP and RSUO (42% and 34% of all implantations respectively, table 1). The commonest site of implantation was the left parasternal position (902 patients, 63%), median procedural time was 20 minutes (IQR 15-25). During a median follow-up of 397 days (134-1094), infections requiring ILR extraction or pocket revision occurred in 13 patients (0.9%). A definitive diagnosis was achieved in 500 (35%) patients after a median time of 206 days (IQR 60-533) [table 1 shows details and action taken following diagnosis for each indication subgroup]. At multivariable analysis, age and PR interval duration were significantly associated with the need for PM/ICD implantation among patients receiving ILR for RSUO whilst age was associated with AF detection among those with CRYSP (table 2). Conclusions In this cohort of patients use of ILR was associated with a good diagnostic yield regardless of the initial indication, triggered timely therapeutic actions and was overall safe.

Biomarkers of Atrial Fibrillation Recurrence in Patients with Paroxysmal or Persistent Atrial Fibrillation Following External Direct Current Electrical Cardioversion.

Atrial fibrillation (AF) is associated with atrial remodeling, cardiac dysfunction, and poor clinical outcomes. External direct current electrical cardioversion is a well-developed urgent treatment strategy for patients presenting with recent-onset AF. However, there is a lack of accurate predictive serum biomarkers to identify the risks of AF relapse after electrical cardioversion. We reviewed the currently available data and interpreted the findings of several studies revealing biomarkers for crucial elements in the pathogenesis of AF and affecting cardiac remodeling, fibrosis, inflammation, endothelial dysfunction, oxidative stress, adipose tissue dysfunction, myopathy, and mitochondrial dysfunction. Although there is ample strong evidence that elevated levels of numerous biomarkers (such as natriuretic peptides, C-reactive protein, galectin-3, soluble suppressor tumorigenicity-2, fibroblast growth factor-23, turn-over collagen biomarkers, growth differential factor-15) are associated with AF occurrence, the data obtained in clinical studies seem to be controversial in terms of their predictive ability for post-cardioversion outcomes. Novel circulating biomarkers are needed to elucidate the modality of this approach compared with conventional predictive tools. Conclusions: Biomarker-based strategies for predicting events after AF treatment require extensive investigation in the future, especially in the presence of different gender and variable comorbidity profiles. Perhaps, a multiple biomarker approach exerts more utilization for patients with different forms of AF than single biomarker use.

PO-02-164 VALUE OF CARDIONEUROABLATION WITH VAGAL DENERVATION CONFIRMED BY VAGUS NERVE STIMULATION ON PULMONARY VEIN ISOLATION FOR ATRIAL FIBRILLATION CATHETER ABLATION

Despite good results, Atrial fibrillation(AF) ablation shows a relatively high recurrence rate. Therefore, we sought to verify whether endocardial denervation by cardioneuroablation(CNA) can change the AF recurrence post-pulmonary vein isolation(PVI). To compare the long-term AF recurrence post-PVI versus PVI plus vagal denervation (PVI+CNA) by CNA with vagal denervation confirmation by extracardiac vagal stimulation(ECVS). Case-control study of 127 patients, 104(81.9%) males, 53.7±12 years-old, with paroxysmal 71(55.9%) or persistent 56(44.1%) symptomatic AF, refractory to medications without cardiopathy, LA=39.8±6.8, EF=0.66±0.55. Two equivalent groups were established: PVI alone (55 cases) and PVI+CNA (72 cases). The ECVS was performed by intravenous catheter, near the jugular foramen with 50Hz/50microsec/1V/Kg/up to 70V. Endocardial CNA was biatrial over the four main ganglionated plexus and in the AF-Nests regions tagged by fractionation software. The endpoint of CNA was the elimination of the vagal effect induced by ECVS. PVI was achieved in all cases. ECVS effectively induced a vagal reaction in all PVI+CNA patients, and it was possible to eliminate the vagal effect in 88.9% of cases. In 11.1%, there was a slight residual vagal response. Patients were followed up to 45 months (mean FU=21.4±14.2 and 20.4 ± 14.3 months). Recurrences were 17 in the PVI group, and 4 in the PVI+CNA group: Log-Rank p<0.00, HR:5.38(1.78-16.29,p=0.003). No significant complications occurred. The addition of vagal denervation to PVI, with validation of the vagal denervation by ECVS, significantly increased the success rate of the PVI with a marked reduction in AF relapses without increasing complications.

Association between weight loss and outcomes in patients undergoing atrial fibrillation ablation: a systematic review and dose–response meta-analysis

BackgroundObesity is an strong risk factor for atrial fibrillation (AF), and obesity can affect the prognosis of AF. However, the role of weight loss on outcomes after ablation remains unclear.ObjectivesThis study aims to determine the relationship between weight loss and outcomes in patients with AF ablation, as well as the potential dose–response relationship.MethodsThe Cochrane Library, PubMed, and Embase databases were searched to identify studies that reported a relationship between weight loss and ablation up to August 17, 2021. Relative risks (RRs) were pooled using random-effects models.ResultsOne randomized, open-labeled clinical trial and seven cohort studies involving 1283 patients were included. The mean body mass index of all included studies was over 30 kg/m2. The clinical trial showed a non-significant benefit of weight loss intervention on AF recurrence (Odd risk [OR] = 1.02, 95% confidence interval [CI] 0.70–1.47). Meta-analysis based on observational studies showed that the recurrence rate of AF after ablation was significantly reduced (RR = 0.43, 95% CI 0.22–0.81, I2 = 97%) in relatively obese patients with weight loss compared with the control group. Each 10% reduction in weight was associated with a decreased risk of AF recurrence after ablation (RR = 0.54, 95% CI 0.33–0.88) with high statistical heterogeneity (I2 = 76%). An inverse linear association (Pnon-linearity = 0.27) between AF relapse and increasing weight loss was found.ConclusionsOur results first suggest an inverse dose–response association between weight loss and risk of recurrent AF after ablation, with moderate certainty.Graphical

587 LEFT ATRIAL APPENDAGE OCCLUSION: A REAL SOLUTION TO CARDIOEMBOLIC RISK OF ATRIAL FIBRILLATION?

Abstract 82-year-old woman comes to our clinical observation for worsening exertional dyspnea, with ECG evidence of atrial fibrillation (AF) with high ventricular response. Past medical history: previous right breast carcinoma treated in 1998 with quadrantectomy, radiotherapy and hormone therapy. Previous ischemic transitory attack. Hypertension. Dyslipidemia. The patient reports the first episode of paroxysmal AF in 2016, for which anticoagulant therapy with new oral anticoagulants NOACs was started for CHA2DS2VASc=6. During anticoagulant therapy episode of ocular haemorrhage for which the patient discontinued therapy with NOACs and used low-molecular-weight heparin LMWH "as needed" in the course of arrhythmic relapses. In July and August 2019 relapses of symptomatic paroxysmal AF. Multiple attempts to take different anticoagulants (Rivaroxaban, Edoxaban) poorly tolerated. The patient undergoes catheter ablation by isolation of the pulmonary veins (considered first line according to ESC guidelines for the control of symptoms in patients with paroxysmal AF) and percutaneous left atrial appendage occlusion (LAAO), with indication of anticoagulation therapy for at least 4 weeks after the procedure (Apixaban 2.5 mg bid, reduced dose due to the presence of age&amp;gt;80 years and weight&amp;lt;60 kg). At the entrance to our hospital, an ECG is performed with a finding of total arrhythmia from AF with a high ventricular response (HR 130 bpm), conducted with left bundle branch block (LBBB); cardiac echo-Doppler ultrasound is performed with a slight reduction in left ventricular systolic function (EF 45%), second degree diastolic dysfunction with increased filling pressures, moderate mitral valve insufficiency, severe left atrial dilatation (LAVi 125 ml/m2), moderate tricuspid valve insufficiency with moderate pulmonary arterial hypertension (PAPS 55 mmHg), right atrial dilatation, circumferential pericardial detachment, dilated inferior vena cava hyporeactive with breath acts. At blood tests: BNP 1022 pg/ml, sodium 145 mmol/l, potassium 3.5 mmol/l, creatinine 1.17 mg/dl with eGFR 43 ml/min/1.73mq. Rate control therapy with ß-blockers and Digoxin and diuretic therapy with Furosemide and Canrenone is set, with improvement of symptoms and clinical conditions. Anticoagulant therapy with LMWH is also undertaken but the patient shows poor adherence. After home discharge, the patient goes back to the emergency room for dyspnea. Further cardiac echo-Doppler ultrasound is performed with evidence of thrombotic formation in the left atrium of the size of 30×25 mm. Therapeutic dosage LMWH therapy is started with subsequent Warfarin embrication according to INR, obtaining complete resolution of the thrombotic formation. A systematic review of device-related thrombosis (DRT) after left atrial appendage occlusion (LAAO) proved that the overall incidence of DRT was 3.9% and the median time from procedure to diagnosis of DRT was 1.5 months. According to currently reported cases, most DRTs occur within one year after LAAO. This particular clinical case of DRT three years after LAAO underlines the importance of accurate assessment of the patient's risk profile: LAAO is a valid alternative to anticoagulant therapy in patients at high risk of bleeding but with low embolic risk profile. It's known that high CHA2DS2VASc values ​​and reduced cardiac function are recognized risk factors for thrombus formation, such as patient compliance with antithrombotic therapy. Surely additional studies are needed to determine if the current practice of antithrombotic regimens and duration after LAAO is sufficient.

984 ARRHYTHMOGENIC DYSPLASIA: JUST A PROBLEM OF THE YOUNG?

Abstract Arrhythmogenic dysplasia is a disease of genetic aetiology characterised by the progressive replacement of functioning myocardium by fibro-adipose tissue with high arrhythmogenic potential, as well as by morpho-functional impairment. Molecular genetic studies have revealed a deficiency of demosomal proteins such as placoglobin, desmoglein, desmoplazine, placophylline and desmocollin. It usually begins at a young age and in sports subjects. It mainly affects the right ventricle, although over time it can also affect the left sections due to a biventricular alteration of the heart pump. Forms with major left-sided involvement have been described in the literature, but these are rare. A 73-year-old man, a sportsman with over 40 marathons, presented with an episode of sustained VT during exercise in 2011. Admitted to our hospital, he was diagnosed with arrhythmogenic cardiomyopathy and was subsequently implanted with an ICD-DR mod.Teligen 100F. After 3 months, however, there was a new episode of VT, so it was decided to subject the patient to transcatheter ablation with radiofrequency, using an endocardial approach, which proved ineffective. Two months later, a new attempt at radioablation with an endocardial approach. Due to the persistence of arrhythmic symptoms, sustained VT episodes, in February 2012 it was decided to proceed with a third ablation, but adopting an endo-epicardial approach, with apparent resolution of the symptomatology. After severals episodes of atrial fibrillation, he underwent a new ablation with pulmonary vein isolation and ablation line at the level of the cavo-tricuspid isthmus in August 2020. On echocardiogram, the left ventricle had normal dimensions with upper limit thicknesses, diffuse parietal hypokinesis with markedly reduced EF (30%), dilated right ventricle (DTD 48 mm) with parietal hypertrabeculature and free wall hypokinesis (TAPSE 1.4) and dilated right atrium. In May 2020 new relapse of atrial fibrillation successfully cardioverted, maintenance therapy set up with sotalol. In the literature, mainly forms of arrhythmogenic dysplasia in youth (30 years) have been described, whereas older forms appear to be rare. A search of the Medline database (National Library of Medicine, Bethesda, MD) found 5 cases of ARVD among the elderly; all these patients had died and were diagnosed by histology. The diagnosis is multi-parametric and the main aim of therapy is the prevention of sudden cardiac death. Currently, ICD defibrillator implantation is the only effective therapy for the prevention of sudden death. New drug therapies, radiofrequency ablation and defibrillators are likely to have a favourable impact on the survival of these patients and make it not unlikely that elderly patients with ARVD will be present. The possibility of a late onset of the disease should also be suspected.