Episodes Of Atrial Flutter Research Articles

The impact of right atrial volume on ablation outcomes in patients with pulmonary hypertension and atrial flutter

BackgroundCatheter ablation has evolved as a safe treatment for atrial flutter (AFL) in patients with pulmonary hypertension (PH), and the recurrence of AFL may accelerate clinical decompensation. The aim of this study was to determine the recurrence rate and risk factors for recurrent AFL in PH patients after ablation.MethodsAll PH patients who underwent AFL ablation at Fuwai Hospital between May 2015 and December 2020 were followed up. The recurrence rate and risk factors for recurrence were analyzed.ResultsA total of 68 PH patients (mean age 44.0 ± 13.0 years, 36.8% male) were enrolled. The majority patients diagnosed PH had congenital heart disease-associated PH (63.2%), and 30.9% had idiopathic pulmonary arterial hypertension. At baseline, most patients (80.9%) had only cavotricuspid isthmus (CTI)-related AFL; the occurrence of non-CTI-related AFL among patients was 8.8%, and 10.3% of the patients had both types of AFL. During a median follow-up of 17.5 months, 22 patients developed at least one recurrent AFL episode (AFL-free survival: 76.5% at 1 year). The immediate success of ablation (HR 0.061, 95% CI 0.009 to 0.438; P = 0.005) and the right atrial volume index (RAVi, per 10 ml/m2; HR 1.064, 95% CI 1.011 to 1.120; P = 0.018) were associated with long-term ablation outcomes in PH patients. With 166.64 ml/m2 as a cutoff value, AFL-free survival was significantly greater in patients whose RAVi was < 166.64 ml/m2 (log-rank P = 0.024).ConclusionThe immediate success of ablation and the RAVi are associated with recurrent AFL. Patients with a RAVi ≥ 166.64 ml/m2 are likely experience recurrence.

RawECGNet: Deep Learning Generalization for Atrial Fibrillation Detection From the Raw ECG.

Deep learning models for detecting episodes of atrial fibrillation (AF) using rhythm information in long-term ambulatory ECG recordings have shown high performance. However, the rhythm-based approach does not take advantage of the morphological information conveyed by the different ECG waveforms, particularly the f-waves. As a result, the performance of such models may be inherently limited. To address this limitation, we have developed a deep learning model, named RawECGNet, to detect episodes of AF and atrial flutter (AFl) using the raw, single-lead ECG. We compare the generalization performance of RawECGNet on two external data sets that account for distribution shifts in geography, ethnicity, and lead position. RawECGNet is further benchmarked against a state-of-the-art deep learning model, named ArNet2, which utilizes rhythm information as input. Using RawECGNet, the results for the different leads in the external test sets in terms of the F1 score were 0.91-0.94 in RBDB and 0.93 in SHDB, compared to 0.89-0.91 in RBDB and 0.91 in SHDB for ArNet2. The results highlight RawECGNet as a high-performance, generalizable algorithm for detection of AF and AFl episodes, exploiting information on both rhythm and morphology.

A deep learning modular ECG approach for cardiologist assisted adjudication of atrial fibrillation and atrial flutter episodes

BackgroundDetection of atrial tachyarrhythmias (ATA) on long-term ECG recordings is a pre-requisite to reduce ATA-related adverse events. However, the burden of editing massive ECG data is not sustainable. Deep Learning (DL) algorithms provide improved performances on resting ECG databases. However, results on long-term Holter recordings are scarce. ObjectiveWe aimed to build and evaluate a DL modular software using ECG features well known to cardiologists with a user interface that allows cardiologists to adjudicate the results and drive a second DL analysis. MethodsUsing a large (n=187 recordings, 249,419 one-minute samples), beat-to-beat annotated, two-lead Holter database, we built a DL algorithm with a modular structure mimicking expert physician ECG interpretation to classify atrial rhythms. The DL network includes 3 modules (cardiac rhythm regularity, electrical atrial waveform, and raw voltage by time data) followed by a decision network and a long-term weighting factor . The algorithm was validated on an external database. ResultsF1 scores of our classifier were 99% for ATA detection, 95% for Atrial fibrillation and 90% for Atrial flutter respectively. Using the external MIT-database, the classifier obtains F1-score of 97% for the NSR class and 96% for the ATA class. Residual errors could be corrected by manual deactivation of one module in 7/15 of the recordings with an accuracy < 90%. ConclusionA DL modular software using ECG features well known to cardiologists provided an excellent overall performance. Clinically significant residual errors were most often related to the classification of the atrial arrhythmia type (fibrillation vs. flutter). The modular structure of the algorithm helped to edit and correct the AI-based first-pass analysis and will provide a basis for explainability.

Atrial Flutter After Radiofrequency Ablation for Barrett's Esophagus: A Case Report.

BACKGROUND Barrett's esophagus (BE) is a metaplastic change in the normal esophageal squamous epithelium and is a well-recognized precursor of esophageal adenocarcinoma (EAC). Nowadays, focal radiofrequency ablation is a valid technique for BE treatment by inducing a superficial and focal thermic destruction of metaplastic tissues. According to the literature, the most frequent patient-related adverse events of this procedure are esophageal iatrogenic stenosis, mucosal laceration or perforation of the esophagus, chest pain, and odynophagia/dysphagia. Postoperative heart rhythm abnormalities have been reported very rarely. CASE REPORT A 74-year-old patient with HE was treated by radiofrequency ablation (RFA) with the Barrx™ catheter system. He had 2 symptomatic episodes of atrial flutter in the immediate postoperative period requiring an external electrical cardioversion to induce a return to sinus cardiac rhythm. After atrial flutter ablation, 2 more radiofrequency procedures were performed, without adverse events. A laparoscopic Nissen fundoplication was carried out with complete endoscopic and histologic eradication of BE after 12-month follow-up. To the best of our knowledge, this is the first reported case of atrial flutter after esophageal RFA. Different mechanisms acting on an anatomic predisposing substrate can potentially play a role in starting atrial flutter, and include inflammation, autonomic activation, and myocardial injury. CONCLUSIONS The occurrence of this new type of adverse effect could potentially modify indications and postoperative monitoring of RFA treatment for BE. Endoscopists should know the possibility of this procedural complication in high-risk patients and they should propose alternative techniques or implement close cardiac monitoring in the postoperative period.

ARTERIAL HYPERTENSION DOES NOT SLEEP

Objective: Sleep apnea is a secondary cause of hypertension and is suggested by non-dipper profile at ambulatory blood pressure monitoring (ABPM). The prevalence is estimated between 30-50% in hypertensive patients. Design and method: A 60 year-old man with cardiovascular risk factors (hypertension, diabetes, dislipidemia, obesity, transient ischemic attack) presented to the outpatient clinic with high values of self-monitoring blood pressure despide multiple lowering blood pressure therapy. On physical examination his body mass index was 39.6 kg/m2, neck circumference 50 cm. The ECG was in sinus rhythm with hypertrophic phenotype confirmed by echocardiogram, which also showed left ventricle preserved ejection fraction, grade III diastolic dysfunction, mildly enlarged left atrium. Laboratory tests exluded endocrinologic and renal causes. Despite lifestyle changes and a good adherence to multiple associated antihypertensive treatment, ABPM revealed a non-dipper profile (dipping index 4.86%) (figure 1). The patient underwent the polygraphy test which showed the apnea-hypopnea index (AHI) of 10.6, which led to a diagnosis of mild sleep apnea, the t90% of 57 pointed out severe hypoxia and high pulse variances 104 (figure 1). The further Holter monitoring revealed episodes of atrial flutter and atrial fibrillation. Results: After 3 months of continuous positive airways pressure (CPAP) therapy, on top of the same antihypertensive drugs and anticoagulation, led to optimal blood pressure values and normal ABPM profile (figure 2). The polygraphy parameters AHI, t90% and pulse variances normalised too. (figure 1) Conclusions: Obstructive sleep apnea is a prevalent secondary cause of hypertension and atrial arythmias, still greatly underdiagnosed. It is associated with abdominal obesity, large neck, snoring, daytime fatigue and a decrease in the quality of life. Polygraphy is a feasible method for diagnose sleep apnea and monitoring the treatment. CPAP treatment abolishes apnea, normalises blood oxigenation thereby prevents arterial pressure surges, restoring the nocturnal ‘dipping’ pattern and normal sinus rythm.

Association of Intravenous Potassium and Magnesium Administration With Spontaneous Conversion of Atrial Fibrillation and Atrial Flutter in the Emergency Department

Whether the simultaneous intravenous administration of potassium and magnesium is associated with the probability of spontaneous conversion to sinus rhythm (SCV) in the acute treatment of atrial fibrillation (AF) and atrial flutter (AFL) is unknown. To assess potassium and magnesium administration and SCV probability in AF and AFL in the emergency department. A registry-based cohort study was conducted in the Department of Emergency Medicine of the Medical University of Vienna, Austria. All consecutive patients with AF or AFL were screened between February 6, 2009, and February 16, 2020. Intravenous administration of potassium, 24 mEq, and magnesium, 145.8 mg. The primary outcome was the probability of SCV during the patient's stay in the emergency department. Multivariable cluster-adjusted logistic regression was used to estimate the association between potassium and magnesium administration and the probability of SCV. A total of 2546 episodes of nonpermanent AF (median patient age, 68 [IQR, 58-75] years, 1411 [55.4%] men) and 573 episodes of nonpermanent AFL (median patient age, 68 [IQR, 58-75] years; 332 [57.9%] men) were observed. In AF episodes, intravenous potassium and magnesium administration vs no administration was associated with increased odds of SCV (19.2% vs 10.4%; odds ratio [OR], 1.98; 95% CI, 1.53-2.57). In AFL episodes, in contrast, no association was noted for the probability of SCV with potassium and magnesium vs no administration (13.0% vs 12.5%; OR, 1.05; 95% CI, 0.65-1.69). The findings of this registry-based cohort study on intravenous administration of potassium and magnesium suggest an increased probability of SCV in nonpermanent AF, but not AFL, during a patients' stay in the emergency department.

C81 CORRECTION OF MASSIVE TRICUSPIDAL INSUFFICIENCY WITH PERCUTANEOUS TRICLIP SYSTEM IN WOMAN WITH MARFAN‘S SYNDROME

Abstract The interventional–percutaneous therapy of valve pathologies has undergone, in recent years, an enormous technological development in traditional surgery. In particular, the recent introduction for the percutaneous treatment of tricusp insufficiency allows you to correct forms otherwise not surgically treatable. We report a case of a 58–year–old woman suffering from Marfan‘s Sd with massive tricuspidal insufficiency in relation to valve leaf prolapse, complicated by retrograde heart failure and recurrent episodes of atriale flutter, Anamnestic cardiovascular hystory began at the age of 38 (2000) when patient underwent to the first cardiac surgery in emergency contest, with replacement of the ascending aorta and aorto–coronary bypass for acute dissection (type A); after one year (2002) perform surgery to replace the aortic arch with reimplantation of the neck vessels; at the age of 45 (2009) she underwent aortic valve replacement surgery with mechanical prosthesis, for severe aortic valve insufficiency; finally, at the age of 48 (2012) she underwent surgery to replace the thoraco–abdominal aorta and reimplantation of the abdominal vessels for chronic dissecting aneurysm. Given the high risk of re–surgery for tricuspid valve repair/replacement, the Heart–Team has indicated the percutaneous correction of tricuspid insufficiency using the valve clip. The procedure was performed under general anesthesia, ultrasound–guided with transesophageal; three clips were placed at the level of the commissure between the anterior flap and septal flap with the final result of an 80% reduction in the degree of tricuspid insufficiency, absence of peri and post procedural complications; discharge of the patient on day 3. The follow–up was completed at six months: asymptomatic patient, significant reduction of arrhythmic episodes, absence of peripheral venous stasis, reduction of hepatomegaly; echocardiographic control showed persistence of optimal alignment of the clips in the closing rim of the anterior and septal tricuspid flap; normal volume and function of the right ventricle, absence of indirect signs of hypertension in the small circulation, to report a significant reduction in arrhythmic events (two episodes of atrial flutter treated effectively with drug therapy).

Ефективність кардіоверсії в пацієнтів з поєднанням фібриляції і тріпотіння передсердь

The aim – to compare the effectiveness of restoration of sinus rhythm by transesophageal pacing (TEECP) in patients with prolonged episodes of isolated typical atrial flutter (AFl) and in patients with a combination of atrial fibrillation (AF) and AFl.Materials and methods. 325 procedures of TEECP were performed in cases of longlasting episodes of AFl: from 8 days to 2 years (average 68.2±4.76 days). Prior to hospitalization, all subjects underwent ineffective medical cardioversion. The sinus rhythm was restored using TEECP, and in case of its ineffectiveness by means of electropulse therapy (EPT). All patients were divided into two groups: group I (n=237) – patients with a lone atrial flutter, and group II (n=88) – patients with the history of AF or in case of transformation AF into AFl because of antiarrhythmic therapy. Both groups were comparable by age, paroxysm duration, presence of hypertension and organic disorders of the heart conductive system, comorbidities, echocardiographic and hemodynamic parameters. Electrocardiographical parameters revealed no significant differences in the tachycardia cycle length and the average frequency of ventricular contractions.Results and discussion. Patients in the group II were characterized by a significantly longer history of arrhythmia, more severe heart failure, higher frequency of arrhythmia paroxysms and detection of thyroid disorders; recorded significantly lower amplitudes of the F wave on the surface electrocardiogram and A wave on the esophageal electrogram, which was associated with the processes of electrophysiological remodeling of the atria. Also, in contrast to patients with typical AFl, there was a significant decrease in the effectiveness of TEECP (63.6 and 89 %); more frequent use of EPT (10.2 and 3 %) and more often arrhythmia has transformed into a permanent form (25 and 7.2 %).Conclusions. In patients with prolonged episodes of typical AFl, a highly effective method of cardioversion is TEECP, regardless of the arrhythmia duration. In patients with concomitant AF, the restoration of sinus rhythm should be performed by EPT, due to its higher efficancy.

Case 288.

History A 46-year-old woman was admitted to our hospital with decompensated congestive heart failure and pericardial effusion diagnosed on echocardiography. She had no family history of sudden cardiac death. She was born at term and experienced no cardiac events until 4 years of age, at which point she was hospitalized because of three syncopal episodes that were not related to exercise. Over the next 10 years, she experienced two additional episodes of syncope not related to exercise. She had another hospital admission at 12 years of age. Clinical examination did not reveal cyanosis or clubbing, peripheral pulses were normal, and blood pressure was 90/60 mmHg. Her venous pressure was elevated, but the liver was not enlarged, and the lung fields were clear. Electrocardiography showed sinus rhythm, right bundle branch block, T-wave inversion in V6, and evidence of right atrial dilatation. Two-dimensional echocardiography showed normal intracardiac connections, with the tricuspid valve in the normal position and normal size of the left atrium and left ventricle with a normal ejection fraction. The right ventricle was dilated without evidence of right ventricular outflow tract obstruction. Implantation of an implantable cardioverter-defibrillator was considered but was ultimately contraindicated because of right ventricle anatomy. Thus, the patient received conservative care and was started on digoxin and diuretics. At 32 years of age, she experienced an episode of atrial flutter that was treated with electrical cardioversion. As stated earlier, at 46 years of age, she was admitted to our hospital with decompensated heart failure to be evaluated for a heart transplant. She underwent electrocardiography, echocardiography, cardiac MRI with and without administration of contrast media, and non-cardiac-gated multidetector CT with and without contrast media to rule out pulmonary embolism. The following quantitative results were obtained with MRI: Left ventricular end-diastolic volume (LVDV) was 40 mL (LVDV per body surface area [BSA], 25 mL/m2); left ventricular end-systolic volume (LVSV), 21 mL (LVSV/BSA, 13 mL/m2); stroke volume (SV), 19 mL (SV/BSA, 12 mL/m2); and ejection fraction, 47%. Right ventricular end-diastolic volume (RVDV) was 262 mL (RVDV/BSA, 164 mL/m2); right ventricular end-systolic volume (RVSV), 198 mL (RVSV/BSA, 124 mL/m2); stroke volume (SV), 64 mL (SV/BSA, 40 mL/m2); and ejection fraction, 24%. Phase contrast sequences in the aorta and pulmonary artery showed systemic output of 20 mL and pulmonary output of 18 mL. Tricuspid regurgitation was massive (46 mL) (Figs 1-4).

Abstract 16465: Mode of Death and Outcomes of Implantable Cardioverter Defibrillators in Transthyretin Cardiac Amyloidosis

Introduction: Patients with transthyretin cardiac amyloidosis (ATTR-CM) may have higher risk of sudden cardiac death yet the role of implantable cardioverter defibrillators (ICD) remains poorly defined. We report our experience with ICDs in a cohort with ATTR-CM. Methods: A single center observational cohort study of patients who had been seen at our Amyloidosis Center with either wild-type or hereditary ATTR-CM diagnosed between 2005-2019. ICD implant was at discretion of treating cardiologists. Device data was obtained from record review. Results: Ninety-seven patients with ATTR-CM (mean age 71.4±11 years, 89.7% male) had mean follow-up 2.2±1.9 years. Twenty-one patients (21.6%) got ICD - 19 for primary prevention and 2 for secondary prevention - with cumulative 137 interrogations over mean 2.0±2.7 years of device follow-up. In patients with primary prevention ICD, 1 patient got 2 inappropriate shocks - both for 1 episode of atrial flutter in the VT therapy zone; 1 patient got appropriate ATP on 3 occasions. In those with secondary prevention ICD, 1 patient got 15 appropriate shocks for 3 discrete episodes of VT storm; the other got ATP for 1 episode of monomorphic VT. In patients without ICD, 101 ambulatory monitors were reviewed (cumulative 12,313 hours) without sustained ventricular arrhythmia. In this group, 13/76 met at least a class IIB criterion for ICD per current guidelines. EF was higher in those without ICD versus with primary prevention ICD (45.0±13.9 vs 33.4±15.1 %, p=&lt;0.01). Death was seen with similar frequency in those with primary prevention ICD and those without ICD (p=0.60) and mode of death did not vary between them (Table 1). Conclusions: Patients with ATTR-CM and primary prevention ICD have low rates of appropriate device therapy without differing in mode of death compared to those with no ICD. Use of ICD for secondary prevention was uncommon but all patients got appropriate device therapy. Further study on ICDs in ATTR-CM is needed to inform best care.

Comparison of Arrhythmia Detection by 24-Hour Holter and 14-Day Continuous Electrocardiography Patch Monitoring.

Although 24-hour Holter monitoring is routinely used for patients with suspected paroxysmal arrhythmia, its sensitivity in detecting such arrhythmias is insufficient. We compared a 14-day electrocardiography (ECG) monitor patch - a single-use, noninvasive, waterproof, continuous monitoring patch - with a 24-hour Holter monitor in 32 consecutive patients with suspected arrhythmia. The 14-day ECG patch was well tolerated, and its rates of detection of relevant arrhythmias on days 1, 3, 7, and 14 were 13%, 28%, 47%, and 66%, respectively. The detection rate of paroxysmal arrhythmias was significantly higher for the 14-day ECG patch than for the 24-hour Holter monitor (66% vs. 9%, p < 0.001). Among the 32 patients, 202 atrial fibrillation or atrial flutter episodes were detected in 6 patients (22%) with the 14-day ECG patch; however, only 1 atrial fibrillation episode was detected in a patient (3%, p < 0.05) with the 24-hour Holter monitor. Other clinically relevant arrhythmias recorded on the 14-day ECG patch included 21 (65.5%) episodes of supraventricular tachycardia, 2 (6.3%) long pause, and 2 (6.3%) ventricular arrhythmias. The mean dermal response score immediately after removal of the 14-day ECG patch from the patients was 0.64, which indicated minimal erythema. The 14-day ECG patch was well tolerated and allowed for longer continuous monitoring than the 24-hour Holter monitor, thus resulting in improved clinical accuracy in the detection of paroxysmal arrhythmias. Future studies should examine the long-term effectiveness of 14-day ECG patches for managing selected patients.

P6575Evaluation of arrhythmias using an insertable cardiac monitor in patients with hypertrophic cardiomyopathy

Abstract Background Hypertrophic cardiomyopathy (HCM) is a heterogeneous disease associated with arrhythmias. Life-threatening ventricular tachycardia (VT) or fibrillation is the main cause of sudden cardiac death (SCD) in HCM, even though bradycardia does occur. An implantable cardioverter-defibrillator effectively prevents SCD. Non-sustained VT is a risk factor for SCD and part of current risk stratification. Furthermore, atrial fibrillation (AF) is believed to be common in HCM and increases the risk of stroke. Notably, novel oral anticoagulant (NOAC) is recommended in HCM with AF, even in the absence of other risk factors. Routinely, arrhythmias are evaluated by 24–48 hours of ambulatory monitoring occasionally. Thus, the true burden of arrhythmia is unknown but may be elucidated by an insertable cardiac monitor (ICM). Purpose The purpose of this study was to ascertain the incidence of NSVT, AF, and significant bradycardia in unselected HCM patients by use of an ICM. Methods In total, 30 adults with HCM had an ICM Confirm Rx implanted subcutaneously at the level of the fourth rib on the left side. None had a cardiac device implanted previously since they were considered to be at low risk for SCD according to ESC risk score. The application for monitoring was installed in the patients' phone which also allowed for patient activation in case of symptoms. The ICM was programmed as follows: VT ≥160 beats per minute (bpm) during ≥8 intervals, AF ≥2minute of duration, and bradycardia ≤40 bpm or pause ≥3.0 s. Clin Trial Reg: NCT03259113. Results In total, 29 patients, mean age 51.2±12.3 years, 24 (82.8%) males, completed the monitoring and 1 had the phone disconnected the vast majority of time and was excluded for analyses. During a follow-up of 14–18 months, 9 patients (31.0%) had AF and were started on NOAC and potential dose-adjustment of beta-blocker. One of these patients had syncope due to rapidly conducted AF. One of the patients with AF also had episodes of atrial flutter. At least one episode of NSVT was detected in 6 patients (20.7%). In 11 patients (37.9%), sino-atrial block/sinus arrest were seen, typically 30–40 bpm. In 9 patients (31.0%) no significant arrhythmia were detected. Conclusion In this first study of ICM in HCM, evaluation of arrhythmia burden in low risk patients with HCM, yielded 31.0% AF, 20.7% NSVT, and 37.9% sino-atrial block/arrest. Acknowledgement/Funding Abbott

Modeling Framework for the Generation of Synthetic RR Series during Atrial Arrhythmias.

We introduced a modeling framework for the generation of realistic ventricular interval (RR) series to be used in the validation of atrial arrhythmia detection algorithms. The framework included three previously proposed models, which reproduced the specific variability properties of RR series in normal sinus rhythm, atrial flutter (AFL) and atrial fibrillation (AF). Transitions between the three rhythms were governed by a three-state continuous-time Markov chain model, which could be tuned to obtain arrhythmic episodes of the requested length. As a representative application, the modeling framework was used to generate a database of RR series for the validation of a previously proposed AF detection algorithm, which was based on RR pattern similarity. The validation showed the deterioration of detector performance in presence of simulated AFL episodes. Thanks to the detailed reproduction of the specific features of the two most common atrial arrhythmias, our modeling framework may constitute a novel tool for the assessment and comparison of detection algorithm performance.

Clinical Case: Tuberculous Myopericarditis in the Cardiology Practice

Pericarditis is not enough researched and described in literature despite the emergence of a large quantity of up-to-date laboratory and instrumental methods of verification. The main problem is that pericarditis might be a sign of many infectious and non-infectious diseases. It is quite difficult to define the etiopathogenetic reason of process. The article presents a clinical observation of a 53 years old mail patient with paroxysms of atrial flutter, non-symptomatic febrile fever, arthralgia and signs of exudative pericarditis, which were manifested after the acute viral infection. The symptoms have been lasting for 8 months before the patient’s hospitalization. In lab tests anemia, leucopenia, increase level of platelets and increase antinuclear antibody level were found. Several conceptions were considered: cancer with paraneoplastic syndrome, systemic disease, infectious process, myeloma, which were subsequently excluded. Due to the fact that pericardial effusion may often be associated with tuberculosis Diaskin test and T-SPOT were performed and they appeared to be positive. After several months of antituberculous treatment temperature normalized, atrial flutter episodes and arthralgia diminished. So empirically and laboratory tuberculous pericarditis with atypical manifestation was confirmed. The particularity of this observation is a nontypical clinical picture and the absence of a primary focus of infection. That is why the clinicians could not define the diagnosis rapidly.

Atrial fibrillation with flutter episode in patient with mitral stenosis

Mitral stenosis (MS) is a condition which happened because of congenital or acquired event. The most common etiology of MS in Indonesia is Rheumatic Heart Disease (RHD). Chronic inflammation on the mitral valve could lead to stenosis from mild to severe degree. Mitral stenosis could lead to many complications such as pulmonary hypertension and atrial fibrillation (AF). The prevalence of AF in patients with MS is related to the severity of valve obstruction and patient age. AF event in patient with MS could be happen because of Left Atrial (LA) dilatation of the patient. The mechanism that responsible for AF in patient with MS is a complex one. AF even with or without atrial flutter episode could lead a deterioration of patient hemodynamic. In the other way, the patient also predisposes to left atrial thrombus formation and systemic embolic events. Good awareness in diagnosis and management of atrial fibrillation in patient with MS are mandatory to reduce the morbidity and mortality.

Additional cavotricuspid isthmus ablation may reduce recurrent atrial tachyarrhythmia after total thoracoscopic ablation for persistent atrial fibrillation.

Unlike catheter ablation, little is known about the benefits of cavotricuspid isthmus (CTI) ablation in total thoracoscopic ablation (TTA) of atrial fibrillation (AF). This study aimed to investigate the incidence of recurrent atrial tachyarrhythmia (ATa) according to additional CTI ablation after TTA in patients with persistent AF. Among 208 consecutive patients who underwent TTA for persistent AF at the Samsung Medical Center from February 2012 to January 2016, a total of 63 patients with CTI ablation and 91 patients without CTI ablation were included in the final analysis. CTI ablation was performed in patients who had long-standing AF or atrial flutter episodes during the admission period. There was no difference in baseline characteristics between the CTI ablation and non-CTI ablation groups, except for a higher number of male patients in the CTI ablation group. The CTI ablation group showed a significantly higher survival rate free from recurrent ATa than that of the non-CTI ablation group at 5 years (52.5% vs 41.4%, P = 0.046). In the multivariable analysis, CTI ablation (hazard ratio 0.46, 95% confidence interval 0.217-0.971; P = 0.042) and left atrial volume index (hazard ratio 1.05, 95% confidence interval 1.029-1.070; P < 0.001) were significantly correlated with recurrent ATa. Patients with CTI ablation showed a better survival rate free from recurrent ATa compared with the non-CTI ablation group. The additional CTI ablation may reduce recurrent ATa after TTA in patients with documented atrial flutter or long-standing AF.

Electrophysiological Parameters of Sinus Node Function in Patients with Paroxysmal Tachyarrhythmias

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Characterization of rate and regularity of ventricular response during atrial tachyarrhythmias. Insight on atrial and nodal determinants

Objective: Ventricular rate and regularity affect hemodynamic stability and are targets of rate control therapy in patients with atrial flutter (AFL) and atrial fibrillation (AF). Nevertheless, the characteristics and determinants of ventricular response during these atrial arrhythmias are poorly understood. This work aims to investigate the effects of changes in atrial activity and atrioventricular (AV) conduction patterns on ventricular response in patients with atrial tachyarrhythmias by a combined quantitative analysis of atrial and ventricular time series. Approach: Time series were determined in patients during 24 episodes of AFL and 13 episodes of AF. Ventricular response was characterized in terms of mean ventricular interval, time-domain variability parameters, and entropy-based irregularity measures (quadratic entropy rate, QSE, and coefficient of sample entropy, COSEn). Atrial activity was characterized in terms of mean atrial rate and variability. AV conduction was analyzed by AV synchrogram method, quantifying the stability of AV coupling and the average AV conduction ratio. The dependence of ventricular features on atrial/AV determinants was investigated by correlation analysis. Main results: The analysis showed ventricular response to display a wide spectrum of variability and irregularity features at changing atrial and AV properties. The ventricular interval was significantly correlated with the AV conduction ratio (Spearman correlation coefficient ρ = −0.76, p < 0.005), while it did not correlate with atrial rate. The variability and irregularity of ventricular response were influenced by both atrial and AV parameters. QSE and COSEn significantly increased at shorter atrial cycle lengths (ρ = −0.67 and −0.71, p < 0.005), at higher atrial variability (ρ = 0.80 and 0.77, p < 0.005), at reduced AV coupling (ρ = −0.91, p < 0.005) and at smaller AV conduction ratios (ρ = −0.65 and −0.52, p < 0.005). Significance: The identification of the determinants of ventricular rate and regularity may have significant implications in the development of efficacious rate control strategies in patients with atrial tachyarrhythmias.

Incidence, type of atrial fibrillation and risk factors for stroke: a population-based cohort study.

PurposeThe aims of this study were to estimate the incidence of atrial fibrillation and atrial flutter (AF), to assess the presence of provoking factors and risk factors for stroke and systemic embolism, and to determine the type of AF in patients with first-diagnosed AF.Patients and methodsThis cohort study was performed in northern Sweden between January 1, 2011 and December 31, 2012. Diagnosis registries were searched for the International Classification of Diseases-10 code for AF (I48) to identify cases of incident AF. All AF diagnoses were electrocardiogram-verified. Data pertaining to provoking factors, type of AF and presence of risk factors for stroke and systemic embolism according to the CHA2DS2-VASc score were obtained from medical records.ResultsThe incidence of AF in the entire population was 4.0 per 1,000 person-years. The incidence was 27.5 per 1,000 person-years in patients aged ≥80 years. A total of 21% of all patients had a provoking factor in association with the first-diagnosed episode of AF. The CHA2DS2-VASc score was 2 or higher in 81% of the patients. Permanent AF was the most common type of AF (29%).ConclusionThere was a considerable increase in the incidence of AF with age, and a provoking factor was found in one-fifth. The most common type of AF was permanent AF. Four in five patients had a CHA2DS2-VASc score of 2 or more.

Cardiac safety of adjuvant non-pegylated liposomal doxorubicin combined with cyclophosphamide and followed by paclitaxel in older breast cancer patients

PurposeTo investigate the cardiac safety of adjuvant Non-Pegylated Liposomal Doxorubicin (NPL-DOX) combined to Cyclophosphamide (CTX) and followed by weekly Paclitaxel, in older patients (≥65 years) with diagnosis of high risk breast cancer. The main end point of this prospective study was the detection of early episodes of symptomatic congestive heart failure (CHF). MethodsThe cardiac function was evaluated by left ventricular ejection fraction (LVEF) measurements with repeated echocardiograms, performed 2 weeks before the beginning of chemotherapy and every 6 months, until 30 months after the study entry; then yearly for at least 5 years. ResultsForty-seven patients were enrolled from two Italian Divisions of Medical Oncology. Final results revealed no early episodes of symptomatic CHF within the first 12 months from the enrolment. Only two cardiac events were observed: an episode of atrial flutter after the first cycle of NPL-DOX and CTX, with a quick return to normal rhythm, and a grade 3 (scored to NCI-CTCAE, version 3.0) CHF episode, 18 months later chemotherapy start. No other relevant toxicities were reported. ConclusionsThis adjuvant combination including NPL-DOX in elderly patients, resulted in a low rate of cardiac toxic effects. Comparative trials should be encouraged to confirm these findings.