History Of Permanent Atrial Fibrillation Research Articles

Complementary use of conduction system pacing techniques for the “pace and ablate” strategy in permanent atrial fibrillation - a case report

Abstract Introduction The feasibility of the conduction system pacing combined with atrioventricular node ablation was demonstrated in patients with atrial fibrillation in whom rate control can’t be achieved with medication and heart failure. Clinical case We present a case of an 82-year-old man with a personal history of permanent atrial fibrillation, admitted with symptoms of heart failure. The resting electrocardiogram showed a very fast ventricular response, and the echocardiography showed a depressed left ventricular function, raising the suspicion of a tachycardia-mediated cardiomyopathy. Since the patient was on maximum doses of atrioventricular nodal-blocking drugs, we opted for a physiological pacing and atrioventricular node ablation strategy. First, the His bundle capture was achieved at low pacing thresholds, and ablation of the atrioventricular node was attempted. Unfortunately, after several failed attempts, an acute increase in the His bundle capture threshold was noted, suggesting inadvertent tissue ablation beneath the pacing lead. In this scenario, we removed the lead from the His bundle area and achieved optimal left bundle branch area pacing. With the lead in this position, atrioventricular node ablation was performed during the first attempt. At the six-month follow-up, there was no recovery of atrioventricular node conduction. Device interrogation revealed stable pacing and sensing parameters, and there was a significant improvement in clinical status and left ventricular function. Conclusions Mastering both His bundle pacing and left bundle branch area pacing offers the potential to overcome intraprocedural challenges, giving alternative strategies to achieve physiological pacing. These approaches can be used interchangeably based on the evolving dynamics of the procedure and the patient’s specific needs.

A clinical case of a patient after COVID 19 infection and a thrombus in the right atrium, deep phlebothrombosis, and pulmonary embolism

Background: The coronavirus disease (COVID-19 disease) leads to multiple organ disease, inflammation of the endothelium, and micro- or macrovasculitis that may result in thrombosis of the small vessels, and thrombosis of vessels in various organs, as well as intracardiac thrombosis. Some of the complications may be long-lasting, as in our case, which makes it particularly interesting to discuss. Case report: We present a 73-year-old male patient with a history of permanent atrial fibrillation and chronic heart failure (II NYHA class), popliteal phlebothrombosis, and surgery of the left hip joint. 53 days after a positive rapid test for Covid 19 performed because of fever and coughing, the patient, who is not vaccinated for Covid 19, was hospitalised at our Department with clinical signs of mild respiratory failure and cardiogenic shock.  The laboratory tests revealed elevated markers of inflammation. The ECG showed tachyarrhythmia (170/min) and atrial fibrillation. The EchoCG displayed evidence of right systolic dysfunction, pulmonary hypertension, and a massive thrombus in the right atrium. The Doppler ultrasonography revealed the presence of right femoropopliteal thrombosis, while the CT-pulmoangiography showed evidence of massive bilateral PE. A decision was made to perform systemic fibrinolysis, which the patient tolerated without complications. During the hospitalisation, the examinations revealed no evidence of an oncological disease. Conclusion: The reported clinical case confirms the high risk of thrombosis due to a COVID-19 infection, such as phlebothrombosis, atrial thrombosis, and massive bilateral PE, in the absence of optimal anticoagulant therapy and against the backdrop of the administration of antiplatelet therapy roughly 2 months after the onset of the COVID-19 symptoms.

Is It The Blame of The Occluder? Two Cases of Massive Thrombosis in the Left Atrium in Patients with Bioprosthetic Mitral Valve and the Presence of the Occluder Implanted Percutaneously

In the following case report, we present two clinical cases of patients after valvular intervention and percutaneous occluder implantation into the left atrium. The first patient is a 68-year-old male admitted to the Department of Cardiology because of Non-ST-Elevation Myocardial Infarction (NSTEMI). He had a medical history of paroxysmal atrial fibrillation and implantation of a biological mitral prosthesis due to severe secondary mitral regurgitation. Due to contraindications to the chronic use of anticoagulants, the patient underwent percutaneous closure of the left atrium appendage. The second patient is an 80-year-old man with a history of permanent atrial fibrillation. 8 years ago, the patient underwent percutaneous atrial septal defect type II (ASD II) closure with and the Amplatz occluder. A year later, the patient underwent Coronary Artery Bypass Graft (CABG) and biological mitral valve implantation due to multivessel coronary disease accompanied by severe mitral regurgitation. In both patients, Transthoracic Echocardiogram (TTE) showed massive thrombosis in the left atrium.

Spontaneous Hemopericardium: A Lesson on Risk-Benefit Profile of Contemporary Oral Anticoagulant Therapy Prompted by an Uncommon Occurrence

Anticoagulation therapy is of paramount importance in atrial fibrillation (AF) because of the substantial risk for stroke associated with high morbidity and mortality. The current therapeutic options include vitamin K antagonists and novel oral anticoagulant agents. Despite meticulous therapy selection, the risk for bleeding remains with all forms of anticoagulation and has infrequently been reported in the form of hemopericardium. We highlight a patient case of an 84-year-old man with a history of permanent atrial fibrillation on warfarin who presented with shortness of breath and was found to have a massive hemopericardium.

Blood Plasma Resistin and Atrial Fibrillation in Patients With Cardiovascular Disease.

BackgroundAtrial fibrillation (AF) affects quality of life and prognosis of patients with cardiovascular disease. Resistin plays an important role in inflammatory response to internal and external factors. The aim of this study is to evaluate the association between resistin and permanent AF (PAF) in patients with cardiovascular disease.MethodsIn our study, we included 146 patients with cardiovascular disease. Plasma resistin concentrations and demographic characteristics of patients were recorded. The patients were divided in two groups: 118 patients without a history of PAF (NonAF group), and 28 patients with a history of PAF (AF group). Association of resistin with PAF and other variables was examined by parametric and non-parametric tests, and multivariable linear and univariable logistic regression analysis.ResultsNo differences of demographic characteristics (gender, age and body mass index (BMI)) between two groups were observed (P > 0.05). Higher median levels of resistin were observed in group AF than in group NonAF (6.90 ng/mL vs. 5.83 ng/mL, P = 0.03). Multivariate linear regression analysis (adjusted to gender, age, BMI, hypertension, diabetes mellitus, coronary artery disease, and mitral valve disease) showed that resistin was associated with PAF (β = 0.79, 95% confidence interval (CI): 0.08 to 1.51, P = 0.03).ConclusionsOur analysis showed that plasma resistin was associated with PAF, and resistin concentration was higher in patients with AF compared to those without AF.

504 Intramural hematoma post transcatheter valve replacement

Abstract Background Transcatheter valve replacement (TAVR ) is currently the optimal treatment for patients with severe aortic stenosis who are considered to have an intermediate to high operative risk for surgical intervention. Intramural hematoma secondary to balloon-expandable TAVR is a poorly reported complication with unknown outcome. Among the risk factors associated with this complication are advanced age, female gender, bulky calcifications, significant basal hypertrophy and severe prothesis oversizing. Case report We report the case of a 84 year old woman with a history of permanent atrial fibrillation, who was diagnosed with severe aortic stenosis symptomatic with heart failure NYHA class III. An important comorbidity was liver cirrhosis of viral etiology (hepatitis C virus) with secondary thrombocytopenia. Transthoracic and transoesophageal echocardiography (TEE) showed severe aortic stenosis with asymmetric calcifications, with preserved gradient (a peak velocity of 4.7 m/s, mean gradient of 63.3mmHg), mild left ventricular disfunction (ejection fraction 45%), and calculated aortic valve area of 0,9 cm2. As a frail, high risk patient, the heart team recommended transcatheter aortic valve implantation. After complete computer tomographic evaluation, a 26 mm Edwards Sapien 3 valve was implanted through a femoral approach. Intraprocedural transesophageal echocardiography showed the developement of an intramural hematoma in the aortic root (right coronary and noncoronary sinuses), associated with a small pericardial effusion. After administration of Protamine, betablockers and strict blood pressure control, no extension of the hematoma was noted. Serial TEE showed significant regression of the hematoma and of the pericardial effusion, with normal parametres of the prothesis, with a transprothetic gradient of 23 mmHg, no aortic leak, no other complications.The patient was discharged 12 days after the procedure, clinically stable. Conclusion Aortic intramural hematoma may occur during intra-TAVR procedure. Although it may have a benign course, timely recognition and adequate imaging follow-up are mandatory in order to limit the extent and prevent life-threatening complications.

P6544A real world study of high frequency atrial anti-tachycardia pacing in new algorithm for atrial arrhythmia

Abstract Background Advanced pacemakers feature atrial antitachycardia pacing (aATP) therapies for terminating atrial arrhythmia. Previous studies showed the efficacy of combined atrial preventive pacing and aATP in patients with pacemakers. The independent effect of aATP and the impact for patients outside the clinical trials has not been well elucidated. Methods In a single center, prospective, all-comers trial, we enrolled 567 patients implanted cardiac devices with Reactive ATP function. History of permanent atrial fibrillation (AF) was not included. After device interrogation of the AF burden and the longest AF duration in the last 6 months, aATP was programmed as a bit more aggressive setting than MINERVA trial (time interval was set as every 2 hours). As for newly implanted devices, aATP was activated after at least 3 months run-in period. Primary and secondary outcomes were the longest AF duration and cumulative percentage of progression into permanent AF, respectively. Results Of 541 eligible patients, aged 75.3±10.7 years, 356 pacemaker, 82 ICD and 103 CRT patients, the longest single episode of AF lasted ≤6 min in 439 patients (81.1%), >6 min to 6 h in 43 (8.0%), >6–24 h in 33 (6.1%), and >24 h in 26 (4.8%) at the enrollment. During mean follow-up of 1.9 years, the longest AF episode lasted >24 h in 49 patients (9.1%) and 14 patients (2.6%) progressed into permanent AF. According with baseline longest single episode of AF, patients with AF ≤6 min developed an episode >24 h in 0.8% at 1 year and 3.2% at 2 years follow up; patients with AF >6 min to 6 h developed an episode >24 h in none at 1 year and 7% at 2 years follow up; and patients with AF >6–24 h developed an episode >24 h in 19% at 1 year and 42% at 2 years follow up, respectively. In a subgroup analysis of in 192 patients with at least 1 aATP, 46 patients with high efficacy (>44%) did not developed an episode >24 h. Only one patient developed into permanent AF without aATP therapy. On multivariate analysis, neither ICD nor CRT was independent risk factor for developing the longest AF episode >24 h. Conclusions The independent use of aATP without atrial preventive pacing was effective for preventing AF progression in a real world cohort. Even without the previous AF episodes, aATP could prevent AF development, especially in patients showing high aATP efficacy. Future research is required to enhance the aATP success rate.

ACUTE PULMONARY EDEMA SECONDARY TO HYDROCLOROTHIAZIDE ADMINISTRATION

Objective: To describe the clinical presentation and evolution of a severe and rare adverse reaction to hydroclorothiazide. Design and method: We present the case of a 74-year-old woman with a personal history of permanent atrial fibrillation under treatment with acenocumarol, pacemaker carrier, rheumatic valvular heart disease (moderate aortic stenosis and mitral mechanical prosthesis), chronic heapitis B viral infection and autoimmune hypothyroidism. She had previous severe adverse reactions with antihypertensive combined drugs in two ocasions: with hydroclorothiazide/valsartan and amilorid/ hydroclorothiazide. The patient was derivated to the emergency room from the Allergy Day Hospital. While perfoming an allergy provocation test with hydroclorothiazide (HCTZ) she rapidly developed hypotension (60/40 mmHg), fever (37.8 °C), dyspnea and desaturation with congestive symptoms. The patient required intensive care management with not invasive mechanical ventilation and vasoactive support. Results: The patient evolved favorably with rapid improvement of the congestive symptoms after supportive management and diuretics. Blood analyses revealed transient leukopenia 700/μL (Neutrophils 300/ μL; Lymphocytes 300/ μL), eosinophilia was not observed. Hemoglobin and platelets were whithin normal range and no renal, hepatic or ionic alterations were observed. Troponin levels were normal. C-reactive protein and Nt-proBNP were mild elevates (5.4 mg/dL and 2686 ng/L respectively). No changes were observed in the electrocardiogram. Chest X-ray showed bilateral pleural effusion and vascular redistribution. An echocardiogram was performed, without changes in the left ejection fraction, valvulopathies or contractility compared to the previous one performed a few months earlier. Blood and urine cultures and the patch test for HCTZ was negative. The leukopenia resolved and Nt-proBNP normalized in about 48 hours. Conclusions: There have been sporadic reports of hydroclorothiazid causing noncardiogenic pulmonary edema as an idiosyncratic reaction. The onset of symptoms typically occurs quickly after ingesting the medication (often within an hour). Due to the rare incidence of this reaction (less than 50 cases described in the literature), the diagnosis of HCTZ-induced pulmonary edema is often made only on re-exposure to the medication and may masquerade as septic shock and acute respiratory distress syndrome from a pneumonia. The possible mechanisms of the pulmonary edema still remain unknown.

Left ventricular hypertrophy diagnosed after a stroke: a case report

BackgroundStroke is a recognized clinical course of hypertrophic cardiomyopathy. This interesting case showed notable difference on the electrocardiogram of a patient 4 months prior to suffering a stroke and 10 days after suffering a stroke. The pre-stroke electrocardiogram showed atrial fibrillation with a narrow QRS complex, while the post-stroke electrocardiogram showed marked left ventricular hypertrophy. Left ventricular hypertrophy was diagnosed using the Sokolow-Lyon indices. The development of left ventricular hypertrophy a few days after suffering a stroke has not previously been reported.Case presentationAn 83-year-old white British woman with a background history of permanent atrial fibrillation, hypertension, and previous stroke attended the emergency department with a 2-day history of exertional dyspnea, and chest tightness. On examination, she had bibasal crepitations with a systolic murmur loudest at the apex.In-patient investigations include an electrocardiogram, blood tests, chest X-ray, contrast echocardiogram, coronary angiogram, and cardiovascular magnetic resonance imaging. An electrocardiogram showed atrial fibrillation, with inferolateral T wave inversion, and left ventricular hypertrophy. A chest X-ray showed features consistent with pulmonary edema. A contrast echocardiogram showed marked hypertrophy of the mid to apical left ventricle, appearance consistent with apical hypertrophic cardiomyopathy. Coronary angiography showed eccentric shelf-type plaque with non-flow-limiting stenosis in the left coronary artery main stem. Cardiovascular magnetic resonance imaging reported findings highly suggestive of apical hypertrophic cardiomyopathy. Our patient was treated and discharged on rivaroxaban, bisoprolol, and atorvastatin with a follow-up in the cardiomyopathy outpatient clinic.ConclusionsElectrocardiogram diagnosis of left ventricular hypertrophy led to the diagnosis of apical hypertrophic cardiomyopathy in this patient. Left ventricular hypertrophy was only evident a few days after our patient suffered a stroke. The underlying mechanisms responsible for this remain unclear. Furthermore, differential diagnosis of hypertrophic cardiomyopathy should be considered in people with electrocardiogram criteria for left ventricular hypertrophy. Cardiovascular magnetic resonance imaging is an important diagnostic tool in identifying causes of left ventricular hypertrophy. Family screening should be recommended in patients with new diagnosis of hypertrophic cardiomyopathy.

When Heart Failure has to do with Past Abdominal Surgery

A 70-year-old woman, with a past medical history of permanent atrial fibrillation, cholecystectomy for symptomatic gallstones and obesity (54 kg/m² body mass index), was admitted to the hospital for rapidly increasing dyspnea (NYHA class III). At admission, heart rate was 110 beats per minute (bpm) and blood pressure was 125/73 mmHg. Physical examination revealed clinical signs of right heart failure including major peripheral oedema, hepatomegaly, bilateral pleural effusion, and ascites with no signs of portal hypertension or hepatocellular insufficiency.

Too Much of a Good Thing: Digitalis Toxicity

PRESENTATION Never underestimate a patient’s willingness to alter the prescribed therapeutic plan. A 79-year-old man with a history of permanent atrial fibrillation was brought to the emergency department after 3 days of severe nausea and nonbloody/nonbilious emesis. He also reported a decrease in urine output, extreme fatigue, and worsening blurry vision with “flashing white lights.” Eighteen days prior to his presentation, he had a pharyngeal cyst removed and tracheostomy and gastrostomy tubes were placed. Postoperatively, his digoxin formulation was changed from tablet to an equivalent dosage of liquid preparation. He was discharged on postoperative day 8.

Atrial antitachycardia pacing and managed ventricular pacing in bradycardia patients with paroxysmal or persistent atrial tachyarrhythmias: the MINERVA randomized multicentre international trial.

AimsAtrial fibrillation (AF) is a common comorbidity in bradycardia patients. Advanced pacemakers feature atrial preventive pacing and atrial antitachycardia pacing (DDDRP) and managed ventricular pacing (MVP), which minimizes unnecessary right ventricular pacing. We evaluated whether DDDRP and MVP might reduce mortality, morbidity, or progression to permanent AF when compared with standard dual-chamber pacing (Control DDDR).Methods and resultsIn a randomized, parallel, single-blind, multi-centre trial we enrolled 1300 patients with bradycardia and previous atrial tachyarrhythmias, in whom a DDDRP pacemaker had recently been implanted. History of permanent AF and third-degree atrioventricular block were exclusion criteria. After a 1-month run-in period, 1166 eligible patients, aged 74 ± 9 years, 50% females, were randomized to Control DDDR, DDDRP + MVP, or MVP. Analysis was intention-to-treat.The primary outcome, i.e. the 2-year incidence of a combined endpoint composed of death, cardiovascular hospitalizations, or permanent AF, occurred in 102/385 (26.5%) Control DDDR patients, in 76/383 (19.8%) DDDRP + MVP patients [hazard ratio (HR) = 0.74, 95% confidence interval 0.55–0.99, P = 0.04 vs. Control DDDR] and in 85/398 (21.4%) MVP patients (HR = 0.89, 95% confidence interval 0.77–1.03, P = 0.125 vs. Control DDDR). When compared with Control DDDR, DDDRP + MVP reduced the risk for AF longer than 1 day (HR = 0.66, 95% CI 0.52–0.85, P < 0.001), AF longer than 7 days (HR = 0.52, 95% CI 0.36–0.73, P < 0.001), and permanent AF (HR = 0.39, 95% CI 0.21–0.75, P = 0.004).ConclusionIn patients with bradycardia and atrial tachyarrhythmias, DDDRP + MVP is superior to standard dual-chamber pacing. The primary endpoint was significantly lowered through the reduction of the progression of atrial tachyarrhythmias to permanent AF.ClinicalTrials.gov IdentifierNCT00262119.

Scrotal Edema in Dilated Cardiomyopathy

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Abstract 19141: Natural History of Tricuspid Annulus and Right Atrial Remodeling in Permanent Atrial Fibrillation

Background: The natural history of tricuspid annulus and right atrial (RA) remodeling in patients with permanent atrial fibrillation (AF) has not been assessed. We aimed to determine the rate of change in tricuspid annulus diameter and RA volume in patients with permanent AF. Methods: This cohort study included 160 patients with a history of permanent AF who had at least 2 transthoracic echocardiograms performed between 2005 and 2010 at Vancouver General Hospital in British Columbia. Patients with structural valve disease at onset, congenital heart disease, and patients with more than mild-moderate tricuspid or mitral regurgitation were excluded from analyses. The tricuspid annulus diameter, defined as the distance between the points of attachment of the anterior and septal tricuspid leaflets from the apical 4-chamber view, was measured during end-systole and end-diastole. Maximal RA size was measured in terms of RA volume using single plane Simspon’s method from 4 chamber view. Linear mixed effects modelling was used in analyzing the changes in measurements over time. Results: Of the 160 subjects included in this analysis, 100 were men (62.5%). The mean age at study entry was 74±10 yrs. The median number of echocardiographic studies performed was 3 (range 2 - 6). All 160 patients showed progressive increase in tricuspid annulus diameter over time. There was a significant increase in tricuspid annulus diameter at end-systole and end-diastole over a mean follow up time of 3.2 ± 2.8 years. Respectively, the increase was 0.68 mm/ year, 95% CI 0.232 -1.02, P=0.0027) and end-diastole 0.63 mm/year, 95% CI 0.182-0.93, P=0.0015). Mean RA volume increased from a mean of 39 mL/m2 to 81 mL/m2 for the cohort, or 13 mL/m2 per year, which was significantly greater than the increase in left atrial volume (10 mL/m2 per year, P&lt;0.001). Conclusions: Permanent AF was associated with significant increase in tricuspid annulus diameter and RA volume over time. The rate of changes appeared greater on the right side than on the left. How these differential changes relate to the frequent findings of right heart failure in these patients warrant further investigations.

Abstract 19185: Remodeling of Mitral Annulus and Left Atrium in Permanent Atrial Fibrillation: Relationship to Severity of Mitral Regurgitation

Background: Left atrial (LA) size increases in atrial fibrillation (AF). How changes in mitral annulus and atrial volume over time relate to severity of mitral regurgitation (MR) is unknown. Methods: This cohort study included 160 patients with a history of permanent AF who had at least 2 transthoracic echocardiograms (TTE) performed between 2005 and 2010 at Vancouver General Hospital (British Columbia, Canada). Patients with structural mitral valve disease, congenital heart disease, more than mild-moderate mitral/tricuspid regurgitation on their first TTE were excluded from analyses. LA volume was determined using biplane area-length method, averaged over 3 cardiac cycles. The mitral annulus diameter (MAD), defined as the distance between the hinge points of the anterior and posterior mitral leaflets from the apical 4-chamber view, was measured during end-systole and end-diastole. Linear mixed effects modeling was used in analyzing the above measurements for change over time. Mitral regurgitation was classified into 3 grades (mild, moderate, or severe) using standard color Doppler and PISA easurements where available. Results: Of the 160 subjects included in this analysis, 100 were men (62.5%). The mean age at study entry was 74±10 years. The median number of TTE performed was 3 (range 2 - 6). All 160 patients showed a progressive increase in MAD over time. There was a significant increase in MAD at end-systole and end-diastole over a mean follow-up of 3.2 ± 2.8 years; the increases were 0.48 mm/year (95% CI 0.124 -0.75, P=0.0037) and 0.45 mm/year (95% CI 0.102-0.716, P=0.0029) respectively. LA volume increased from a mean of 43 mL/m2 to 75 mL/m2 for the cohort, or 10 mL/m2 per year. Adjusting for age, sex, and left ventricular ejection fraction, an increase in MR severity by at least 1 grade was strongly and independently associated with an increase in MAD. A 15% increment in MAD was associated with an increase in MR severity by 1 grade. Conclusion: Permanent AF was associated with significant increases in MAD and LA volume over time. Severity of MR also significantly increased over time, and was independently related to the change in MAD. Further investigations as to whether this represents a mechanism for left heart failure in patients with permanent AF are warranted.

Long term follow-up from amplatzer cardiac plug European multicenter post market observational study

Purpose: The AMPLATZER® Cardiac Plug (ACP) is a percutaneous transcatheter device intended to prevent thrombus embolizations from the left atrial appendage (LAA) in patients with non-valvular atrial fibrillation (AF). The objective of this prospective, open-label study is to evaluate safety and performance of the ACP device in closure of the LAA and report the initial long-term follow-up results out to two years. Methods and results: We report safety results on a total of 40/161 (24.8%) patients who have been followed for two years post ACP implantation at ten investigative centers in Germany, Spain, United Kingdom, Ireland and the Czech Republic. Study follow-up included rigorous neurological and echocardiographic assessments at baseline, 1, 6, 12 months and 2 years post implant, as well as after a suspected stroke, TIA or systemic embolism. The study is being 100% monitored. An independent Data Monitoring Board is utilized and adjudicates seriousness and relatedness of all the safety events. In comparison to previously presented studies on ACP and other percutaneous LAA closure devices, this cohort was older and had a higher incidence of comorbidities. The majority of reconsented patients (50.9%) had a history of permanent AF, mean age was 70.48±12.54, mean CHA2DS2VASc score 3.27±1.55, and mean HAS-BLED score 2.857±1.15. Prior stroke or TIA was reported in 20.7% of reconsented patients. 100% of subjects with reported 2 year follow up TOE's reported closure of the LAA. Closure is defined as absence of flow or flow of < 3 mm jet into the LAA as assessed by transoesophageal echocardiography (TOE). From implant to six months, two ischemic strokes were adjudicated as unrelated to the device or procedure in a subject population of 204. With 40 subjects completing 6 months to 2 year follow-up, one new ischemic stroke occurred at 256 days post implant in a patient with a risk factor of prior ischemic stroke. Long term follow-up data revealed a total of 19 safety events occurring after the 6 month follow-up period in 9/40 (22.5%) patients. There have been no reported hemorrhagic strokes in any subjects post implant. There have been no reported thrombus on the device or device embolization after 6 months. Conclusion: The ACP device is a good alternative for high risk patients based on the reported excellent closure status. One out of five re-consented patients had a history of prior stroke/TIA and current long-term follow-up data revealed only one new stroke occurring after 6 months. The rate of safety events compares favorably with other LAA closure devices.

Abstract 19544: Rate and Magnitude of Atrial Remodeling in Permanent Atrial Fibrillation

Background: Atrial fibrillation (AF) is associated with progressive enlargement of atrial size. Yet, the rate of change in left atrial (LA) and right atrial (RA) size is poorly defined. Methods: This cohort study included 51 patients with a history of permanent AF who had serial transthoracic echocardiograms performed between 2005 and 2010 at Vancouver General Hospital in British Columbia, a large university-based tertiary care hospital. Each had at least 3 transthoracic studies completed and had adequate views for assessment of LA and RA volume. Echocardiographic measurements were performed offline by one person using standardized methodology. Apical 4-chamber LA and RA volume by Simpson’s method was used for assessment of atrial size. Linear mixed effects modeling was used in analyzing changes over time. Results: Of the 51 subjects who underwent 183 studies in total, 28 were men (55%). The mean age at study entry was 72±10 yrs (47-85 yrs). The mean follow-up time was 3.2±2.9 years. The findings for the first 3 consecutive studies for these patients are shown in the attached table. There was a significant increase in LA and RA volume; the increases were 2.98 mL/m2 per year (95% CI 1.23-4.73, P&lt;0.0001) and 1.25 mL/m2 per year (95% CI 1.01-1.61, P&lt;0.0001) respectively. In parsimonious models adjusting for age, sex, and length of follow-up, left ventricular ejection fraction of less than 50% at first study was associated with a significantly more rapid increase in LA volume over time (P&lt;0.001). Conclusion: Both LA and RA volume increased over time in patients with permanent AF. The absolute magnitude of increase appeared greater, and the rate of change faster, for LA than RA volume. Further studies are needed to determine the factors that mediate these changes and their reversibility.

Winding without twiddling of a pacemaker wire

A 82-year-old obese woman with a history of permanent atrial fibrillation with slow ventricular response and syncope underwent pacemaker implantation using a single passive-fixation lead. Before discharge, a chest X-ray revealed a pacemaker lead placed in the right ventricular apical region, and an ECG recording showed a proper function of …

AHA 2011 Scientific Sessions highlight key studies

AHA 2011 Scientific Sessions highlight key studies

Dronedarone in High-Risk Permanent Atrial Fibrillation

Dronedarone restores sinus rhythm and reduces hospitalization or death in intermittent atrial fibrillation. It also lowers heart rate and blood pressure and has antiadrenergic and potential ventricular antiarrhythmic effects. We hypothesized that dronedarone would reduce major vascular events in high-risk permanent atrial fibrillation. We assigned patients who were at least 65 years of age with at least a 6-month history of permanent atrial fibrillation and risk factors for major vascular events to receive dronedarone or placebo. The first coprimary outcome was stroke, myocardial infarction, systemic embolism, or death from cardiovascular causes. The second coprimary outcome was unplanned hospitalization for a cardiovascular cause or death. After the enrollment of 3236 patients, the study was stopped for safety reasons. The first coprimary outcome occurred in 43 patients receiving dronedarone and 19 receiving placebo (hazard ratio, 2.29; 95% confidence interval [CI], 1.34 to 3.94; P=0.002). There were 21 deaths from cardiovascular causes in the dronedarone group and 10 in the placebo group (hazard ratio, 2.11; 95% CI, 1.00 to 4.49; P=0.046), including death from arrhythmia in 13 patients and 4 patients, respectively (hazard ratio, 3.26; 95% CI, 1.06 to 10.00; P=0.03). Stroke occurred in 23 patients in the dronedarone group and 10 in the placebo group (hazard ratio, 2.32; 95% CI, 1.11 to 4.88; P=0.02). Hospitalization for heart failure occurred in 43 patients in the dronedarone group and 24 in the placebo group (hazard ratio, 1.81; 95% CI, 1.10 to 2.99; P=0.02). Dronedarone increased rates of heart failure, stroke, and death from cardiovascular causes in patients with permanent atrial fibrillation who were at risk for major vascular events. Our data show that this drug should not be used in such patients. (Funded by Sanofi-Aventis; PALLAS ClinicalTrials.gov number, NCT01151137.).