Atrial Flutter Research Articles

Comparison of Clinical Outcomes in Patients with Acute Lower Limb Ischaemia Undergoing Endovascular Therapy and Open Surgical Revascularisation: A Large Scale Analysis in Japan

The recommended revascularisation methods for acute limb ischaemia (ALI), which is caused by embolism and atherosclerotic thrombosis, include endovascular therapy (EVT) and open surgical revascularisation (OSR); however, treatment choices based on patient characteristics remain controversial. This retrospective analysis from the Japanese Registry of All Cardiac and Vascular Diseases - Diagnosis Procedure Combination database (April 2012 to March 2020) evaluated differences in clinical outcomes and identified prognostic predictors in patients with ALI. This study analysed 10 977 patients with lower limb ALI. EVT was defined as catheter directed thrombolysis, percutaneous thrombectomy, or percutaneous angioplasty with balloon dilatation and or stenting. OSR was defined as Fogarty thrombectomy, bypass surgery, or thromboendarterectomy. The EVT and OSR groups were compared after propensity score matching (PSM) considering ten clinical covariates. The EVT group had more patients at higher risk of atherosclerotic disease than the OSR group. The OSR group had more patients at a higher risk of embolism, including atrial fibrillation and atrial flutter, than the EVT group. In the EVT group, 20.4% of patients underwent catheter directed thrombolysis using urokinase, the only thrombolytic agent available in Japan that is covered under insurance. After PSM, in hospital mortality (odds ratio [OR] 1.33, 95% confidence interval [CI] 1.11 - 1.59; p = .002), major amputation rate (OR 1.43, 95% CI 1.19 - 1.72; p < .001), major amputation and or death rate (OR 1.42, 95% CI 1.24 - 1.62; p < .001), and total hospitalisation cost (1.16 vs. 0.97 million yen; p < .001) were statistically significantly higher in the EVT group than in the OSR group. In interaction analyses, peripheral artery disease (PAD) was a factor responsible for reducing OSR efficacy in terms of major amputation and or death rate (with PAD, OR 0.94, 95% CI 0.68 - 1.29; without PAD, OR 1.56, 95% CI 1.34 - 1.82; p = .004). In Japan, EVT was a less effective primary treatment for patients with ALI than OSR, except for those with PAD.

Milvexian vs apixaban for stroke prevention in atrial fibrillation: The LIBREXIA atrial fibrillation trial rationale and design

Direct oral anticoagulants are the standard of care for stroke prevention in eligible patients with atrial fibrillation and atrial flutter; however, bleeding remains a significant concern, limiting their use. Milvexian is an oral Factor XIa inhibitor that may offer similar anticoagulant efficacy with less bleeding risk. LIBREXIA AF (NCT05757869) is a global phase III, randomized, double-blind, parallel-group, event-driven trial to compare milvexian with apixaban in participants with atrial fibrillation or atrial flutter. Participants are randomly assigned to milvexian 100 mg or apixaban (5 mg or 2.5 mg per label indication) twice daily. The primary efficacy objective is to evaluate if milvexian is noninferior to apixaban for the prevention of stroke and systemic embolism. The principal safety objective is to evaluate if milvexian is superior to apixaban in reducing the endpoint of International Society of Thrombosis and Hemostasis (ISTH) major bleeding events and the composite endpoint of ISTH major and clinically relevant nonmajor (CRNM) bleeding events. In total, 15,500 participants from approximately 1,000 sites in over 30 countries are planned to be enrolled. They will be followed until both 430 primary efficacy outcome events and 530 principal safety events are observed, which is estimated to take approximately 4 years. The LIBREXIA AF study will determine the efficacy and safety of the oral Factor XIa inhibitor milvexian compared with apixaban in participants with either atrial fibrillation or atrial flutter. ClinicalTrials.gov NCT05757869.

Emergence of Atrial Fibrillation and Flutter in COVID-19 Patients: A Retrospective Cohort Study.

COVID-19 is associated with various cardiovascular complications, including arrhythmias. This study investigated the incidence of new-onset atrial fibrillation (AFB) and atrial flutter (AFL) in COVID-19 patients and identified potential risk factors. We conducted a retrospective cohort study at a tertiary-care safety-net community hospital including 647 patients diagnosed with COVID-19 from March 2020 to March 2021. Patients with a prior history of AFB or AFL were excluded. Data on demographics, clinical characteristics, and outcomes were collected and analyzed using chi-square tests, t-tests, and binary logistic regression. We found that 69 patients (10.66%) developed AFB or AFL, with 41 patients (6.34%) experiencing new-onset arrhythmias. The incidence rates for new-onset AFB and AFL were 5.4% and 0.9%, respectively. Older age (≥65 years) was significantly associated with new-onset AFB/AFL (OR: 5.43; 95% CI: 2.31-12.77; p < 0.001), as was the development of sepsis (OR: 2.73; 95% CI: 1.31-5.70; p = 0.008). No significant association was found with patient sex. Our findings indicate that new-onset atrial arrhythmias are a significant complication in COVID-19 patients, particularly among the elderly and those with sepsis. This highlights the need for targeted monitoring and management strategies to mitigate the burden of atrial arrhythmias in high-risk populations during COVID-19 infection.

Nationwide Trends in Hospitalizations for Atrial Fibrillation and Flutter in the United States before and during the Outbreak of the COVID-19 Pandemic.

Background/Objectives: Atrial fibrillation (AF) and flutter (AFL) are the most common cardiac arrhythmias worldwide. Cardiovascular complications are a common manifestation of acute and post-acute COVID-19 infection. We aimed to analyze the nationwide trends in clinical characteristics and outcomes of patients hospitalized for AF/AFL before and during the COVID-19 outbreak in the U.S. Methods: This study is a retrospective analysis of patients, aged 18 and older, hospitalized for AF/AFL in the U.S. between 2016 and 2020. We drew data from the National Inpatient Sample (NIS) database. Baseline sociodemographic and clinical data, as well as outcomes including stroke, acute coronary syndrome (ACS), and mortality, were analyzed. Multivariable analysis was performed to identify independent associations between the different clinical and demographic characteristics and the composite endpoint of Mortality/ACS/Stroke. Results: An estimated total of 2,163,699 hospitalizations for AF/AFL were identified. The hospitalization volume between 2016 and 2019 was stable, averaging 465,176 a year, followed by a significant drop to 302,995 in 2020. Patients' median age was 72 years (IQR 62-80), 50.9% were male, and 81.5% were white. The composite endpoint steadily increased from 6.5% in 2016 to 11.8% in 2020 (Ptrend < 0.001). In a multivariable regression analysis, age > 75 (OR: 1.35; 95% CI 1.304-1.399, p < 0.001), ischemic heart disease (OR: 1.466; 95% CI: 1.451-1.481; p < 0.001), and chronic kidney disease (OR: 1.635; 95% CI: 1.616-1.653; p < 0.001) were associated with the composite endpoint. COVID-19 was associated with the composite endpoint outcome in the year 2020 (OR: 1.147; 95% CI: 1.037-1.265; p = 0.007). Conclusions: Hospitalization for AF/AFL dropped significantly during the first year of the COVID-19 pandemic outbreak, possibly due to patients' avoidance of hospital visits. The composite endpoint of Mortality/ACS/Stroke uptrended significantly during the study period. COVID-19 was shown to be independently associated with the adverse composite outcome Mortality/ACS/Stroke.

Three-year cardiovascular and non-cardiovascular adverse events in patients with chronic lymphocytic leukemia or small cell lymphocytic lymphoma treated with Bruton tyrosine kinase inhibitors acalabrutinib or ibrutinib: a real-world analysis.

Bruton tyrosine kinase (BTK) inhibitors play an important role in targeted treatment of B-cell lymphoproliferative disorders. However, adverse events may limit the proper course of treatment in many patients. The purpose of this study is to compare the risk of cardiovascular and non-cardiovascular adverse events in patients with chronic lymphocytic leukemia (CLL) or small cell lymphocytic lymphoma (SLL) treated with the first-generation BTK inhibitor ibrutinib versus second-generation acalabrutinib, using real-world data from a collaborative multinational network. We used data from the network (TriNetX), which encompasses more than 100 healthcare organizations worldwide. We queried the database for patients aged ≥ 18 years with chronic lymphocytic leukemia or small-cell lymphomas treated with ibrutinib or acalabrutinib in the past ten years before the analysis. We used propensity score matching to balance the cohorts. The 3-year cumulative incidences and hazard ratios for the following outcomes were calculated: atrial flutter or fibrillation, other arrhythmias, heart failure, ischemic stroke or peripheral embolism, acute coronary syndrome, bleeding, and sepsis. We compared 2,107 patients in each group. Atrial fibrillation or flutter occurred in 150 (7.1%) patients with acalabrutinib and 310 (14.7%) patients with ibrutinib during the 3-year follow-up (hazard ratio, 0.68, 95% CI 0.55-0.84). New-onset hypertension occurred in 342 (16.3%) patients in the acalabrutinib group and 584 (27.7%) patients in the ibrutinib group (hazard ratio 0.81, 95% CI 0.66-0.98). Sepsis was diagnosed in 136 (6.5%) patients in the acalabrutinib group versus 239 (11.3%) patients in the ibrutinib group (hazard ratio 0.77, 95 CI 0.60-0.98). The two groups had no significant differences concerning the other adverse events. In a large retrospective cohort using real-world data from electronic medical registers, patients with CLL or SLL treated with acalabrutinib had a better cardiovascular and non-cardiovascular safety profile than those treated with ibrutinib, with lower risks of atrial flutter or fibrillation, new-onset arterial hypertension, and sepsis.

Outcome after ablation of atypical atrial flutter: Is induction a feasible approach?

BackgroundAtypical atrial flutter (AAF) is an increasingly relevant clinical problem. Despite advancements in mapping and ablation techniques, the general management of these patients remain challenging especially when mapping cannot be performed during ongoing arrhythmia. There are no data whether induction of AAF is a feasible approach in these cases. MethodsWe retrospectively analyzed patients who underwent catheter ablation of AAF and compared procedural results between patients with ongoing tachycardia when starting the procedure and patients with induced AAF. ResultsWe analyzed 97 ablation procedures performed in 76 patients with a mean follow-up of 13.2 ± 12.2 months. In 68 procedures (70.1 %) AAF was ongoing at the beginning of the procedure and in 29 cases (29.9 %) AAF had to be induced.There was no statistically significant difference regarding acute procedural success. The recurrence rate of any arrhythmia during follow-up was significantly higher after ablation of ongoing AAF compared to induced AAF (63.2 % vs. 42.9 %; p = 0.047) driven by a significant higher rate of AAF-recurrence (57.4 % vs. 34.5 %; p = 0.039). The number of ablated tachycardias per patient as well as the number of de-novo tachycardias found during re-ablation showed no significant difference between both groups. ConclusionStarting a procedure with ongoing arrhythmia did not result in better short- or mid-term outcome in patients undergoing AAF ablation. Furthermore, based on our results inducing AAF seems a legitimate approach for AAF ablation in patients presenting in sinus rhythm.

Evaluation of risk factors for long-term atrial fibrillation development in patients undergoing typical atrial flutter ablation: amulticenter pilot study.

Atrial flutter (AFL) and atrial fibrillation (AF) are the most commonly detected supraventricular arrhythmias and share similar pathophysiological mechanisms. After the successful ablation of AFL, AF frequently occurs in the long-term follow-up. As emphasized in some studies, certain mechanisms seem to predispose to the development of AF in AFL patients, and approximately 20% of these patients have accompanying AFL. We aimed to analyze independent risk factors that predict the development of AF in patients who underwent typical AFL ablation. This was a multicenter, cross-sectional, and retrospective study. Atotal of 442 patients who underwent typical AFL ablation at three different centers between January1, 2018 and January1, 2022 were included retrospectively. After the ablation procedure the patients were divided into those who developed AF and those who did not. The patients were followed up for an average of 12(4-20) months. In the post-procedural period, atrial arrhythmias were investigated with 24‑h Holter and ECG at 1month, 6months, and 12months and then at 6‑month intervals thereafter. Overall, AF developed in 206 (46.6%) patients in the long-term follow-up. Age, hypertension (HT), obstructive sleep apnea syndrome (OSAS), previous cerebrovascular accident (CVA), left atrium anteroposterior diameter, severe mitral regurgitation, hemoglobin, blood glucose, and HbA1c values were found to be significant in univariable analysis. According to multivariable analysis, HT (p = 0.014; HR: 1.483 [1.084-2.030]), OSAS (p = 0.008; HR: 1.520 [1.117-2.068]) and previous CVA (p = 0.038; HR: 1.749 [1.031-2.968]) were independently associated with the development of AF in AFL patients who underwent ablation procedure. In the present study, we found that HT, OSAS, and previous CVA were independently correlated with the development of AF in the long-term follow-up of patients who underwent typical AFL ablation. We consider that AFL patients with such risk factors should be followed up closely following cavotricuspid isthmus ablation for the development of AF.

Achado incidental de taquicardia supraventricular com evolução para Flutter atrial após cardioversão elétrica em neonato

Cardiac arrhythmias in newborns, although rare, are often associated with prematurity and congenital heart defects. Atrial flutter, a tachyarrhythmia with a continuous, elevated atrial rhythm, occurs in about 1% of pediatric cases and usually in previously healthy hearts. Supraventricular tachycardia (SVT), an abnormality in electrical conduction above the ventricles, can cause symptoms such as difficulty feeding and irritability. In neonates, SVT may be asymptomatic for long periods but may lead to sudden hemodynamic decompensation. Treatment includes antiarrhythmic medications, with adenosine being the first line. In refractory cases, such as the one described, amiodarone and synchronized electrical cardioversion may be necessary. The case reported describes a newborn with SVT and persistent Atrial Flutter, treated with adenosine, amiodarone and synchronized electrical cardioversion, resulting in normalization of the heart rhythm. The patient progressed well with oral amiodarone, with no sequelae. The combination of drugs and electrical cardioversion is effective for treating complex neonatal arrhythmias.

Abstract Tu070: Impact of Hypertrophic Cardiomyopathy in Hospitalizations with Aortic Stenosis : A National Inpatient Sample survey

Background: The management of patients with combined aortic stenosis (AS) and hypertrophic cardiomyopathy (HCM) is tricky. HCM causes a dynamic obstruction, while AS causes a fixed obstruction, both causing a hindrance to left ventricular output. We aim to study the outcomes of hospitalizations with co-prevalent HCM and AS. Methods: We queried the National Inpatient Sample 2018-2020 for adult hospitalizations with AS. This sample was stratified based on the prevalence of HCM. Mortality, arrhythmia prevalence, and acute cardiac complications were compared in aortic stenosis hospitalizations with and without AS. A multivariate regression analysis was performed to study the impact of HCM on mortality, arrhythmias, and other complications in patients with AS. Results: In hospitalizations with aortic stenosis (n=2483854), a total of 11820 had underlying HCM (0.47%). The mean age was 76 years and 64% were females. Hospitalizations with AS and HCM as compared to those without HCM had a higher prevalence of arrhythmias including first degree AV block, atrial flutter, atrial fibrillation, ventricular tachycardia and ventricular fibrillation (Table 1). The occurence of cardiogenic shock was also higher in this subgroup. The difference in mortality, acute coronary syndrome, acute heart failure and cardiac arrest was not statistically significant in AS hospitalizations with and without HCM (Table 1). Multivariate regression analysis revealed a higher odds of arrhythmias (OR-1.44; C.I: 1.36-1.62; P&lt;0.001) and cardiogenic shock (OR-1.58; C.I: 1.22-2.06; P&lt;0.001) with HCM in AS hospitalizations. Conclusion: Prior studies have demonstrated worse outcomes in AS patients with pre-existing HCM, especially post TAVI. Our study concludes that HCM was associated with a higher odds of arrhythmias and cardiogenic shock in AS hospitalizations.

Cardiac Substructure Radiation Dose and Associations With Tachyarrhythmia and Bradyarrhythmia After Lung Cancer Radiotherapy

BackgroundArrhythmias are common following radiotherapy for non–small cell lung cancer. ObjectivesThe aim of this study was to analyze the association of distinct arrhythmia classes with cardiac substructure radiotherapy dose. MethodsA retrospective analysis was conducted of 748 patients with locally advanced non–small cell lung cancer treated with radiotherapy. Cardiac substructure dose parameters were calculated. Receiver-operating characteristic curve analyses for predictors of Common Terminology Criteria for Adverse Events grade ≥3 atrial fibrillation (AF), atrial flutter, non-AF and non–atrial flutter supraventricular tachyarrhythmia (SVT), bradyarrhythmia, and ventricular tachyarrhythmia (VT) or asystole were calculated. Fine-Gray regression models were performed (with noncardiac death as a competing risk). ResultsOf 748 patients, 128 (17.1%) experienced at least 1 grade ≥3 arrhythmia, with a median time to first arrhythmia of 2.0 years (Q1-Q3: 0.9-4.2 years). The 2-year cumulative incidences of each arrhythmia group were 8.0% for AF, 2.7% for atrial flutter, 1.8% for other SVT, 1.4% for bradyarrhythmia, and 1.1% for VT or asystole. Adjusting for baseline cardiovascular risk, pulmonary vein (PV) volume receiving 5 Gy was associated with AF (subdistribution HR [sHR]: 1.04/mL; 95% CI: 1.01-1.08; P = 0.016), left circumflex coronary artery volume receiving 35 Gy with atrial flutter (sHR: 1.10/mL; 95% CI: 1.01-1.19; P = 0.028), PV volume receiving 55 Gy with SVT (sHR: 1.03 per 1%; 95% CI: 1.02-1.05; P < 0.001), right coronary artery volume receiving 25 Gy with bradyarrhythmia (sHR: 1.14/mL; 95% CI: 1.00-1.30; P = 0.042), and left main coronary artery volume receiving 5 Gy with VT or asystole (sHR: 2.45/mL; 95% CI: 1.21-4.97; P = 0.013). ConclusionsThis study revealed pathophysiologically distinct arrhythmia classes associated with radiotherapy dose to discrete cardiac substructures, including PV dose with AF and SVT, left circumflex coronary artery dose with atrial flutter, right coronary artery dose with bradyarrhythmia, and left main coronary artery dose with VT or asystole, guiding potential risk mitigation approaches.

Paradoxical under-sensing of atrial lead at high sensitivity setting in dual chamber pacemaker during atrial flutter – What is the mechanism?

IntroductionThe causes of atrial undersensing in a dual chamber pacemaker include true undersensing (low amplitude electrogram), functional undersensing (related to the effect of special timing cycles in the presence of an adequate signal) and paradoxical undersensing. This case report describes paradoxical atrial undersensing at a higher programmed atrial sensitivity and with the return of normal atrial sensing at a lower programmed sensitivity.

Safety and feasibility of cardiac electrophysiology procedures in ambulatory surgery centers

BackgroundDespite their improved safety, by and large, cardiac electrophysiology procedures including catheter ablation (CA), are presently performed in hospital outpatient departments. ObjectiveThis large multicenter study investigated the safety and outcomes associated with various cardiac electrophysiology procedures performed at 6 ambulatory surgery centers (ASCs), primarily during the coronavirus disease 2019 pandemic under the Center for Medicare and Medicaid Services Hospitals Without Walls program. MethodsWe retrospectively analyzed the outcomes from consecutive electrophysiology procedures performed in ASCs with same-day discharge, including transesophageal echocardiography, cardioversion, cardiac implantable electronic device (CIED) implantation, electrophysiology studies, and CA for atrial fibrillation (AF), atrial flutter (AFL)/supraventricular tachycardia, ventricular premature complexes (VPCs), and atrioventricular node. ResultsAltogether, 4037 procedures were performed, including 779 transesophageal echocardiography/cardioversion procedures (19.3%), 1453 CIED implantation procedures (36.0%), 26 electrophysiology studies (0.6%), and 1779 CA procedures (44.1%) for AF (75.4%), AFL/supraventricular tachycardia (18.8%), VPC (4.7%), and atrioventricular node (1.1%). Overall, 80.2% of CA procedures were for left-sided atrial arrhythmias (AF/atypical AFL) requiring transseptal catheterization. Left-sided VPC ablation procedures (42.2%) were performed using a transseptal/retrograde approach. Adverse event rates were low, but comparable between CIED implantation and CA (0.76% vs 0.73%; P = .93), as were the incidences of urgent/unplanned postprocedure hospitalization (0.48% vs 0.45%; P = .89), respectively. Moreover, the adverse event rates in ASCs vs hospital outpatient departments did not differ for CIED (0.76% vs 0.65%; P = .71) or CA (0.73% vs 0.80%; P = .79). ConclusionThe results from this large multicenter study suggest that ASCs represent a safe and effective setting to perform a variety of cardiac electrophysiology procedures including CA. These findings bear important implications for healthcare delivery and policy.

Comparison of Postoperative Continuous Wireless Cardiac Rhythm Monitoring with Traditional Telemetry in Cardiac Surgery Patients: the SMART-TEL Study.

Telemetry monitoring (conventional cardiac monitoring system [CCMS]) is a universal method for postoperative arrhythmia detection; however, the clinical challenge of alarm fatigue, primarily associated with noise or cable disconnections, persists. The introduction of wireless continuous cardiac monitoring (WCCM) represents a potential solution to enhance recording fidelity. Patients were simultaneously outfitted with both a monitoring device considered the standard of care and a novel adhesive wireless patch. A 48-h cardiac monitoring session with the two devices occurred after cardiac surgery in a unit equipped with a telemetry system. A total of 53 patients with a mean age of 60 ± 17 years were included in the trial. The number of events detected by the two systems was significantly different at 190 versus 174 for the CCMS and the WCCM system, respectively (P < .05). However, the percentage of agreement was not significantly different at 91% versus 88% (P = .37). Events were classified as follows: pause (2 events, 1%), atrial or premature ventricular contractions (18 events, 11%), atrial flutter or fibrillation (76 events, 45%), bradycardia (12 events, 7%), and tachycardia (61 events, 36%). False alarms were significantly more frequent with the CCMS (n = 21) than with the WCCM system (n = 5; P = .002). The study successfully demonstrated the feasibility and usability of wireless monitoring for patients requiring telemetry. The overall results are compelling, as the WCCM system performed satisfactorily, achieving results comparable to those obtained with the CCMS, even with significantly fewer false alarms.

Voltage-guided pulmonary vein isolation for atrial fibrillation

BackgroundBipolar voltage amplitude is capable of helping determine the ideal lesion size index (LSI) setting during radiofrequency ablation for atrial fibrillation (AF). ObjectiveWe aimed to determine whether voltage-guided pulmonary vein isolation (PVI) is noninferior to conventional LSI-guided PVI in patients with nonvalvular AF. MethodsThis was a multicenter randomized trial conducted during a period of 12 months. The primary efficacy end points of the study were AF recurrence, atrial flutter, and atrial tachycardia, and the noninferiority margin was set at a hazard ratio of 1.4. The primary safety end point was a composite of procedure-related complications. ResultsA total of 370 patients underwent randomization; 189 and 181 were assigned to the voltage (underwent voltage-guided PVI) and control (underwent conventional LSI-guided PVI) groups, respectively. The primary efficacy end point occurred in 22 patients (12.0%) in the voltage group and 23 patients (12.9%) in the control group (1-year Kaplan-Meier event-free rate estimates, 88.0% and 87.1%, respectively; hazard ratio, 1.00; 95% confidence interval, 0.80–1.25). The primary safety end points were 4.8% in the voltage group and 6.6% in the control group (P = .2791). PVI time was significantly shorter in the voltage group (35.7 ± 14.5 minutes vs 39.7 ± 14.7 minutes; P < .001). ConclusionVoltage-guided PVI was noninferior to conventional LSI-guided PVI with respect to efficacy in the treatment of patients with AF, and its use significantly reduced procedure time.UMIN Clinical Trials Registry: UMIN000042325

Importance of fourth heart sound and preserved left atrial function in wild-type transthyretin amyloidosis.

A fourth heart sound (S4) was reported to be almost never present in patients with amyloid light-chain cardiomyopathy. There have been no reports on S4 in patients with wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM). This study aimed to clarify the clinical implications of S4 in patients with ATTRwt-CM. Seventy-six patients with ATTRwt-CM (mean age: 80.4±5.4years, 68 males) who had undergone phonocardiography (PCG) were retrospectively assessed. We measured S4 amplitude on digitally recorded PCG. S4 was considered to be present when its amplitude was 1.0mm or greater on the PCG. Distinct S4 was defined as S4 with an amplitude of 2.0mm or greater, which is usually recognizable by auscultation. According to the rhythm and presence or absence of S4, the patients were divided into three groups, namely, sinus rhythm (SR) with S4, SR without S4, and non-SR. Non-SR consisted of atrial fibrillation, atrial flutter, and atrial tachycardia. Thirty-six patients were in SR and the remaining 40 patients were in non-SR. In the 36 patients in SR, S4 was shown by PCG to be present in 17 patients (47%), and distinct S4 was recognized in 7 patients (19%) by auscultation. In patients who were in SR, those with S4 had higher systolic blood pressure (124±15 vs. 99±8mmHg, P<0.001), lower level of plasma B-type natriuretic peptide (308 [interquartile range (IQR): 165, 354] vs. 508 [389, 765] pg/mL, P=0.034) and lower level of high-sensitivity cardiac troponin T (0.068 [0.046, 0.089] vs. 0.109 [0.063, 0.148] ng/mL, P=0.042) than those without S4. There was no significant difference in left atrium (LA) volume index or LA reservoir strain between patients with S4 and without S4. Patients with S4 had more preserved LA systolic function than those without S4 (peak atrial filling velocity: 53±25 vs. 34±9cm/s, P=0.033; LA contractile strain: 4.1±2.1 vs. 1.6±2.0%, P=0.012). Patients in SR without S4 had worse short-term prognosis compared with the other two groups (generalized Wilcoxon test, P=0.033). S4 was present in 47% of the patients in SR with ATTRwt-CM. Patients in SR without S4 had more impaired LA systolic function than those in SR with S4. The absence of S4 portends a poor short-term prognosis in patients with ATTRwt-CM.

Arrhythmia in patients with systemic sclerosis: incidence, risk factors and impact on mortality in a Swedish register-based study

ObjectivesThe objectives of this study are to study the risk of developing cardiac arrhythmia and its subtypes over time in patients with systemic sclerosis (SSc), to assess potential risk factors...

A stroke patient with an unusual electrocardiogram

We present a case of a 70 year old man with a history of paroxysmal atrial flutter who was admitted to the hospital with symptoms and imaging consistent with an acute stroke. Physical exam was notable for a pulse rate of 50 beats per minute and right sided facial droop with mild dysarthria. Admission ECG shows a junctional bradycardia with evidence of dual AV node physiology, rarely manifested in a retrograde fashion on a standard ECG. The patient likely experienced parasympathetic sinus node slowing in the setting of acute stroke. During post-stroke monitoring, the patient demonstrated return of sinus rhythm with chronotropic competence and he had no additional arrhythmia during admission.

Registro español de ablación con catéter. XXIII informe oficial de la Asociación del Ritmo Cardiaco de la Sociedad Española de Cardiología (2023)

Introduction and objectivesWe report the results of the 2023 Spanish catheter ablation registry. MethodsProcedural data were collected and incorporated into the REDCap platform by all participating centers through a specific form. ResultsThere were 104 participating centers in 2023 compared with 103 in 2022. In 2023, the total number of ablation procedures was 26 207, indicating a stabilization of the increase observed in 2022 following the pandemic. The increase was mainly due to procedures for atrial fibrillation (AF), with a total of 9942 ablations, representing 38% of all substrates. Notably, pulse-field ablation represented 10.3% of all AF ablation procedures, leading single-shot ablation strategies to outnumber point-by-point AF ablation for the first time in the history of the registry. Cavotricuspid isthmus ablation remained the second most targeted substrate (19% of all substrates, n=5067). The overall acute success rate remained high (97%), with a downward trend in the complication rate (1.6% vs 1.8% in 2022) and mortality rate (0.03%; n=7). Compared with 2022, there was a significant increase in procedures performed using electro-anatomical mapping and zero-fluoroscopy techniques for cavotricuspid isthmus ablation (52% vs 26%), AV node re-entrant tachycardia (48% vs 34%), and accessory pathways (62% vs 22%). We registered 466 ablations in pediatric patients. ConclusionsThe data indicate a stabilization in the post-pandemic increase in ablation procedures, with an absolute and relative increase in AF as the predominant substrate. Success rates remained stable with a modest reduction in complication and mortality rates.

Risk assessment of esophageal ulceration following left atrial radiofrequency linear ablation.

Esophageal safety following radiofrequency (RF) left atrial (LA) linear ablation has not been established. To determine the esophageal safety profile of LA linear RF lesions, we performed systematic esophagogastroduodenoscopy in all patients with intraesophageal temperature rise (ITR) ≥ 38.5°C. Between December 2021 and July 2023, a total of 200 consecutive patients with atrial tachyarrhythmia (ATA) underwent linear ablation with posterior dome (roof or floor) or posterior mitral isthmus line transection. Patients with ITR ≥ 38.5°C were scheduled for esophageal endoscopy ~3 weeks after ablation. Patient and ATA characteristics, procedural parameters, endoscopy findings and ablation lesion data were collected and analyzed. One hundred thirty-threeout of 200 (67%) patients showed ITR ≥ 38.5°C during LA linear ablation. ITR (with maximal temperature of 45.7°C) was more frequently observed during floor line ablation (82% of cases). ITR was less observed during roof line ablation (34%) and posterior mitral isthmus ablation (4%). Endoscopy, performed in 115 patients after 24 ± 10 days, showed esophageal ulceration in four patients (two patientsKansas City classification [KCC] 2a and two patients KCC 2b). No patient showed esophageal perforation or fistula. Temperature rise during LA linear ablation is frequent and ulceration risk exists, particularly when floor line is performed. Safety measures are needed to avoid potential severe complications like esophageal perforation and fistula.

Comprehensive Analysis of Anticoagulant Therapy in Patients with Isolated Atrial Flutter

Limited comparative data exist regarding the risk of cardiogenic emboli in patients with isolated atrial flutter (AFL). Some studies suggest a lower complication risk in AFL compared to atrial fibrillation (AFib), but methodological limitations and conflicting reports necessitate a comprehensive investigation. Our analysis proposes that isolated AFL carries a lower risk of ischemic events and left atrial thrombus formation than AFib. Importantly, we caution against applying stroke risk assessment approaches designed for AFib to AFL patients, as it may lead to harmful overestimations and unnecessary anticoagulant prescriptions. Furthermore, we highlight the current lack of sufficient data to determine the overall clinical benefit of prolonged anticoagulant therapy in patients with isolated AFL, especially when CHA2DS2-VASc index values are below 4. This review challenges existing perceptions, offering insights into the nuanced risk profiles of the transitional nature of isolated AFL due to the high incidence of AFib development within a year of AFL diagnosis. In conclusion, tailored risk assessments and further research are essential for precise clinical decision-making in this dynamic landscape.