Cardioversion Research Articles

Prevalence and risk factors associated with decompensated heart failure after successful elective cardioversion for atrial fibrillation and atrial flutter

Study objectiveTo determine the incidence of and risk factors for HF after successful electrical and ablative cardioversion (CV) of atrial fibrillation (AF) and atrial flutter (AFL). DesignRetrospective cohort study. SettingSingle center academic institution. ParticipantsSeven hundred fifty-five patients underwent successful elective CV from July 1, 2018 to May 20, 2019. Patients presenting in arrhythmias other than AF or AFL, those who developed HF due to alternative etiologies, and those who developed arrhythmia recurrence within 30 days were excluded. Medical records of the remaining 451 patients were reviewed before and after CV. Main outcomes measuredDevelopment of heart failure despite sinus rhythm following CV and the risk factors associated with this outcome. ResultsThirty-three (7.3 %) of 451 patients who met inclusion criteria for our study developed new or worsening HF symptoms while maintaining sinus rhythm (SR) after successful CV. Symptoms were reported an average of 5.1 days following CV (range 0–17 days, SD 4.71). Following a multivariate stepwise logistic regression model, prior HF hospitalization (OR 3.91, 95 % CI 1.82–8.39), BMI (OR 1.06, 95 % CI 1.02–1.11), and valve disease (OR 2.51, 95 % CI 1.12–5.60) remained significant risk factors, and anti-arrhythmic drug (AAD) use was marginally significant (OR 2.02, 95 % CI 0.95–4.31). ConclusionDespite maintenance of SR, 7.3 % of patients developed decompensated HF in the 30 days following successful CV of AF or AFL, indicating this complication may be more frequent than previously believed. Predictors of HF post-CV included elevated BMI, valve disease, previous HF hospitalization, and prior AAD use.

Digital devices for heart rhythm monitoring in atrial fibrillation patients scheduled for elective electrical cardioversion. Kardiover study

Abstract Introduction the management of patients with recent-onset atrial fibrillation (AF) is to achieve sinus rhythm (SR) by electrical or pharmacological cardioversion (CV). However, frequently SR is spontaneously restored, making scheduled admission and/or transesophageal echocardiogram (TEE) unnecessary and therefore causing misutilization of healthcare resources. Emerging medical technology has allowed for accurate heart rhythm monitoring. Objective to evaluate the diagnostic ability of a smart device ECG monitor to detect spontaneous conversion to SR in AF patients, preventing unnecessary admission and providing an earlier management. Methods A prospective multicenter study (Kardiover study) was designed including patients with paroxysmal, persistent or first diagnosed AF scheduled for elective electrical CV in cardiology departments of 7 hospitals in Spain. Patients were asked to submit ECG recordings to a central Corelab daily, twice a day and whenever they present symptoms, until CV (spontaneous or scheduled) and a week afterwards. Whenever a spontaneous conversion to SR was detected, investigators were contacted to confirm SR and abort admission, likewise when AF recurrence after CV was detected. Patients’ satisfaction was evaluated using a test for perceived utility and value, convenience, and accessibility. Results A total of 74 patients were enrolled (age 62 ± 10 years). Twenty-two patients (30%) showed spontaneous conversion to SR correctly detected by the devices. 86% of the spontaneous CV occurred during the first week. Among 52 patients admitted for CV, 45 (88%) were discharged in SR. During follow up after conversion to SR (spontaneous or electrical), recurrences of AF occurred in 24 patients (34%). At the end of the follow-up 51 patients (69%) remained in SR. Due to the early detection of spontaneous conversion to SR, a total of 22 admissions and 16 TEE were prevented and these resources used for other patients. Patients’ adherence to the protocol in regard to ECG recording transmissions was high, the CoreLab received 93% of the expected transmissions. Patient’s overall satisfaction was also high with a punctuation of 9.1 over 10 in the feedback test. Conclusion Digital devices for heart rhythm monitoring can optimize the management of AF patients scheduled for CV, preventing unnecessary admissions and providing a more rational use of healthcare resources.Baseline characteristicsStudy design and results

How much does elective cardioversion increase the risk of ischaemic stroke compared to the baseline risk in atrial fibrillation? A nationwide study

Abstract Background Patients with atrial fibrillation (AF) undergoing cardioversion (CV) are exposed to an increased risk for stroke during the post-cardioversion period, but the exact magnitude of this risk after elective CV with preceding appropriate oral anticoagulant (OAC) therapy is unknown. Purpose We explored the rate of ischaemic stroke (IS) after elective CV and compared the IS rate during the post-cardioversion period with the long-term stroke rate in patients with AF using guideline-recommended OAC therapy. Methods This is a nationwide register-based study, including all AF patients undergoing their first-ever elective CV between 2012-18 in Finland. Data were collected from the Finnish health care registers covering uniquely all levels of care. Visual assessment of the survival curve identified a cut-off point in IS rate at 1 week after CV. Therefore, the follow-up time was split into two intervals, the 1-week post-cardioversion period and the subsequent period up to 360 days. Stroke rates were calculated separately for these periods. Unadjusted and adjusted incidence rate ratios were estimated with Poisson regression. Moreover, interaction between the two follow-up periods and conventional IS risk factors as well as OAC treatment was assessed. Results A total of 9625 AF patients undergoing their first elective CV were identified (mean age 67.7±9.9 years, 61.2% men, mean CHA2DS2-VASc score 2.6±1.6). Warfarin was used in 6 245 (64.9%) and non-vitamin K oral anticoagulants in 3 380 (35.1%) patients. Overall, 92 (1.0%) patients suffered an IS during the year after CV. The survival plot displayed a higher incidence of IS within the first week after CV, stabilizing thereafter to a consistent level (Figure). In the adjusted regression analyses, IS rate within the first week after elective CV was 13.6-fold (95% confidence interval [CI]: 8.6-21.5) compared the subsequent rate of IS (Table). We observed no significant interaction between any of the conventional IS risk factors or OAC treatment and the two follow-up time periods, indicating that their association with IS rate did not differ during the post-cardioversion period compared to the subsequent time period. Conclusions In this nationwide study, the rate of IS was roughly 14 times higher during the first week after elective CV compared to the subsequent follow-up time.Cumulative risk of IS after elective CVIncidence rates of IS after elective CV

Dispositivos digitales para la monitorización del ritmo cardiaco en pacientes con fibrilación auricular programados para cardioversión eléctrica ambulatoria

Introduction and objectivesManagement in recent-onset atrial fibrillation (AF) is to achieve sinus rhythm (SR) by cardioversion (CV). However, frequently SR is spontaneously restored, making scheduled admission unnecessary and causing misutilization of healthcare resources. Emerging medical technology allows accurate heart rhythm monitoring. This study evaluated this technology in these patients, preventing unnecessary admission and providing an earlier management. MethodsA multicenter study was designed including patients with AF scheduled for elective electrical CV. Patients submitted ECG recordings to a central CoreLab daily, twice a day and whenever they present symptoms, until CV (spontaneous or scheduled) and a week afterwards. Whenever a spontaneous conversion to SR was detected, investigators were contacted to confirm SR and abort admission. Patients’ satisfaction was evaluated using a test for perceived utility, convenience, and accessibility. Results74 patients were enrolled (age 62±10 years). Twenty-two patients (30%) showed spontaneous conversion to SR. A total of 22 admissions and 16 transesophageal echocardiograms were prevented. Among 52 patients admitted for CV, 45 (88%) were discharged in SR. During follow-up after conversion to SR (spontaneous or electrical), recurrences of AF occurred in 24 patients (34%). At the end of the follow-up 51 patients (69%) remained in SR. The CoreLab received 93% of the expected ECG transmissions. Patient's overall satisfaction score was 9.1 over 10. ConclusionDigital devices for heart rhythm monitoring can optimize the management of AF patients scheduled for elective CV, preventing unnecessary admissions and providing a more rational use of healthcare resources.

Presence and predictors of atrial low voltage zones in patients with non cardiovertable atrial fibrillation

Abstract Background Interventional treatment of persistent atrial fibrillation (pAF) presents a challenge due to the lack of clear evidence on adjunctive strategies beyond pulmonary vein isolation (PVI). One promising approach is ablation of left atrial low voltage zones, which has been shown to improve outcomes in patients with pAF. However, reliable assessment of left atrial endocardial voltage requires sinus rhythm (SR). In a significant proportion of patients with persistent atrial fibrillation (pAF) however, restoration of sinus rhythm (SR) cannot be achieved. These may lead to extensive ablations such as defragmentation or empirical isolation of the posterior wall of the left atrium. This study aims to investigate the potential of unsuccessful cardioversion prior ablation as a predictor for the presence of low voltage zones (LVZ) in the left atrium. Methods This retrospective, single-centre study was conducted on 264 patients (31,8% female; age: 67±10 years; mean AF duration: 1-2 years) diagnosed with pAF who underwent catheter ablation for pAF between 01/2017 and 01/2020. All patients underwent electrical cardioversion (CV) before ablation. If restoration of SR was achieved, high-density contact mapping was performed in sinus rhythm before pulmonary vein isolation (PVI), in case of unsuccessful initial cardioversion, high-density contact mapping was performed after repeated CV followed the PVI, respectively. Results Initial cardioversion was unsuccessful in 53 out of 264 (19.7%) patients. Subsequent to pulmonary vein isolation, cardioversion was successful in 47 out of 53 (81%) patients initially considered non-cardiovertible. In 32 out of 53 (60.4%) patients who had an initial unsuccessful cardioversion, no left atrial low voltage was identified. Amongst patients who underwent a successful initial cardioversion, left atrial low voltage zones were apparent in 77 out of 211 patients (36.5%). There is no significant difference in the the presence of left atrial low voltage between patients who had initially successful and unsuccessful CV (χ²(1) = 0.178, p = 0.673, φ = 0.026). According to the ROC analysis, the success of CV does not have any predictive value for LVZ (AUC 0.511). Conclusion Cardioversion failure before pulmonary vein isolation does not predict left atrial low-voltage zones (LVZ). PVI alone may be adequate even in patient with clinically "end stage" non-cardiovertible atrial fibrillation. Ablation beyond pulmonary vein isolation have the potential to overtreat this specific patient group, resulting in an increase in secondary arrhythmias. These findings indicate that even single-shot devices such as balloon-based techniques may be a considerable ablation strategy in these patient cohort.

Efficacy of smart device heart rhythm monitoring to detect spontaneous conversion to sinus rhythm in patients scheduled for electric cardioversion of atrial fibrillation. Kardiover Study

Abstract Introduction the management of patients with recent-onset atrial fibrillation (AF) is to achieve sinus rhythm (SR) by electrical or pharmacological cardioversion (CV). However, frequently SR is spontaneously restored, making scheduled admission and/or transesophageal echocardiogram (TEE) unnecessary and therefore causing misutilization of healthcare resources. Emerging medical technology has allowed for monitoring of heart rhythm abnormalities. Objective A prospective multicenter study was designed to evaluate the diagnostic ability of a smart device ECG monitor to detect spontaneous conversion to SR in AF patients, preventing unnecessary admission and providing an earlier management. Methods A prospective multicenter study was designed including patients with first diagnosed, paroxysmal or persistent AF scheduled for ambulatory electrical cardioversion in cardiology departments of 7 hospitals of Spain. Patients were asked to submit ECG recordings to a central Corelab daily, twice a day and whenever they present symptoms, until cardioversion (spontaneous or scheduled) and a week afterwards. Whenever a spontaneous conversion to SR was detected, investigators were contacted to confirm SR and abort admission, likewise when AF recurrence after cardioversion was detected. Patients’ satisfaction was evaluated using a test for perceived utility and value, convenience, and accessibility. Results A total of 62 patients were enrolled (age 62±10 years). Baseline characteristics of the study population are described in the Table. Fifteen patients (24%) did not undergo CV as they showed spontaneous conversion to SR. Among 47 patients admitted for CV, it was successful in 41 (87%). One patient aborted CV because of atrial thrombus on TEE. During follow up after conversion to SR (spontaneous or electrical), recurrences of AF occurred in 20 of 56 patients (36%) correctly detected by the devices. At the end of the follow-up 41 of 56 patients (73%) remained in SR. Due to the early detection of spontaneous conversion to SR, a total of 15 admissions and 9 TEE were prevented and these resources used for other patients. Adherence was high with a rate of ECG transmission over 80% in 56 patients (90%). Perceived satisfaction was also high with an overall punctuation of 9 over 10 in the patient’s feedback test. Conclusion Digital devices for heart rhythm monitoring can optimize the management of AF patients scheduled for CV, avoiding unnecessary admissions and providing a more rational use of healthcare resources.Table

A novel score to predict left atrial appendage thrombus and sludge in patients with persistent atrial fibrillation on chronic anticoagulants

Abstract Introduction Left atrium (LA) and left atrial appendage (LAA) thrombus may occur during atrial fibrillation (AF) and atrial flutter (AFl), and potentially cause main embolic events. Sludge is a pre-thrombotic condition, associated with long term adverse outcomes. Current guidelines do not recommend to perform transesophageal echocardiography (TEE) before cardioversion (CV) of patients with persistent AF/AFl when at least 3 weeks of anticoagulation are administered with appropriate compliance. Instead, they suggest TEE before atrial ablations (Abl), even in anticoagulated patients. Evidence to support these approaches are weak and conflicting, due to not infrequent occurrence of peri-procedural stroke and several reports of not negligible prevalence of LAA thrombus finding. Purpose Aim of the study was to evaluate the real prevalence of LAA thrombus and sludge in a retrospective cohort of consecutive anticoagulated patients with persistent AF and AFl, who underwent TEE before a scheduled cardioversion or catheter ablation. Moreover, clinical and echocardiographic characteristics were analyzed to develop a score that could predict the individual risk of combined thrombus/sludge. Methods We conducted a retrospective, monocentric, observational study, recruiting 1037 consecutive patients with persistent AF/AFl referred to our center for CV or Abl. TEE had been always performed to rule out thrombus and sludge before procedures. We collected data about patients characteristics, medication and compliance, electrographic and echocardiographic findings and type of scheduled procedure. Data was compared in univariate and multivariate analysis to identify possible predictors of LAA thrombus and sludge, and we used the last significant results to create a predictive score with logistic regression analysis. We identified best cutoff value with ROC curve. Results 767 patients were included in final dataset. Mean CHA2DS2-VASc was 3.2. LA/LAA thrombus and sludge were identified in 63 subjects (8.21%), 17 thrombi (2.21%) and 45 sludge (5.86%). Presence of valvular AF (+1), previous stroke or TIA (+1.5), heart failure history (+1), ventricular systolic (LVEF < 45%)(+0.5) and diastolic (Lateral E/e’ > 9) dysfunctions (+1) were significantly associated to higher risk of thrombus/sludge occurrence, meanwhile AFl (-1) was associated to lower risk. A novel score, called HEELP score, was developed based on these variables, and a threshold of 1 point showed high sensitivity (89%) and remarkable negative predictive value (98%). Conclusion Thrombus and sludge prevalence is not infrequent in anticoagulated patients with persistent AF/AFl. A strategy to perform TEE before procedures in patients with high risk features according to our score could be effective in preventing main embolic events, but it has to be validated in further studies.LAA empty (1), sludge (2), thrombus (3)HEELP score

Novel electrocardiographic classification for stroke prediction in atrial fibrillation patients undergoing cardioversion

BackgroundAbnormal conduction, structure, and function of the atrial myocardium predispose to atrial fibrillation (AF) and stroke. The usefulness of electrocardiographic indices in predicting stroke or systemic embolism (SSE) in patients undergoing cardioversion (CV) for AF remains unknown, especially in those at low estimated risk. ObjectiveWe systematically evaluated the performance of various P-wave abnormalities (PWAs) in predicting SSE 30 days after CV (derivation cohort) and in the long term (validation cohort). MethodsElectrocardiograms (n = 1773) of AF patients undergoing an acute CV were manually reviewed. The 30-day post-CV data were used to derive a composite PWA variable. The electrocardiographic findings were validated by the long-term follow-up of patients with no anticoagulation. Electrocardiograms of 27 CAREBANK study patients with right atrial appendage biopsies were further analyzed for histopathologic validation. ResultsDuring data derivation, the best performance was found with a combination of prolonged P-wave (≥180 ms), deflected P-wave morphology in lead II, biphasic P-waves in inferior leads, or increased P-terminal force (≥80 mm·ms) as markers for extensive PWA. In the validation cohort, 219 of 874 (25.1%) had extensive PWA. During a median follow-up of 4.9 years, there were 51 patients (5.8%) with SSE in total. In a competing risk model, PWA predicted SSE (adjusted hazard ratio, 2.1 per category; 95% CI, 1.4–3.1; P < .001). Areas under the curve for SSE at 3 years were 0.77, 0.79, and 0.86 for PWA, CHA2DS2-VASc, score, and their combination, respectively. On histologic evaluation, extensive PWA was associated with interstitial fibrosis (P = .033). ConclusionNovel electrocardiographic PWA classification provided additional prognostic insight in AF patients.

MINOCA and Coronary Ectasia: a rare combination of causes of infarction

to describe a patient with myocardial ischemia with multiple causes. This clinical case describes a 58-year-old man with a history of hypertension, dyslipidemia, COPD and previous myocardial infarction (AMI). He went to the emergency room with chest pain and dyspnea. Findings included bibasal crackles, electrocardiogram with old anterior fibrosis, elevated NT-ProBNP, and echocardiogram with septoapical akinesia. During hospitalization, he experienced tachyarrhythmia and hemodynamic deterioration, undergoing electrical cardioversion (CVE). Non-ST segment elevation acute coronary syndrome (NSTEACS) complicated with ventricular arrhythmia and acute pulmonary edema was diagnosed. Coronary angiography revealed coronary ectasias without obstructive lesions, but with mild stenosis in three vessels. The patient was successfully treated with non-invasive ventilation, diuretics, vasodilators and anticoagulation. The discharge was granted with the plan to further studies to optimize and guide treatment and finally the diagnosis of Myocardial Infarction with Non-Obstructive Arteries (MINOCA) and the presence of coronary ectasias was addressed. it is important to highlight the non-ischemic causes in MINOCA and the association between coronary ectasia and cardiovascular events, which is why we emphasize the need for more studies to better understand the relationship between these phenomena.

Functional tricuspid regurgitation and efficacy of electrical cardioversion in patients with atrial fibrillation and atrial functional mitral regurgitation.

Atrial functional mitral regurgitation (afMR) is common in patients with atrial fibrillation (AF). The presence of functional tricuspid regurgitation (fTR), which arises as a secondary effect of afMR, has the potential to impact the effectiveness of procedures aimed at restoring normal heart rhythm. In this study, we sought to evaluate the efficacy of electrical cardioversion (CVE) in AF regarding the presence and degree of fTR in patients with afMR. Retrospective analysis included 521 patients with persistent AF on optimal medical therapy undergoing CVE. 157 (30.1%) patients had afMR (characterized by left ventricle ejection fraction ≥ 50% and LA dilatation) and were divided into 2 groups: the group with fTR (107, 68.2%) and the group without fTR (50, 31.9%). Patients with afMR and fTR had a higher prevalence of metabolic syndrome (p = 0.02) and greater right atrial area (p < 0.01) compared to patients without fTR. The efficacy of CVE was lower in the group with fTR in comparison to patients with isolated afMR (82.2% vs. 94%; p = 0.048) and it was unrelated to the degree of fTR (p = 0.15) and RVSP (p = 0.56). The energy required for successful CVE was comparable regardless of the presence (p = 0.26) or severity of fTR (p = 0.94). The fTR frequently coexists with afMR and it significantly diminishes the effectiveness of CVE for treating AF. The degree of fTR does not appear to influence the efficacy of CVE.

Atrial Thrombosis Prevalence Before Cardioversion or Catheter Ablation of Atrial Fibrillation: An Updated Systematic Review and Meta-Analysis of Direct Oral Anticoagulants Versus Vitamin K Antagonists

Left atrial or left atrial appendage thrombosis (LAT) is contraindicated for cardiac ablation (CA) or cardioversion (CV) of atrial fibrillation (AF). This study was aimed to compare the frequency of LAT detected by transesophageal echocardiography (TEE) before CA or CV in patients with AF treated with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). We searched PubMed, Scopus, Web of Science, and Cochran Library databases from inception through July 13, 2023 to select studies reporting data on LAT identification before CA or CV using TEE in patients with AF treated with DOACs or VKAs. Pooled odds ratios (ORs) with 95% confidence interval were calculated with a random-effects model. Studies retrieved were 50 (38 observational), 29 on CA, 15 on CV, and 6 on both procedures (17,096 patients on DOACs and 13,666 on VKAs). The overall prevalence of LAT was smaller in DOACs than in VKAs, with an OR of 0.66 (0.52 to 0.84), confirmed at sensitivity analysis and in most subgroups. This finding was consistent for the 3 most reported DOACs: the pooled OR for LAT was 0.68 (0.50 to 0.90) in apixaban, 0.67 (0.51 to 0.88) in dabigatran, 0.61 (0.43 to 0.89) in rivaroxaban, and 1.10 (0.74 to 1.64) in edoxaban (not significant). In conclusion, in this large meta-analysis in patients with AF, the prevalence of LAT by TEE evaluation performed before CV or CA appears lower in those treated with DOACs than in those on VKAs. Additional research may help in better understanding differences between these classes of anticoagulant drugs in the setting of protection against AF-related left atrial thrombotic formation.

Pulmonary hypertension is an adverse risk factor for peri-procedural complications in patients undergoing cardioversion for atrial fibrillation

Abstract Background Atrial Fibrillation (AF) poses a significant burden on the American Healthcare system. Heart failure and AF commonly coexist in patients. Elevated left ventricular and atrial pressures result in progressive left atrial dilation and remodeling which in turn predisposes to the generation of AF. Many of these patients develop pulmonary hypertension (PHT) due to the remodeling and elevated left-sided pressures. Cardioversion (CV) for non-valvular atrial fibrillation (AF) is commonplace for patients during their initial presentation. Since many who undergo CV for AF could have PHT, we aimed to assess the periprocedural outcomes in this population. Methods We utilized the National Inpatient Sample from 2016-2019 to identify roughly 330,820 hospitalized adults who had CV for AF. These hospitalizations were further stratified based on the presence of PHT. A multivariate regression model was used to adjust for confounders and analyze the variables. Results Of those who underwent CV for AF, 45,345 (13.7%) had PHT. In-hospital mortality was interestingly lower in those with PHT (9.6% vs 10.37%; p&amp;lt;0.001). Figure 1 shows the Forrest plot for multivariate analysis of in-hospital outcomes when adjusted for patient demographics, comorbidities, and hospital characteristics. When adjusted similarly, patients who underwent CV for AF and PHT had longer length of stay (LOS) by 2.11 days (p&amp;lt;0.001) and had additional hospital costs (HC) of $29,470 (p&amp;lt;0.001). Conclusion In this study, patients who underwent CV for AF with co-existing PHT had significantly worse outcomes in terms of LOS, HC, pulmonary embolism, atrial flutter, VT, SVT, AKI, and intubation. Of note, they interestingly had better outcomes in terms of in-hospital mortality, respiratory failure, and strokes. Returning the patient to sinus rhythm likely improved the left heart hemodynamics reducing post capillary pulmonary hypertension explaining the reduced mortality rate in this population. One major limitation of our study is the lack of outpatient follow up and the inability to differentiate between the different groups of PHT. Since several outcomes are worse in the setting of PHT, potential strategies for aggressive rate and volume control for those in AF should be pursued to avoid negative cardiac remodeling that would predispose to the development of PHT. AF patients with co-existing PHT should be aggressively monitored during hospitalizations as they have the potential to have worse outcomes.

Abstract 16784: Utility of 4D Flow MRI to Quantify Improvement of Left Atrial Hemodynamics Following Cardioversion for Atrial Fibrillation

Background: Cardioversion (CV) for persistent atrial fibrillation (PeAF) restores sinus rhythm (SR) but its effects on left atrial (LA) and LA appendage (LAA) flow are not well established. Research question: Does restoring sinus rhythm improve LA/LAA hemodynamics in patients with PeAF? Aims: To compare changes in LA/LAA 4D flow MRI characteristics post-CV for PeAF versus repeated measurements in a control group without AF. Methods: We performed 4D flow MRI (3T Skyra) in 9 PeAF patients (8 males, age 68±8 yrs, 78% HTN, 44% DM, 22% CAD, CHA2DS2-VASc 2.7±1.5, LVEF 53±17%) prior to and 62±44 days after CV (in SR) (minimum 4 weeks after CV). We also performed repeat MRIs in 9 SR controls (6 males, age 51±11 yrs, 78% HTN, 22% DM, 11% CAD, CHA2DS2-VASc 1.6±0.9, LVEF 62±4%) 60±19 days apart, both in SR (minimum 4 weeks apart). Data analysis included 3D segmentation of LA and LAA for evaluation of atrial velocity data. Absolute atrial velocities were calculated for each voxel and time frame inside the LA and LAA, and used to derive blood stasis (quantified by determining number of cardiac time frames with velocities below a threshold of 20 cm/s, normalized by the total number of cardiac time frames: Stasis%= (Nstasis/ NTotal)*100 ) and median velocity. Results: In PeAF, restoring SR improved 4D flow characteristics by reducing stasis and increasing median velocity (p&lt;0.003, figure). In the controls, there was no significant change in median velocity or stasis % between the two scans in either the LA or LAA. Bland-Altman analysis for the two control scans showed no significant differences in the controls. Pre-CV median velocities and stasis% in PeAF significantly differed from controls while post-CV, they did not. Conclusion: AF is associated with impaired LA and LAA flow characteristics that improve substantially with CV toward control values. Use of 4D MRI to quantify LA and LAA hemodynamic function is feasible; future studies are needed to correlate 4D MRI measurements to thromboembolic risk.

Abstract 17670: Double Trouble: Exploring the Rare Coexistence of Right and Left Atrial Thrombus After Left Atrial Appendage Ligation and Maze Procedure

Introduction: Left atrial appendage (LAA) harbors around 90% of thrombus in patients with Atrial Fibrillation(AF) related strokes. Incomplete surgical ligation and LAA stump are independent risk factors for stroke and thromboembolism in AF patients. To our knowledge, we report the first case of biatrial thrombus occurring within 1 week of surgery. Case Presentation: A 76-year-old man with Paroxysmal AF and three-vessel coronary artery disease presented with 3-week exertional and resting shortness of breath and chest pain. Troponins were negative, and EKG revealed AF. Cardiothoracic surgery planned coronary bypass, MAZE procedure, and LAA clipping. Intra-operative transoesophageal echocardiogram(TEE) showed ejection fraction of 35% without LAA clot. Post-operatively, despite anticoagulation(AC) and beta blocker therapy, AF recurred within a week. Subsequent TEE prior to anticipated cardioversion(CV) revealed thrombus on the superior vena cava border of right atrium, anterolateral wall of left atrium and near the mitral valve annulus. CV was deferred, and he was sent to rehab with AC. We hypothesize that the thrombus may be attributed to a stunned atrium caused by ischemic myocardial injury. Our case underscores the need for heightened suspicion of thrombus in individual cases. Discussion: Left atrial appendage occlusion (LAAO) was implemented as stroke prophylaxis strategy in AF during surgical interventions like maze and coronary bypass. while the European Society of Cardiology advises continuing AC after LAAO, studies suggest discontinuing AC in high-risk bleeding patients after successful surgical AF ablation and LAAO if sinus rhythm is maintained for ≥3 months. LAAOS III study shows economic benefit of concomitant surgical LAAO during cardiac surgery in AF patients with CHA2DS2-VASc score ≥2 for stroke prevention. When used alongside AC, it offers incremental benefits. Safety of discontinuing AC after LAAO requires further investigation.

Case Report: Late Presentation of Hypertrophic Cardiomyopathy in a 65- Year- Old Sudanese Man at Royal Care International Hospital

Background: HCM Syndrome is a left ventricle hypertrophic in the absence of another cardiac or other systemic condition. An epidemiologic study reported that the prevalence of HCM is 0.02in the general population. Case Presentation: We report a case report of a 65- year- old man who was referred to the clinic after presenting with a typical symptom. Past medical history and family history were insignificant. Echocardiography showed asymmetrical basal septal hypertrophy with a preserved ejection fraction of 65%. The patient was asymptomatic with no functional limitation but later developed atrial fibrillation with mild diastolic heart failure, which was treated by pharmacological medication and cardio version. Conclusion: In conclusion, the earlier the diagnosis, better the prognosis. HCM has a lot of complications including atrial fibrillation. Therefore, awareness of how often AF and other arrhythmias are associated with HCM patients will lead to lower mortality as a follow-up ECG and echocardiography can be performed to prevent subsequent complications.

Accuracy of a Standalone Atrial Fibrillation Detection Algorithm Added to a Popular Wristband and Smartwatch: Prospective Diagnostic Accuracy Study

Silent paroxysmal atrial fibrillation (AF) may be difficult to diagnose, and AF burden is hard to establish. In contrast to conventional diagnostic devices, photoplethysmography (PPG)-driven smartwatches or wristbands allow for long-term continuous heart rhythm assessment. However, most smartwatches lack an integrated PPG-AF algorithm. Adding a standalone PPG-AF algorithm to these wrist devices might open new possibilities for AF screening and burden assessment. The aim of this study was to assess the accuracy of a well-known standalone PPG-AF detection algorithm added to a popular wristband and smartwatch, with regard to discriminating AF and sinus rhythm, in a group of patients with AF before and after cardioversion (CV). Consecutive consenting patients with AF admitted for CV in a large academic hospital in Amsterdam, the Netherlands, were asked to wear a Biostrap wristband or Fitbit Ionic smartwatch with Fibricheck algorithm add-on surrounding the procedure. A set of 1-min PPG measurements and 12-lead reference electrocardiograms was obtained before and after CV. Rhythm assessment by the PPG device-software combination was compared with the 12-lead electrocardiogram. A total of 78 patients were included in the Biostrap-Fibricheck cohort (156 measurement sets) and 73 patients in the Fitbit-Fibricheck cohort (143 measurement sets). Of the measurement sets, 19/156 (12%) and 7/143 (5%), respectively, were not classifiable by the PPG algorithm due to bad quality. The diagnostic performance in terms of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy was 98%, 96%, 96%, 99%, 97%, and 97%, 100%, 100%, 97%, and 99%, respectively, at an AF prevalence of ~50%. This study demonstrates that the addition of a well-known standalone PPG-AF detection algorithm to a popular PPG smartwatch and wristband without integrated algorithm yields a high accuracy for the detection of AF, with an acceptable unclassifiable rate, in a semicontrolled environment.

AP-453071-5 SHOCKED BY EFFICIENCY: PATIENTS RECEIVE QUALITY CARE IN AN ALLIED PROFESSIONAL CARDIOVERSION PROGRAM THAT ALLEVIATES LAYERS OF SYSTEMIC STRAIN

Performance of electrical cardioversion (CV) for atrial fibrillation (AF) by allied professionals (APs) can reduce physician resource utilization and may be associated with greater efficiency without compromising patient safety. To demonstrate that a cardioversion service overseen and performed by APs is associated with improved efficiency and reduced physician utilization while maintaining patient safety. In July 2020, we initiated a protocol whereby electrophysiology APs were trained, privileged, and credentialed to independently perform CVs at our institution. Each AP performed ten supervised CVs and subsequently proceeded independently with periprocedural documentation, CV performance, coordination of care, and patient education for those referred to the program. An analysis was performed assessing a cohort of patients (randomly selected from 2018-2022) to compare the average patient length of stay and adverse events under the EP AP service vs the EP/Cardiologist service. Since the initiation of the AP CV protocol (from July 2020 to November 2022), there were 422 CVs performed by an AP out of 1,048 total CVs. A chart review was performed assessing a random cohort of 104 CVs from 2018-2022: 52 (50%) by APs and 52 (50%) by MDs. The average length of stay in the procedure suite for AP CV was 90.8±26.3min vs 114.1±33.5min when performed by a physician, representing a time savings of 23.3min per patient (p <0.01). In addition, the time from outpatient elective CV order to time of CV was 18.4±11.8 days for APs vs 19.4±12.5 days for physicians. There were no adverse events in any of the AP CVs. The APs involved in the CV service universally felt that this independent activity improved job satisfaction. Independent performance of CVs by APs is significantly more time efficient without compromise in patient safety. Additional benefits to the EP AP CV service include improved scheduling availability, easier coordination with anesthesia services, offloading of physician workload, and increased AP job satisfaction.

PO-02-204 COLCHICINE USAGE FOR PREVENTION OF POST ATRIAL FIBRILLATION ABLATION PERICARDITIS IN PATIENTS UNDERGOING HIGH POWER SHORT DURATION ABLATION

Radiofrequency ablation (RFA) for atrial fibrillation (AF) can be associated with up to 10% incidence of post-operative pericarditis, suspected to be more prevalent with the advent of high-power short duration (HPSD) ablation. This has led to widespread use of colchicine, an anti-inflammatory medication, for prevention of post-AF ablation pericarditis. However, the utility of preventative colchicine remains unproven. To evaluate the efficacy of a routine post-operative colchicine regimen for prevention of post-ablation pericarditis in patients (pts) undergoing HPSD ablation for AF. We retrospectively evaluated consecutive single-operator HPSD AF ablation procedures at our institution from June 2019 to July 2022. A colchicine protocol was introduced in June 2021 for prevention of post-ablation pericarditis. None of the pts before this date received preventative colchicine while all consecutive pts after this date received routine colchicine 0.6 mg twice daily for 14 days starting on the procedure day. Pts were divided into colchicine and non-colchicine groups (gps). We recorded the incidence of post ablation chest pain, emergency room (ER) visit for chest pain, pericardial effusion, pericardiocentesis, any ER visit, hospitalization, AF recurrence and cardioversion (CV) for AF within the first 30 days post-ablation. We also recorded colchicine-related side effects and medication compliance. Out of 225 consecutive procedures, 20 were excluded for lack of follow-up data, yielding 101 pts in the colchicine gp and 104 pts in the non-colchicine gp. Both gps were well-matched for demographic and procedural parameters (Table 1). There was no significant difference in post-ablation chest pain (9.9% vs 8.6%, p = 0.7), pericardial effusion (2.9% vs 0.9%, p = 0.1), ER visits (11.9% vs 12.5%, p = 0.2), 30-day hospitalization for AF recurrence (0.9% vs 0.96%,p = 0.3) and 30-day need for CV for AF (3.9 % vs 5.7%, p = 0.2) (Table 1). 15 pts had severe colchicine-related diarrhea, out of which 12 discontinued it prematurely (Figure 1). In this single-operator retrospective analysis, preventative colchicine was not associated with any significant reduction in the incidence of pericarditis, pericardial effusion, ER visits or AF recurrence within the first 30 days after HPSD ablation for AF. Colchicine usage was associated with significant diarrhea affecting patient compliance. Our findings argue against routine use of colchicine for prevention of post AF-ablation pericarditis.

Left Atrial Thrombosis before Catheter Ablation or Cardioversion in Patients with Non-valvular Atrial Fibrillation or Atrial Flutter: what Risk Score is Most Informative?

Aim. To compare different scores in assessment of risk of left atrial or its appendage thrombosis (LAAT) in patients with non-valvular atrial fibrillation (AF) or atrial flutter (AFL) undergoing transesophageal echocardiography before catheter ablation (CA) or cardioversion (CV).Material and methods. In retrospective, single-center, case-control study medical records of 1994 patients with non-valvular AF or AF from the period 2014-2019, who underwent transesophageal echocardiography before CA or elective CV, were analyzed. LAAT was detected in 33 of them. For the control group, 167 patients without LAAT were randomly selected from this database. CHADS2, CHA2DS2-VASc, R2CHADS2, R-CHA2DS2-VASc, R2CHA2DS2-VASc, CHA2DS2-VASc-RAF, mCHA2DS2-VASc, CHA2DS2-VASc-AFR, ATRIA scores were evaluated and compared as potential predictors of LAAT.Results. Mean age of studied patients (n=200) was 60.3±10.9, 55% of them were males. Most of patients had non-valvular AF (87,5%) and were assessed before CA (84,0%). All risk scores were associated with LAAT and CHA2DS2-VASc-RAF score was most informative [AUC 0.84; 95% confidence interval (CI) 0.76-0.91]. According to multivariate analysis in a logistic regression model among studied risk scores CHA2DS2-VASc-RAF score was the single independent predictor of LAAT [odds ratio (OR) 1.37; 95% CI 1.21-1.55; p=0.004). OR of LAAT among patients with CHA2DS2-VASc-RAF &gt;3 was 12.8 (95% CI 3.75-43.9; p&lt;0.0001) with sensitivity, specificity, positive and negative predicting values 90.6%, 57.1%, 30.2% and 96.7% respectively Conclusion. In the studied group of patients with non-valvular AF or AFL, without severe structural heart disease and severe concomitant diseases CHADS2, CHA2DS2-VASc, R2CHADS2, R-CHA2DS2-VASc, R2CHA2DS2-VASc, CHA2DS2-VASc-RAF, mCHA2DS2-VASc, CHA2DS2-VASc-AFR, ATRIA scores were associated with LAAT. CHA2DS2-VASc-RAF score was the most informative. &gt;˂0.0001) with sensitivity, specificity, positive and negative predicting values 90.6%, 57.1%, 30.2% and 96.7% respectively.Conclusion. In the studied group of patients with non-valvular AF or AFL, without severe structural heart disease and severe concomitant diseases CHADS2, CHA2DS2-VASc, R2CHADS2, R-CHA2DS2-VASc, R2CHA2DS2-VASc, CHA2DS2-VASc-RAF, mCHA2DS2-VASc, CHA2DS2-VASc-AFR, ATRIA scores were associated with LAAT. CHA2DS2-VASc-RAF score was the most informative.

Predictors of thrombosis of left atrium and its appendage before catheter ablation or cardioversion in patients with non-valvular atrial fibrillation or atrial flutter

Aim. To determine the incidence of left atrial (LA) and/or LA appendage (LAA) thrombosis in patients with non-valvular atrial fibrillation (AF) (NAF) or atrial flutter (AFL) on transesophageal echocardiography (TEE) before elective catheter ablation (CA) or cardioversion (CV) and characterize the predictors of LA/LAA thrombosis among the indicators available in the routine practice of cardiologists and general practitioners.Material and methods. In this retrospective, single-center, casecontrol study, the medical records of 1994 patients with NAF or AFL for the period 2014-2019, who underwent TEE before CA or elective CV, were analyzed. A thrombus in the LA/LAA was detected in 33 (1,6%) of them. For the comparison group, 167 patients were randomly selected without LA/LAA thrombosis. Demographic, anamnestic and clinical parameters, transthoracic echocardiography data, and laboratory results were analyzed as potential predictors of LA/LAA thrombosis.Results. Patients with LA/LAA thrombosis were older (mean age, 64,8±1,6 vs 59,4±10,8 (p=0,01), more often had persistent or longstanding persistent AF, hypertension, heart failure, enlarged LA, lower left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate, as well as more severe symptoms according to the modified European Heart Rhythm Association (EHRA) score and a higher CHA2DS2-VASc score (median, 4,0 vs 2,0; p=0,0001). Oral anticoagulants were taken by 88% of patients; there were no significant differences in the presence and composition of anticoagulant therapy between the groups. Functional class (FC) according to the modified EHRA score (odds ratio (OR), 5,4; 95% confidence interval (CI): 1,9814,96; p=0,001) and LVEF were independent predictors of LA/LAA thrombosis (OR, 0,87; 95% CI: 0,80-0,95; p=0,002). For EHRA class 3-4, the OR was 5,1; 95% CI: 2,3-11,4 (p&lt;0,0001), for LVEF &lt;48% — 7,4; 95% CI: 1,2-46,7 (p=0,03). For EHRA class 3-4, the sensitivity for LA/LAA thrombosis was 93,7%, specificity — 71,9%, positive predictive value — 50,0%, negative predictive value — 87,6%; for LVEF &lt;48% — 66,7, 32,3, 31,9 and 91,6%, respectively.Conclusion. In the studied group of patients with NAF or AFL, without severe structural heart disease and severe concomitant diseases, most of whom received oral anticoagulants, LA/LAA thrombosis at TEE before elective CA or CV was detected in 1,6% of cases. Among the indicators available in routine medical practice, the severity of arrhythmia symptoms, assessed by the modified EHRA score, and lower LVEF were independent predictors of LA/LAA thrombosis.