Failed Catheter Ablation Research Articles

Efficacy and Safety of Stereotactic Radiotherapy in Patients With Recurrent Ventricular Tachycardias: The Czech Experience

BackgroundStereotactic arrhythmia radiotherapy (STAR) has been proposed recently in patients with refractory ventricular tachycardia (VT). ObjectivesThe purpose of this study was to describe the efficacy and safety of STAR in the Czech Republic. MethodsVT patients were recruited in 2 expert centers after at least 1 previously failed catheter ablation (CA). A precise strategy of target volume determination and CA was used in 17 patients treated from December 2018 until June 2022 (EFFICACY cohort). This group, together with an earlier series of 19 patients with less-defined treatment strategies, composed the SAFETY cohort (n = 36). A dose of 25 Gy was delivered. ResultsIn the EFFICACY cohort, the burden of implantable cardioverter-defibrillator therapies decreased, and this drop reached significance for direct current shocks (1.9 ± 3.2 vs 0.1 ± 0.2 per month; P = 0.03). Eight patients (47%) underwent repeated CA for recurrences of VT during 13.7 ± 11.6 months. In the SAFETY cohort (32 procedures, follow-up >6 months), 8 patients (25%) presented with a progression of mitral valve regurgitation, and 3 (9%) required intervention (median follow-up of 33.5 months). Two cases of esophagitis (6%) were seen with 1 death caused by the esophago-pericardial fistula (3%). A total of 18 patients (50%) died during the median follow-up of 26.9 months. ConclusionsAlthough STAR may not be very effective in preventing VT recurrences after failed CA in an expert center, it can still modify the arrhythmogenic substrate, and when used with additional CA, reduce the number of implantable cardioverter-defibrillator shocks. Potentially serious sides effects require close follow-up.

Multi-catheter cryotherapy for the treatment of resistant accessory pathways

ObjectiveTo investigate the utility of simultaneous multi-catheter cryotherapy for the treatment of APs that were previously resistant to standard radiofrequency (RF) catheter ablation. BackgroundCatheter ablation is established in the treatment of accessory pathways (AP), with high rates of permanent procedural success with a single attempt. However, there are still instances of acute procedural failure and AP recurrences with standard RF and cryotherapy methods. MethodsSeven consecutive cases of pre-excitation syndromes with prior failed RF catheter ablation had the novel treatment. Cryotherapy was delivered using two 8 mm tip focal cryoablation catheters (Freezor® Max, Medtronic, Minneapolis, Minnesota, USA). ResultsAccessory pathway localisation was septal in 5 cases, left posterolateral in 1, right lateral in 1. In all cases, ablation of the AP was acutely successful with no procedural complications. Median procedure and fluoroscopy durations were 199 and 35 min, sequentially. Median Procedure duration fell significantly in the second half of series (174 min) compared to the first half (233 min, P = 0.05). One patient had evidence of a recurring AP conduction with pre-excitation at 5-week follow up. After a median follow up of 66.8+-6.5 months, 6 out of 7 patients remained asymptomatic and free of pre-excitation. ConclusionSimultaneous multi-catheter cryotherapy is feasible, safe and can provide definitive cure of accessory pathways that were previously resistant to standard radiofrequency ablation. Further study is required in the assessment of this novel form of advanced cryotherapy to treat complex and resistant arrhythmias.

Optimized Target Delineation Procedure for the Radiosurgery Treatment of Ventricular Tachycardia: Observer-Independent Accuracy

Stereotactic body radiotherapy (SBRT) has shown promising results for patients with recurrent ventricular tachycardia that failed catheter ablation. The simplest method of target delineation based on manual transfer of CTV from several 3D visualizations (electroanatomic mapping system) to planning CT slices (2D) was subjective and very time consuming. Advanced methods are based on merging of electroanatomic maps (EAM) with CT. To date, 2 types of EAM-CT merge were proposed: manual alignment of EAM structures with segmented CT structures [1,2] and use of semi-automatic algorithm [3]. The goal of this work was to modify current method [2] with the use of robust automatic algorithms to assure reasonably short learning curve. This work is based on data of 10 patients who had previously undergone SBRT treatment for ventricular tachycardia (VT). Two observers participated in this study: (1) an electrophysiologist technician (cardiology) with substantial experience in EAM-CT merge, and (2) a clinical engineer (radiotherapy) with minimum experience with EAM-CT merge. Observer (1) performed EAM-CT merge three times for each case with an interval of at least 8h. Observer (2) did EAM-CT merge once for each patient following instructions written by observer 1. EAM-CT merge consist of 3 main steps: segmentation of left ventricle from CT (CT LV), registration of the CT LV and EAM, CTV delineation from EAM specific points. Mean Hausdorff distance (MHD), Dice Similarity Coefficient (DSC) and absolute difference in Center of Gravity (CoG) were used to assess intra/interobserver variability. All quantitative data was expressed as the mean and SD. Intraobserver variability Three segmented CT LVs were compared with each other. The mean DSC was 0,92±0,01 for all cases. The MHD was 1,49 ± 0,23 mm and the mean absolute difference in CoG coordinates was <1.5mm for all cases. The mean DSC and MHD for 3 CTVs altogether was 0,82±0,06 and 0,71 ±0,22 mm. The mean absolute difference in CoG was 0,64mm, 0,95mm and 0,78mm for X, Y, and Z coordinates, respectively. Interobserver variability Segmented CT LVs showed great similarity (mean DSC of 0,91±0,01, MHD of 1,86±0,47 mm) for all cases. The mean DSC comparing CTVs from both observers was 0,81±0,11 and MHD was 0,87±0,45 mm. The difference in CT LV volumes correlates with DSC of compared CTVs (Pearson´s correlation coefficient R = 0,8, p = 0,005) indicating that accurate segmentation of CT LV is crucial for successful precise CTV delineation. Modification of the current method based on incorporating automatic algorithms created a robust and fast method for CTV delineation. High similarity of both, the segmented CT LVs and delineated CTVs between observers confirmed robustness of the proposed method and steep learning curve.

Abstract P1046: Twenty-year Single-center Experience Of Catheter Ablation Of Ventricular Tachycardia And Progression To Heart Transplantation

Objective: Orthotopic heart transplantation (OHT) is often used as salvage therapy after failed catheter ablation for ventricular tachycardia (VT). Little is published on the results of OHT after VT ablation, and predicting which ablation patients need transplantation is difficult. The purpose of this study is to examine the effect of OHT as a therapy for failed VT ablation and to identify echocardiographic measurements that might predict the need for transplantation. Methods: All adult patients who received VT ablations at our institution between 2001 and 2021 were identified. Follow-up data was collected until mid-2022. Echocardiograms obtained at the time of ablation were analyzed by hand tracing and Phillips QLab Advanced Quantification Software (Amsterdam, Netherlands). Survival distributions were compared using a Log Rank test. Continuous variables were analyzed using independent samples T-tests. Results: 205 adult patients underwent an elective VT ablation between 2001 and 2021. Of these patients, 40 were referred for heart transplant evaluation. Of these 40 patients, 18 underwent OHT. There was a significant survival benefit after VT ablation for those who underwent OHT versus those who were referred but did not undergo OHT. There was a mean of 2.42 years of increased survival after VT ablation for the patients who were referred and transplanted versus those referred and not transplanted (p=0.016). The mean survival of patients not referred for transplantation was 4.6 ± 3.4 years. The most common barrier to transplant was obesity (n=6). Factors significantly predictive for referral to transplantation after VT ablation were lower ejection fraction (EF) (33.8% versus 45.6%), increased global longitudinal strain, and decreased fractional shortening (p&lt;0.01, p&lt;0.001, and p=0.001, respectively). Conclusion: Patients ultimately referred for OHT after VT ablation had significantly more cardiac dysfunction at the time of ablation. Once referred, morbid obesity was the most common barrier to transplantation. Lower EF, along with increased strain, was predictive of the need for transplantation. Earlier counseling of weight loss for morbidly obese patients with VT and ventricular dysfunction might lead to better survival.

LB-456089-3 WORLD WIDE EXPERIENCE WITH AN END-HOLE IRRIGATED NEEDLE CATHETER FOR ABLATION OF REFRACTORY VENTRICULAR ARRHYTHMIAS: FINAL REPORT

Deep intramural ventricular arrhythmia (VA) substrate is a frequent cause of failed radiofrequency catheter ablation (RFA). Feasibility of irrigated needle ablation (INA) with a retractable 27G end-hole needle catheter has been previously reported. Here we report the findings, outcomes and complications in the entire population treated with this catheter.

Searching for potential factors associated with failed catheter ablation of atrial fibrillation. Retrospective analysis of electronic medical records using medical decision making support service (SELECT AF study)

Searching for potential factors associated with failed catheter ablation of atrial fibrillation. Retrospective analysis of electronic medical records using medical decision making support service (SELECT AF study)

El fracaso de la ablación por catéter de la fibrilación auricular se asocia con mayor remodelado y menos eficacia de una posterior ablación toracoscópica

Introduction and objectivesRecent observations suggest that patients with a previous failed catheter ablation have an increased risk of atrial fibrillation (AF) recurrence after subsequent thoracoscopic AF ablation. We assessed the risk of AF recurrence in patients with a previous failed catheter ablation undergoing thoracoscopic ablation. MethodsWe included patients from 3 medical centers. To correct for potential heterogeneity, we performed propensity matching to compare AF freedom (freedom from any atrial tachyarrhythmia> 30 s during 1-year follow-up). Left atrial appendage tissue was analyzed for collagen distribution. ResultsA total of 705 patients were included, and 183 had a previous failed catheter ablation. These patients had fewer risk factors for AF recurrence than ablation naïve controls: smaller indexed left atrial volume (40.9± 12.5 vs 43.0±12.5 mL/m2, P=.048), less congestive heart failure (1.5% vs 8.9%, P=.001), and less persistent AF (52.2% vs 60.3%, P=.067). However, AF history duration was longer in patients with a previous failed catheter ablation (6.5 [4-10.5] vs 4 [2-8] years; P<.001). In propensity matched analysis, patients with a failed catheter ablation were at a 68% higher AF recurrence risk (OR, 1.68; 95%CI, 1.20-2.15; P=.034). AF freedom was 61.1% in patients with a previous failed catheter ablation vs 72.5% in ablation naïve matched controls. On histology of the left atrial appendage (n=198), patients with a failed catheter ablation had a higher density of collagen fibers. ConclusionsPatients with a prior failed catheter ablation had fewer risk factors for AF recurrence but more frequently had AF recurrence after thoracoscopic AF ablation than ablation naïve patients. This may in part be explained by more progressed, subclinical, atrial fibrosis formation.

Stereotactic Radiotherapy in the Management of Ventricular Tachycardias: More Questions than Answers?

Stereotactic body radiotherapy is a recent promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias (VTs) in patients with structural heart disease. Initial clinical experience with a single radiation dose of 25Gy shows reasonable efficacy in the reduction of VT recurrences with acceptable acute toxicity. Many unanswered questions remain, including unknown mechanism of action, variable time to effect, optimal method of substrate targeting, long-term safety, and definition of an optimal candidate for this treatment."

Long-term toxicity of radiosurgery for ablation of ventricular tachycardia

Abstract Introduction There is a rising interest in using radiosurgery to modify arrhythmogenic substrate in patients with recurrent VT. However, data on the safety are still inadequate. Purpose This is update of toxicity evaluation based on the compilation from our case series, NIRA-VT and STAR-VT. Methods Between 2014 and March 2021, 36 patients (33 male, 3 females; mean age 66±10 years) with structural heart disease (ischemic cardiopathy, dilated cardiopathy or fibroma associated scar) from two electrophysiology centers in the Czech Republic (Trinec, Prague) underwent radiosurgery for recurrent VT. Radiosurgery was performed after at least one failed catheter ablation for VT. The critical part of the VT substrate was identified by electroanatomic mapping using a combination of voltage mapping, pace mapping, and activation mapping; and it was marked on a contrast-enhanced computer tomography study as a CTV. In NIRA-VT trial, CTV included scar based on PET/CT evaluation. Radiosurgery system with real-time motion tracking using the tip of the electrode of an indwelling defibrillator as a fiducial marker was used. A total radiation dose of 25 Gy was delivered to the ablation target in a single session during free breathing. Radiation-induced toxicity was evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Only patients with follow up longer than 6 months were included in long term radiation related side effects evaluation. Results The mean CTV and PTV were 26±11 ml and 41±22 ml respectively. No patient exhibited acute (up to 3 months) elevation of troponin, pericardial effusion, or a decrease in left ventricular ejection fraction from baseline. Four patients developed acute mild nausea, which waned after antiemetic drugs. Long-term radiation related side effects were evaluated in 19 patients. Two patients (11%) presented radiological signs of lung fibrosis in small area in close distance from PTV. There was no significant decrease in left ventricular ejection fraction during follow up. Six patients (33%) gradually developed significant progression of known mitral regurgitation after SBRT, two (11%) of them had to undergo mitral valve replacement (grade 4 toxicity). Two cases of esophagitis (12%) were seen with one radiation toxicity related death (grade 5 toxicity) due to the unresectable esophagi-pericardial fistula (6%). Conclusions Our data indicate the feasibility of radiosurgery, majority of patients presented no/mild radiation related toxicity and decrease of VT burden. However, we have seen three cases of grade 4,5 toxicity. To further investigate long-term safety and efficacy of radiosuergery for VT, enrolling into a randomized prospective study is in progress. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020

A failed catheter ablation of atrial fibrillation is associated with more advanced remodeling and reduced efficacy of further thoracoscopic ablation

Introduction and objectivesRecent observations suggest that patients with a previous failed catheter ablation have an increased risk of atrial fibrillation (AF) recurrence after subsequent thoracoscopic AF ablation. We assessed the risk of AF recurrence in patients with a previous failed catheter ablation undergoing thoracoscopic ablation. MethodsWe included patients from 3 medical centers. To correct for potential heterogeneity, we performed propensity matching to compare AF freedom (freedom from any atrial tachyarrhythmia> 30 s during 1-year follow-up). Left atrial appendage tissue was analyzed for collagen distribution. ResultsA total of 705 patients were included, and 183 had a previous failed catheter ablation. These patients had fewer risk factors for AF recurrence than ablation naïve controls: smaller indexed left atrial volume (40.9± 12.5 vs 43.0±12.5 mL/m2, P=.048), less congestive heart failure (1.5% vs 8.9%, P=.001), and less persistent AF (52.2% vs 60.3%, P=.067). However, AF history duration was longer in patients with a previous failed catheter ablation (6.5 [4-10.5] vs 4 [2-8] years; P<.001). In propensity matched analysis, patients with a failed catheter ablation were at a 68% higher AF recurrence risk (OR, 1.68; 95%CI, 1.20-2.15; P=.034). AF freedom was 61.1% in patients with a previous failed catheter ablation vs 72.5% in ablation naïve matched controls. On histology of the left atrial appendage (n=198), patients with a failed catheter ablation had a higher density of collagen fibers. ConclusionsPatients with a prior failed catheter ablation had fewer risk factors for AF recurrence but more frequently had AF recurrence after thoracoscopic AF ablation than ablation naïve patients. This may in part be explained by more progressed, subclinical, atrial fibrosis formation.

Determinants of mortality after stereotactic radio-ablation for ventricular tachycardia. Results from the international MUSIC consortium

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Research Council Background SBRT is currently restrained to the most severe patients with drug- and catheter ablation-refractory VT, often associated with advanced heart failure. Purpose To analyze the determinants of mortality after SBRT for VT. Methods Patients with drug- and catheter ablation-refractory VT underwent imaging prior to SBRT. The inHEART technology was used to create image-based 3D models of substrate, cardiac anatomy, and organs at risk (coronaries, phrenic nerve, GI tract, AV node). In MUSIC software (IHU Liryc-Inria), 3D models were fused with prior EP maps, and SBRT targets were interactively drawn in 3D by the referring EP cardiologist. Transmural target volumes and organs at risk were fused with a 4D planning CT and used to plan SBRT in Eclipse (Varian). SBRT was delivered with either Truebeam or Edge systems (Varian), at a total dose of 25 Gy in a single session. The determinants of adverse outcomes after SBRT were analyzed. Results 30 pts from 7 centers were included (age 70±10, 90% men). Mean LVEF was 26±9%. The VT etiology was ischemic in 67%, and non-ischemic or mixed in 47%. Patients had undergone a mean of 1.7±1.2 prior failed catheter ablation procedures. SBRT was delivered on median planning treatment volumes (PTVs) of 96[63-149] mL. Complications attributed to SBRT were observed in 2/30 (7%), none of which were fatal (heart failure and pneumonitis, both managed with steroids). Over a median FU of 4[2-8] months, death or heart transplant occurred in 11(37%) pts, attributed to VT recurrence in 4(13%), and heart failure in 7(23%). On univariate analysis, patients experiencing death or transplant after SBRT were older (77±6 vs. 66±9 years, P=0.001) and showed lower LVEF (22±6 vs. 29±10%, P=0.03). In contrast, mortality or transplant did not relate to the underlying VT etiology (P=0.30), the number of prior catheter ablations (P=0.20), the pre-SBRT VT burden (P=0.20) and the SBRT treatment volume (P=0.18). Conclusion In patients with severe drug- and catheter ablation-refractory VT undergoing cardiac SBRT, mortality is most often due to non-arrhythmic causes, and is more driven by age and LV dysfunction than by the VT substrate, pre-SBRT arrhythmia burden, and SBRT treatment volume.

Short term outcome of distal (ventricular) His bundle pacing and atrioventricular node ablation in patients with symptomatic atrial fibrillation - Refining the concept

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Many patients with atrial fibrillation (AF) do not benefit from rhythm control due to failed catheter ablation, advanced left atrial disease and comorbidities. "Pace and AV node (AVN) ablation" strategy is often adopted for rate control but with a substantial risk of pacing-induced cardiomyopathy. His bundle pacing (HBP) enables physiological biventricular activation through the His Purkinje conduction system. However, the proximity of the HBP lead to the site of AV node ablation may potentially compromise lead integrity in patients who undergo conventional HBP and AVN ablation. Therefore, we have modified HBP by placing the HBP lead distally at the ventricular side of the His bundle (D-HBP) before AVN ablation in patients with symptomatic AF. All patients had a backup RV lead. Method Patients who had D-HBP as part of a "Pace and AVN ablation" strategy were retrospectively analysed. Implant and device clinic follow-up data were collected and analysed. Result Twenty-one patients who had "pace and AVN ablation strategy" with D-HBP between 26th February 2020 and 3rd November 2021 were included. They had a mean age of 75 ± 1.4 years (mean ± SEM), NYHA class of 2.1 ± 0.2, QRS duration of 106 ± 5.3ms and 50% had at least moderately impaired LV systolic function. Seventeen patients (81%) had narrow QRS duration. D-HBP was successful in twenty of twenty-one patients (95%). At D-HBP implant, the mean acute threshold of the HBP lead was 0.96 ± 0.12V at 0.5 ± 0.05ms and the mean HBP lead impedance was 548.1 ± 29.5Ω. Selective HBP pacing was observed in thirteen of twenty patients. The mean QRS duration of HBP paced beats was 104.5 ± 4.7ms. Failure to capture the His bundle was observed in one patient. AVN ablation was performed on the same day after D-HBP in eleven patients and as a subsequent procedure in nine patients. The mean duration of procedure and fluoroscopy for D-HBP were 77.4 ± 4.6 minutes and 11.9 ± 1.4 minutes respectively. There were no acute procedural complications with no lead damage, displacement or lead perforation observed. The median follow-up period was 207 days. The mean D-HBP lead threshold following AVN ablation was 1.1 ± 0.2 V at 0.6 ± 0.07 ms and the mean lead impedance was 433.8 ± 20.7Ω, which were similar to before AVN ablation. One patient was reprogrammed with RV pacing only for elevated HBP lead threshold after AVN ablation to 4.2 V at 1ms. The mean D-HBP percentage was 92.3 ± 6.6% and the mean estimated battery longevity of the pacemaker was 7.9 ± 0.6 years at the last follow up. There was improvement in heart failure symptoms in eight patients from previously symptomatic to NYHA class I following D-HBP and AVN ablation. Conclusion D-HBP appear to be safe with potentially more favourable lead parameters than conventional proximal HBP in patients with symptomatic AF offered "Pace and AVN ablation" strategy.

Stereotactic Ablative Radiotherapy of Ventricular Tachycardia Using Tracking: Optimized Target Definition Workflow.

Background and PurposeStereotactic arrhythmia radioablation (STAR) has been suggested as a promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias in patients with structural heart disease. Cyberknife® robotic radiosurgery system utilizing target tracking technology is one of the available STAR treatment platforms. Tracking using implantable cardioverter-defibrillator lead tip as target surrogate marker is affected by the deformation of marker–target geometry. A simple method to account for the deformation in the target definition process is proposed.MethodsRadiotherapy planning CT series include scans at expiration and inspiration breath hold, and three free-breathing scans. All secondary series are triple registered to the primary CT: 6D/spine + 3D translation/marker + 3D translation/target surrogate—a heterogeneous structure around the left main coronary artery. The 3D translation difference between the last two registrations reflects the deformation between the marker and the target (surrogate) for the respective respiratory phase. Maximum translation differences in each direction form an anisotropic geometry deformation margin (GDM) to expand the initial single-phase clinical target volume (CTV) to create an internal target volume (ITV) in the dynamic coordinates of the marker. Alternative GDM-based target volumes were created for seven recent STAR patients and compared to the original treated planning target volumes (PTVs) as well as to analogical volumes created using deformable image registration (DIR) by MIM® and Velocity® software. Intra- and inter-observer variabilities of the triple registration process were tested as components of the final ITV to PTV margin.ResultsA margin of 2 mm has been found to cover the image registration observer variability. GDM-based target volumes are larger and shifted toward the inspiration phase relative to the original clinical volumes based on a 3-mm isotropic margin without deformation consideration. GDM-based targets are similar (mean DICE similarity coefficient range 0.80–0.87) to their equivalents based on the DIR of the primary target volume delineated by dedicated software.ConclusionThe proposed GDM method is a simple way to account for marker–target deformation-related uncertainty for tracking with Cyberknife® and better control of the risk of target underdose. The principle applies to general radiotherapy as well.

Does left atrial epicardial conduction time reflect atrial fibrosis and the risk of atrial fibrillation recurrence after thoracoscopic ablation? Post hoc analysis of the AFACT trial

ObjectivesTo determine the association between left atrial epicardial conduction time (LAECT), fibrosis and atrial fibrillation (AF) recurrence after thoracoscopic surgical ablation of persistent AF.SettingSingle tertiary care centre in the Netherlands.ParticipantsPatients...

2021 Korean Heart Rhythm Society Guidelines for Catheter or Surgical Ablation of Atrial Fibrillation

Rhythm control therapy is used in atrial fibrillation (AF) management to improve AF-related symptoms along with rate control. AF catheter ablation is effective in maintaining sinus rhythm and has an acceptable complication rate. Compared with antiarrhythmic drugs, AF catheter ablation is superior with respect to arrhythmia-free survival and improvement in the quality of life. Therefore, AF ablation is recommended for rhythm control after the failure of antiarrhythmic drugs and is sometimes considered a first-line therapy for AF patients. Radiofrequency and cryoballoon ablation show similar efficacy, with slightly different complication profiles. Surgery for AF is also an effective rhythm control therapy and should be considered in patients undergoing cardiac surgery or in those with failed catheter ablation. For patients undergoing AF catheter ablation, performing ablation under uninterrupted warfarin or non-vitamin K oral anticoagulant treatment is recommended for periprocedural stroke risk management. Here, we review existing data and discuss the general principles of AF catheter and surgical ablation in patients with AF.

Radiation-Induced Changes in VentricularMyocardium After Stereotactic Body Radiotherapy for Recurrent Ventricular Tachycardia.

Stereotactic body radiotherapy (SBRT) has been suggested as a promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias (VTs) in patients with structural heart disease. This case series is the first postmortem immunohistochemical analysis of morphologic changes in the myocardium early and late after SBRT. The present findings are in line with experimental observations on apoptosis followed by fibrosis. This may explain why the effect of SBRT on VT is not predominantly immediate. Together with observation of early recurrences after SBRT for VT, these data suggest that this strategy may have rather delayed antiarrhythmic effects.

Thoracoscopic ablation for symptomatic atrial fibrillation improves quality of life

Abstract Background Rhythm control has become an essential part of adequate management in atrial fibrillation (AF) to reduce symptoms and ultimately to improve health related quality of life (HRQoL). Totally thoracoscopic ablation has been established over the last years as an effective and safe rhythm control strategy, especially for persistent AF, but quality of life data are lacking. Purpose To assess the impact of totally thoracoscopic ablation on HRQoL in patients with symptomatic AF. Methods Consecutive patients with symptomatic AF undergoing totally thoracoscopic ablation at a referral centre in the Netherlands (July 2016 – October 2019) were included. The primary outcome was quality of life. Short Form 36 and Atrial Fibrillation Effect on Quality-of-Life (AFEQT) health surveys were collected at baseline, 1, 3, 6 and 12 months. Clinical improvement was measured as the relative increase of the QoL-score at 1 year compared to the baseline score (in %). Multilevel regression modelling was used, coupled with fractional polynomials for adjustment of age differences and nonlinear time trends, to investigate the one-year clinical trajectories of sex differences in QoL subscales. Secondary outcomes included rhythm success (freedom from any recurrence of atrial tachyarrhythmia&amp;gt;30 sec), mortality and stroke. Results 191 patients were included (63.9±8.6 years, 68% male, 22.5% paroxysmal AF, 69.6% persistent AF and 7.9% long-term persistent AF, 66.5% having at least one previous failed catheter ablation, with median Cha2ds2 Vasc score of 2 [IQR 1–3]). AFEQT sum scores (52.6 points at baseline) substantially improved after three months (49.8%; p&amp;lt;0.001) and remained stable up to 1-year (54.2%; p&amp;lt;0.001) despite adverse events. Patients with recurrent AF also showed significant improvement at 3 months which remained stable up to 1-year, but patients who remained in sinus rhythm had significantly more increase (61.3% vs 26.9%, p&amp;lt;.001). The SF36 physical and mental summary composite scores significantly improved after 3 months (12.3% and 11.9% respectively; p&amp;lt;.001) and remained stable up to 1-year (16.9% and 16.4% respectively; P&amp;lt;.001). Although female patients had significantly lower AFEQT and physical subscales at baseline, similar improvement in scores were observed over time compared to men, adjusted for age and sex interactions (P&amp;lt;.001). One-year stroke rate was 1.6 per 100 patient-years with an oral anticoagulation rate of 63%. One-year survival was 99.5%. Conclusions This study reveals significant improvement of HRQoL three months after thoracoscopic ablation that persisted up to 1-year, also when adjusted for sex and age differences. Despite AF recurrence or adverse events AF related QoL still improved. Trials are necessary to confirm these data. Funding Acknowledgement Type of funding sources: None.

Case series on stereotactic body radiation therapy in non-ischemic cardiomyopathy patients with recurrent ventricular tachycardia.

The efficacy of stereotactic body radiation therapy (SBRT) as an alternative treatment for recurrent ventricular tachycardia (VT) is still unclear. This study aimed to report the outcome of SBRT in VT patients with nonischemic cardiomyopathy (NICM). The determination of the target substrate for radiation was based on the combination of CMR results and electroanatomical mapping merged with the real-time CT scan image. Radiation therapy was performed by Flattening-filter-free (Truebeam) system, and afterward, patients were followed up for 13.5 ± 2.8 months. We analyzed the outcome of death, incidence of recurrent VT, ICD shocks, anti-tachycardia pacing (ATP) sequences, and possible irradiation side-effects. A total of three cases of NICM patients with anteroseptal scar detected by CMR. SBRT was successfully performed in all patients. During the follow-up, we found that VT recurrences occurred in all patients. In one patient, it happened during a 6-week blanking period, while the others happened afterward. Re-hospitalization due to VT only appeared in one patient. Through ICD interrogation, we found that all patients have reduced VT burden and ATP therapies. All of the patients died during the follow-up period. Radiotherapy-related adverse events did not occur in all patients. SBRT therapy reduces the number of VT burden and ATP sequence therapy in NICM patients with VT, which had a failed previous catheter ablation. However, the efficacy and safety aspects, especially in NICM cases, remained unclear.

Renal sympathetic denervation for the treatment of recurrent ventricular arrhythmias-ELECTRAM investigators.

Renal sympathetic denervation (RSDN) is an alternate management approach for refractory ventricular arrhythmias (VAs). We aimed to perform a systematic review of clinical outcomes on the impact of RSDN on refractory VA patients. A systematic search without language restriction, using PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov from inception to August 18, 2020, was performed for the studies that reported outcomes in patients who underwent RSDN for VA. The outcomes studied were-(1) recurrent VA; and (2) all-cause mortality. Five studies (from 2014 to 2018) with a total of 51 VA patients met study inclusion criteria. The mean age was 61.92±11.76 years, and 78.4% were men. The pooled incidence of short-term (3 months or less) and long-term (more than 3 months) VA recurrence was 63.85% (95% CI 16.75 to 99.32) and 10.52% (95% CI 0.14 to 28.75), respectively. When stratified by the number of VA episodes, there was a significant reduction in mean VA episodes (SMD -3.79, 95% CI -6.59 to -0.98, p<.01), ICD shocks (SMD -1.71, 95% CI -3.0 to -0.42, p<.01) and anti-tachycardia pacing (SMD -1.21, 95% CI -1.98 to -0.44, p<.01) following RSDN denervation. The pooled incidence of all-cause mortality after RSDN was 10.16% (95% CI 1.08 to 24.12). There were no major vascular complications, one minor vascular complication-small non-flow limiting renal artery dissection (no intervention needed). RSDN appears to be a safe and effective treatment strategy in patients with prior failed antiarrhythmic drugs and catheter ablation for recurrent ventricular arrhythmia and electrical storm.

158 Management of Atrial Fibrillation in Patients with Cerebral Amyloid Angiopathy: Multidisciplinary Neuro-Cardiology Approach

Abstract We present two cases that highlight the clinical challenge of anti coagulation in patients with intracerebral haemorrhage (ICH) due to Cerebral Amyloid Angiopathy (CAA) and co-existent non-valvular Atrial Fibrillation (AF). Case 1 78 -Years right-handed functionally independent gentleman presented with right parietal intracerebral haemorrhage (ICH) on Dabigatran that required reversal. He had a background history of hypertension, persistent AF and a previous ICH on warfarin. Post atrial septal defect repair, he had multiple unsuccessful cardioversions for AF, and a failed catheter ablation after the first stroke. Magnetic Resonance Imaging (MRI) brain showed Cerebral Amyloid Angiopathy (CAA), the cause of his recurrent bleeds. Anticoagulation was not started due to severe CAA on imaging and recurrent bleeds. He was referred for left atrial closure device. Case 2 79-Years female presented with left parietal haemorrhage and new onset atrial fibrillation. Work up for ICH showed normal BP readings and clotting profile. Her MRI brain showed a large lobar bleed with mild small vessel disease and evidence of no other imaging features suggestive of CAA. As optimal timing to start anticoagulation after ICH is unknown, she was suggested to take part in a clinical trial. Her family declined the offer of clinical trial and also anti coagulation due to few falls. Her CHAD-VaSc and HAS-BLED score were 4 and 2 respectively. She was then referred to tertiary centre for left atrial appendage closure device. Conclusion Safety and timing to initiate DOAC for AF in this group is not established yet, understanding hemorrhagic risk using Boston Criteria for CAA diagnosis should be considered in addition to HAS-BLED score. Shared decision making and comprehensive discussions with cardiologist are of paramount importance. Non pharmacological intervention studies WATCHMAN and PREVAIL have proven procedural efficacy, however, in elderly population, decision making is complex due to frailty, dementia and co-morbidities.