Late Atrial Arrhythmias Research Articles

Characterization of atrial arrhythmias following mitral valve repair: Incidence and risk factors.

This study aims to investigate the occurrence, type and correlation of early and late atrial arrhythmias following mitral valve repair in patients with no preoperative history of atrial arrhythmias. Patients undergoing mitral valve (MV) repair for degenerative disease were included. Early and late postoperative electrocardiograms were evaluated for the incidence and type of atrial arrhythmia (atrial fibrillation [AF] or atrial tachycardia [AT]). The 192 patients were included. Early atrial arrhythmias occurred in 100/192 (52.1%) patients; AF in 61 (31.8%) patients, early AT in 15 (7.8%) and both in 24 (12.5%). In total 89% of patients were discharged in sinus rhythm. During a follow-up time of 7.3 years, 14 patients (7.3%) died and 49 (25.5%) patients developed late atrial arrhythmias. At 10 years, the cumulative incidence of any late atrial arrhythmia, with death as competing risk, was 64% (95% confidence interval [CI] = 55%-72%). On Fine-Gray model analysis, only early postoperative AF lasting >24 h was related to the development of late AF (hazard ratio 5.99, 95% CI = 1.78%-20.10%, p = .004). Early postoperative ATs were related to the development of late tachycardias, independent of their duration (<24 h hazard ratio 4.25, 95% CI = 1.89-9.57, p = .001 and >24 h hazard ratio 3.51, 95% CI = 1.65-7.46, p = .001). Early and late atrial arrhythmias were common after MV repair surgery. Only early postoperative AF lasting >24 h was a risk factor for the occurrence of late AF. Conversely, any postoperative AT was correlated to the development of late ATs.

Very Late Atrial Arrhythmia Recurrence After Initial Successful AF Ablation: Insights From Continuous Monitoring

Very Late Atrial Arrhythmia Recurrence After Initial Successful AF Ablation: Insights From Continuous Monitoring

Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report.

Late atrial arrhythmias after catheter ablation for atrial fibrillation occur in up to 30% of post-ablation patients and are increasingly encountered by emergency physicians. However, diagnosing the exact mechanism of the arrhythmia on the surface electrocardiogram (ECG) remains challenging due to atrial scarring leading to heterogeneous P-wave morphology. A 74-year-old male with a history of prior catheter ablation for atrial fibrillation presented with palpitations and subacute symptoms of heart failure. The patient's ECG revealed narrow complex tachycardia with more P waves than QRS complexes. The differential diagnosis included typical flutter, atypical flutter, and focal atrial tachycardias with 2:1 conduction block. P waves were positive in V1 and across all precordial leads (absent precordial transition). This favors atypical flutter originating from the left atrium over typical cavotricuspid isthmus-dependent right atrial flutter. Transthoracic echocardiogram showed a reduced ejection fraction due to tachycardia-mediated cardiomyopathy. The patient underwent a repeat electrophysiology study and ablation, which confirmed the presence of an atypical flutter circuit using the mitral annulus, known as perimitral flutter. Repeat catheter ablation resulted in maintenance of sinus rhythm. At follow-up, his ejection fraction recovered. Recognizing ECG findings suggestive of atypical flutter impacts initial emergency department decisions and triage as atypical flutter post-atrial fibrillation ablation is frequently resistant to rate-controlling medications and often requires cardiology and/or electrophysiology consultation if available.

The Prevalence of and Predisposing Factors for Late Atrial Arrhythmias after Transcatheter Closure of Secundum Atrial Septal Defects in Children.

A 24 h Holter study in children after transcatheter secundum ASD (ASD II) closure was conducted to detect the prevalence of defects and/or device-related late atrial arrhythmias (LAAs). ASD II closure with an Amplatzer septal occluder (ASO) is an established procedure. Little is known about LAAs after device implantation. The eligible participants were children who had undergone ASO implantation, with a follow-up of ≥5 years, as well as one pre- and at least one post-procedural Holter ECG. In total, 161 patients (mean age: 6.2 ± 4.3 years), with a mean follow-up of 12.9 ± 3.1 years (range 5-19), were included. A median of four Holter ECGs per patient were available. LAAs occurred before intervention in four patients (2.5%), and it was peri-interventional in four patients (2.5%), sustained in three patients (1.9%), and developed in three patients (1.9%). In patients with pre- and peri-interventional LAAs, the Qp/Qs ratio was higher (6.4 ± 3.9 vs. non-AA: 2.0 ± 1.1 (p = 0.002)) and the IAS/ASO ratio was lower (1.18 ± 0.27 vs. non-AA: 1.7 ± 0.4 (p < 0.001)). The patients with LAAs differed from those without LAAs in their Qp/Qs (6.8 ± 3.5 vs. 2.0 ± 1.3; p < 0.0001) and IAS/ASO ratios (1.14 ± 0.19 vs. 1.73 ± 0.45; p < 0.001). The patients with LAAs had a Qp/Qs ratio ≥2.94:1, and those who developed LAAs had an IAS/ASO ratio <1.15. LAAs occurred in 1.9% of patients and were sustained in another 1.9% of patients but persisted in those with large shunt defects and large occluders in relation to the atrial septal length. The predisposing factors for LAAs after ASD closure were a high Qp/Qs ratio, pre-existing atrial arrhythmias, and a low IAS/ASO ratio.

PO-04-144 IMPACT OF AGE ON ATRIAL ARRHYTHMIA OUTCOMES AFTER PERCUTANEOUS ASD CLOSURE

Atrial Septal Defects (ASD) are one of the most common congenital heart defects, and if unrepaired, increase the risk of atrial fibrillation (AF) and atrial flutter (AFL). AF/AFL are linked to an increased risk of stroke and heart failure yet, it is not clear from existing data whether percutaneous ASD closure reduces the overall burden of AF/AFL and whether AF/AFL prevalence is impacted by closure age. To determine the effect of age at ASD closure on the prevalence of late atrial arrhythmias. All patients who underwent percutaneous ASD closure at Cleveland Clinic from January 2010 to July 2021 were included. Patients without right-sided dilatation and Qp:Qs < 1.5, iatrogenic ASDs, and those with Eisenmenger syndrome were excluded. A non-linear logistic mixed model informed a temporal decomposition model used to analyze the association between age at ASD closure and prevalence of AF/AFL, adjusting for gender and presence of pre-closure AF/AFL. A total of 192 patients met inclusion criteria, 121 (63%) female with a median age of 41.5 years (IQR 19-61) at time of ASD closure. Median follow up time was 2.7 years (IQR 0.64-4.7). 170 (89%) patients had a total of 681 records including ECGs and ambulatory rhythm monitors. Pre-procedural AF/AFL was associated with higher likelihood of late (>6 months) AF/AFL. The prevalence of post-ASD closure AF/AFL was composed of two phases: an early peaking phase of 13% at week 1 with a gradual decrease to 3.2% by 6 months. There was a late rising prevalence from 6 months up to 6 years from 3.2% to 4.7% (Figure 1a). Age ≥ 40 years was associated with higher likelihood of early (≤ 6 months) and late (> 6 months) post procedural AF/AFL prevalence (Figure 1b). Post-device closure, only 7 (3.6%) patients required cardioversions at a median time of 2.6 months, and 5 (2.6%) required ablations at a median time of 7.4 months post ASD closure. There were only 10 arrhythmia related ER visits during the follow up period. There is an increased prevalence of AF/AFL immediately post ASD closure that declines by 6 months. Patients older than 40 years of age and those with pre-procedure AF/AFL have ongoing risk for late AF/AFL post ASD closure. Rhythm monitoring before ASD closure may be indicated in age ≥ 40 to identify those at higher risk of developing late AF/AFL. Parametric estimate of prevalence of AF or AFL after percutaneous ASD closureTime1 day1 week2 week1 month6 month1 year3 year5 year6 yearOverall (%)0.8813106.73.23.54.24.64.7Stratified by age (%)<4002.61.80.630.0130.002000≥401.34332154.656.26.97.1 Open table in a new tab

Surface ECG-based complexity parameters for predicting outcomes of catheter ablation for nonparoxysmal atrial fibrillation: efficacy of fibrillatory wave amplitude.

Catheter ablation (CA) is a well-established therapy for rhythm control in atrial fibrillation (AF). However, CA outcomes for persistent AF remain unsatisfactory because of the high recurrence rate despite time-consuming efforts and the latest ablation technology. Therefore, the selection of good responders to CA is necessary. Surface electrocardiography (sECG)-based complexity parameters were tested for the predictive ability of procedural termination failure during CA and late recurrence of atrial arrhythmias (AA) after CA. A total of 130 patients with nonparoxysmal AF who underwent CA for the first time were investigated. A 10-second sECG of 4 leads (leads I, II, V1, and V6) was analyzed to compute the fibrillatory wave amplitude (FWA), dominant frequency (DF), spectral entropy (SE), organization index (OI), and sample entropy (SampEn). The study endpoints were procedural termination failure during CA and late (≥1 year) AA recurrence after CA. In the multivariate analysis, FWA in lead V1 and DF in lead I were independent predictors of successful AF termination during CA (P <.05). The optimal cut-off values for FWA in lead V1 and DF in lead I were 60.38 μV (area under the curve [AUC], 0.672; P = .001) and 5.7 Hz (AUC, 0.630; P = .016), respectively. The combination of FWA of lead V1 and DF of lead I had a more powerful odds ratio for predicting procedural termination failure (OR, 8.542; 95% CI, 2.938–28.834; P < .001). FWA in lead V1 was the only independent predictor of late recurrence after CA. The cut-off value is 65.73 μV which was 0.634 of the AUC (P = .009).These sECG parameters, FWA in lead V1 and DF in lead I, predicted AF termination by CA in patients with nonparoxysmal AF. In particular, FWA in lead V1 was an independent predictor of late recurrence of AA after CA.

Patient-Reported Atrial Fibrillation After Septal Myectomy for Hypertrophic Cardiomyopathy

BackgroundPatient-reported outcomes are important metrics of medical and surgical care. In this study, we investigated the prevalence and risk factors of patient-reported postdischarge atrial fibrillation (AF) after septal myectomy for obstructive hypertrophic cardiomyopathy. MethodsPatients undergoing transaortic septal myectomy from August 2001 to January 2017 were contacted regarding postdischarge AF through questionnaire-based surveys sent at 3, 5, and 10 years post procedure. For each patient, the most recent survey response was analyzed. ResultsAmong 949 patients, 248 (26.1%) last responded at 3 years post procedure, 353 (37.2%) at 5 years, and 348 (36.7%) at 10 years. The overall incidence of patient-reported postdischarge AF was 34.4% (n = 326), and at 3, 5, and 10 years, the incidences were 22.2%, 34.8%, and 42.5% (P < .001). After multivariable adjustment, history of preoperative AF (odds ratio [OR] 5.566, P < .001), early postoperative AF within the first 30 days (OR 2.211, P < .001), preoperative left atrial volume index (OR 1.014, P = .005), postoperative right ventricular systolic pressure (OR 1.021, P = .013), postoperative moderate or greater mitral valve regurgitation (OR 1.893, P = .022), and preoperative septal thickness (OR 1.043, P = .036) were independently associated with patient-reported postdischarge AF. ConclusionsThe incidence of patient-reported postdischarge AF increases with increasing length of follow-up after septal myectomy. We identified several risk factors for late postdischarge AF that were associated with chronicity of left ventricular outflow tract obstruction, and earlier intervention may mitigate late atrial arrhythmias.

Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure

BackgroundAtrial arrhythmias are well-known complications of atrial septal defect (ASD), and associated with substantial morbidity. After ASD closure, right atrial and ventricular enlargement regresses, however, the risk of atrial arrhythmia development continues. In this study, we aimed to investigate the relationship between the Crochetage sign, which is a possible reflection of heterogeneous ventricular depolarization due to long-term hemodynamic overload, and the development of late atrial arrhythmia after ASD closure. MethodsThis retrospective study included a total of 314 patients (mean age: 39.5 (30–50) years; male: 115) who underwent percutaneous device closure for secundum ASD. The study population was divided into two groups according to the presence or absence of the Crochetage sign. The Crochetage sign was defined as an M-shaped or bifid pattern notch on the R wave in one or more inferior limb leads. Cox-regression analysis was performed to determine independent predictors of late atrial arrhythmia development. ResultFifty-seven patients (18.1%) presented with late atrial arrhythmia. Of these 57 patients, 30 developed new-onset atrial fibrillation/atrial flutter (AF/AFL), and 27 patients with pre-procedure paroxysmal AF/AFL had a recurrence of AF/AFL during follow-up. History of paroxysmal AF/AFL before the procedure (HR: 4.78; 95% CI 2,52–9.05; p < 0.001), the presence of Crochetage sign (HR: 3.90; 95% CI 2.05–7.76; p < 0.001), and older age at the time of ASD closure (HR: 1.03; 95% CI 1.01–1.06; p = 0.002) were found as independent predictors for late atrial arrhythmia. ConclusionThe presence of Crochetage sign may be used to predict the risk of late atrial arrhythmia development after transcatheter ASD closure.

Abstract 16741: A Comparison of High versus Conventional Power Radiofrequency Catheter Ablation for Pulmonary Vein Isolation: A Systematic Review and Meta-Analysis

Objectives: We sought to evaluate the procedural safety and outcomes of high power (HP) versus conventional power (CP) radiofrequency (RF) ablation during pulmonary vein isolation (PVI). Methods: A systematic search was used via MEDLINE, EMBASE, and Cochrane databases between 01/1998 and 05/2020 for studies comparing the safety and efficacy between HP and CP during RF ablation for PVI using contact-force catheters (ThermocoolSmartTouch or TactiCath). The search terms used were “AF” AND “catheter ablation” OR “radiofrequency ablation”. Results: From eight comparative observational studies, we developed a cohort of 992 patients (478 in the HP and 514 in the CP group). The median maximum energy output used in the HP group was 50W vs 35W in the CP group. There was a statistically significant difference noted in acute pulmonary vein reconnection (APVR) in the HP group compared to the CP groups at16% vs 32.6%, respectively (RR: 0.53, 95% CI: 0.33 - 0.86, P = 0.01). Freedom from arrhythmia at 12 months follow-up was also significant and found to be 87.8% of cases in the HP group versus75.2% of cases in the CP group (RR: 0.46, 95%CI: 0.32 - 0.65, P &lt;0.01). The mean RF ablation time was 20.1 minutes in the HP group vs 39.6 minutes in the CP group (P &lt;0.01). The mean total procedural time was 103.5 minutes in the HP group compared to 135 minutes in the CP group (P &lt;0.01). Two patients in the CP group experienced severe adverse events (1 cardiac tamponade and 1 myocardial infarction). No serious AEs were found in the HP group. Non-serious AEs (groin complications, pericardial effusion, and phrenic nerve injury) were reported in 0.35% and 0.51% of cases in the HP and CP group, respectively. Conclusion: This study suggests that HP PVI ablation can be associated with better ablation outcomes by reducing the rate of acute and late PV reconnection and atrial arrhythmia recurrence, with similar safety profiles, and shorter procedural times. These findings merit evaluation in a randomized controlled trial.

Late atrial arrhythmias after lung transplantation: a meta-analysis.

Atrial arrhythmias are common following noncardiac thoracic surgery. In particular, early postoperative atrial arrhythmias after lung transplantation are very frequent, especially atrial fibrillation (AFib). Late atrial arrhythmia occurrence following lung transplantation, instead, has been less commonly reported. The aim of the present systematic review and meta-analysis is to analyse the incidence rate of late atrial arrhythmia and AFib in lung transplantation patients, with a special focus on double lung transplant (DLT), also to assess potential predictors of AFib occurrence. After bibliographic search (PUBMED/Medline and Embase databases), a random-effect model meta-analysis was performed: seven studies were finally included, including 2068 lung transplantation patients. The pooled incidence rate of late atrial arrhythmia was 4.3%/year [95% confidence interval (CI) 2.8-6.1%/year, I = 69%], whereas late AFib incidence rate was 1.5%/year (95% CI 0.7-2.6%/year, I = 87%). In patients undergoing DLT, the pooled incidence rate of late atrial arrhythmia was 4.1%/year (95% CI 2.5-6.0%/year, I = 67%), while the AFib incidence rate was 0.9%/year (95% CI 0.1-2.4%/year, I = 92%). A longer follow-up duration significantly related to the reduced incidence rate of AFib (P = 0.02). History of AFib (hazard ratio 11.2, 95% CI 5.9-21.3) and early postoperative AFib (hazard ratio 10.3, 95% CI 5.9-18.0) emerged, instead, as relevant predictors of AFib occurrence. Late atrial arrhythmia occurrence is not infrequent in lung transplantation patients; however, late Afib incidence was rare and showed a time-dependent decrease, particularly in DLT patients, suggesting that a transmural pulmonary veins isolation, the mainstay of transcatheter ablation, is effective in decreasing the likelihood of experiencing AFib.

Impact of Transcatheter Device Closure of Atrial Septal Defect on Atrial Arrhythmias Propensity in Young Adults.

Atrial septal defect (ASD) is a condition that requires early intervention because of the consequences over the right-side heart. Chronic atrial stretching promotes atrial conduction delay and the imbalance of the conduction homogeneity, which lead to the propensity to atrial arrhythmias (AA). We aim to evaluate the impact of transcatheter closure of ASD on atrial vulnerability markers leading to late AA in young adults. We conducted a prospective, longitudinal study in one hundred patients (mean age 25.2 ± 5.4years) who underwent transcatheter closure of ASD at Cardiocentro Pediátrico William Soler. P-wave maximum (Pmax) and P-wave dispersion (Pd) were analyzed from 12-lead electrocardiogram. Left-side and right-side intraatrial and interatrial electromechanical delay (EMD) were measured with tissue Doppler imaging. Both electrocardiographic and echocardiographic analyses were performed during the study period. Compared to baseline, there was a significant reduction in P max (p ≤ 0.001) and Pd (p ≤ 0.001) after 3 months of procedure. All atrial electromechanical coupling parameters significantly reduced at 6 months of ASD closure and tend to remain at lower values till the last evaluation. Over 9.2 ± 1.6years of follow-up, 15 subjects (15%) developed AA, of which intraatrial reentrant tachycardia (66.6%) became the main rhythm disturbance. Intra-right atrial EMD ≥ 16ms (HR 4.08, 95% CI 1.15-14.56; p = 0.03) and Pd 45ms (HR 1.66, 95% CI 1.06-2.59; p = 0.02) were identified as predictors of late AA. Transcatheter device closure of ASD in young adults promotes a significant reduction of electrocardiographic and echocardiographic markers of AA vulnerability, which persist during the long-term follow-up. Nevertheless, Pd and interatrial EMD were identified as independent risk factors of AA.

Early and Late Atrial Arrhythmias After Lung Transplantation - Incidence, Predictive Factors and Impact on Mortality.

Atrial arrhythmias (AAs) are frequent after lung transplantation (LT) and late postoperatively. Several predictive factors of early postoperative AAs after LT have been identified but those of late AAs remain unknown. Whether AA after LT affects mortality is still being debated. This study assessed in a large cohort of LT patients the incidence of AAs early and late after surgery, their predictive factors and their effect on mortality.Methods and Results:We studied 271 consecutive LT patients over 9 years. Mean follow-up was 2.9±2.4 years. 33% patients developed postoperative AAs. Age (odds ratio (OR) 2.35; confidence interval (CI) [1.31-4.24]; P=0.004) and chronic obstructive pulmonary disease (OR 2.13; CI [1.12-4.03]; P=0.02) were independent predictive factors of early AAs. Late AAs occurred 2.2±2.7 years after transplant in 8.8% of the patients. Pretransplant systolic pulmonary arterial pressure (PTsPAP) was the only independent predictive factor of late AA (OR 1.028; CI [1.001-1.056]; P=0.04). Double LT was associated with long-term freedom from atrial fibrillation (AF) but not from atrial flutter (AFL). Early and late AAs after surgery had no effect on mortality. Double LT was associated with better survival. Early AA following LT is common in contrast with the low occurrence of late, often organized, AA. Early and late AAs do not affect mortality. PTsPAP is an independent predictor of late AA. Double LT protects against late AF but not AFL.

Predictors of late atrial fibrillation recurrence after cryoballoon-based pulmonary vein isolation: a meta-analysis.

The recurrence rate of atrial fibrillation (AF) after cryoballoon ablation in drug refractory AF patients is high. Late-recurrence of AF has various predictors. The aim of the study was to explore the related risk factors that can effectively predict late AF recurrence after cryoballoon-based pulmonary vein isolation. The PubMed and Web of Science databases were searched from 1 January 2013 to 1 August 2016, and studies were chosen that met the pre-stated inclusion criteria. The reference lists of the retrieved articles were also reviewed. Two authors independently extracted information on the designs of the studies. The strength of the relationship between different risk factors and late recurrence was assessed by the adjusted hazard ratio. A total of 16 papers met the inclusion criteria and were included in the meta-analysis. The hazard ratio of late atrial arrhythmia recurrence in patients with early recurrence was 4.19 compared with the reference group (95% CI 2.73-6.44, p < 0.00001); that of increased left atrial diameter was 1.25 (95% CI 1.12-1.3, p < 0.0001); that of a long duration of AF before ablation was 1.10 (95% CI 1.04-1.17, p < 0.0009); and that of persistent AF was 2.44 (95% CI 1.30-4.58, p < 0.006). However, there exists significant heterogeneity for each indicator, and a slight publication bias was observed. Our study suggests that early recurrence in the blanking period, increased left atrial size, a longduration of AF before ablation and persistent AF are independent predictors of late recurrence after cryoballoon ablation.

Efficacy of Short-Term Antiarrhythmic Drugs Use after Catheter Ablation of Atrial Fibrillation-A Systematic Review with Meta-Analyses and Trial Sequential Analyses of Randomized Controlled Trials.

BackgroundThe efficacy of short-term antiarrhythmic drugs (AADs) use compared with no-AADs prescription after catheter ablation of atrial fibrillation (AF) in preventing atrial arrhythmia recurrence is uncertain.MethodsWe searched PubMed, Embase, and the Cochrane Library through December 2015 to identify randomized controlled trials (RCTs) which evaluated the efficacy of short-term AADs use compared with no-AADs prescription after AF ablation in preventing atrial arrhythmia recurrence. The primary outcome was labeled as early atrial arrhythmia recurrence within 3 months after ablation. Secondary outcome was defined as late recurrence after 3 months of ablation. Random-effects model or fixed-effects model was used to estimate relative risks (RRs) with 95% confidence intervals (CIs).ResultsSix RCTs with 2,667 patients were included into this meta-analysis. Compared with no-AADs administration after AF ablation, short-term AADs use was associated with significant reduction of early atrial arrhythmia recurrence (RR, 0.68; 95% CI, 0.52–0.87; p = 0.003). Trial sequential analysis (TSA) showed that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, establishing sufficient and conclusive evidence. However, compared with no-AADs prescription, short-term AADs use after AF ablation didn’t significantly reduce the risk of late atrial arrhythmia recurrence (RR, 0.92; 95% CI, 0.83–1.03; p = 0.15). TSA supported this result; meanwhile the estimated required information size (1,486 patients) was also met.ConclusionShort-term use of AADs after AF ablation can significantly decrease the risk of early atrial arrhythmia recurrence but not lead to corresponding reduction in risk of late atrial arrhythmia recurrence.

0376: Early and late atrial arrhythmias after lung transplantation: incidence, predictive factors and impact on mortality

Atrial arrhythmias (AA) are observed frequently early after lung transplant and also late after the surgery. Several predictive factors of post-operative AA after lung transplant have been already identified whereas those of late AA are still not known. Whether AA after lung transplant impacts mortality and the optimal strategy of rhythm management are still debated. The Purpose of the study was to assess in a large cohort of lung transplanted patients the incidence of AA early and late after surgery, their predictive factors and their impact on mortality. We included 271 consecutive patients single or double lung-transplanted over a 9-years period in a large French center. We collected baseline clinical, surgery and post-operative data. The follow-up was 2,9±2,4 years. 33% patients developed post-operative AA. Age (HR=2,35; CI [1,31-4,24]) and chronic obstructive pulmonary disease (HR=1,028; CI [1,12-4,03]) were independant predictive factors of post-operative AA. Late AA occurred 2,2±2,7 years after transplant in 8.8% of the patients. Systolic pulmonary arterial pressure was the only independent predictive factor of late AA (HR=1,028; CI [1,001; 1,056]). Double lung transplant was associated with long term freedom from AF compared with single transplant (p=0,05) whereas the Kaplan-Meier curve for the development of late atrial flutter was similar in single and double lung transplant. Early and late AA after surgery showed no impact on mortality. Bilateral lung transplant was associated with a better survival. Post-operative AA after lung transplantation are common with good outcome and contrast with the low occurrence of late organized AA. Double lung transplantation protects against AF but not AFL. Underlying electrophysiological mechanisms may explain these observations. Predictive factors of early and late AA after transplantation are different. Nevertheless these AA do not impact mortality after lung transplant (figure next page). Abstract 0376 – Figure: Survival free of late AF and AFL by transplant

40-Year Follow-Up After the Fontan Operation: Long-Term Outcomes of 1,052 Patients

BackgroundThere are limited long-term, single-cohort, follow-up studies available about patients after the Fontan operation. ObjectivesThis study sought to determine the long-term outcome of all patients who had a Fontan operation at the Mayo Clinic. MethodsRecords of all patients who had a modified Fontan operation between 1973 and 2012 were reviewed. A follow-up questionnaire was mailed to all patients alive at the time of the study. ResultsOverall, 10-, 20-, and 30-year survival for 1,052 patients was 74%, 61%, and 43%, respectively. Factors associated with decreased overall or late survival in multivariate analysis included pre-operative diuretic use, longer cardiopulmonary bypass time, operation prior to 1991, atrioventricular valve (AVV) replacement at the time of Fontan operation, elevated post-bypass Fontan (>20 mm Hg) or left atrial (>13 mm Hg) pressures, prolonged chest tube drainage (>21 days), post-operative ventricular arrhythmias, renal insufficiency, and development of protein-losing enteropathy (PLE). Pre-operative and intraoperative sinus rhythm were associated with improved survival. Long-term survival was similar for patients regardless of ventricular morphology. The most common reoperations were pacemaker insertion/revision in 212 patients (20%), Fontan revision/conversion in 117 patients (11%), and AVV repair/replacement in 66 patients (5%). Clinically significant late atrial or ventricular arrhythmias occurred in 468 patients (44%). Ninety-five patients (9%) developed PLE, and 5-, 10-, and 20-year survival after diagnosis of PLE was 50%, 35%, and 19%, respectively. ConclusionsAs the surgical techniques for the Fontan operation have changed over the last 40 years, survival has improved. However, development of PLE and arrhythmias and the need for reoperation during long-term follow-up pose significant management challenges.

Incidence, Risk Factors, Prognosis, and Electrophysiological Mechanisms of Atrial Arrhythmias After Lung Transplantation

ObjectivesThe purpose of this study was to investigate the incidence and timing, risk factors, prognostic significance, and electrophysiological mechanisms of atrial arrhythmia (AA) after lung transplantation. BackgroundAlthough new-onset AA is common after thoracic surgery and is associated with poorer outcomes, prognostic and mechanistic data are sparse in lung transplant populations. MethodsA total of 293 consecutive isolated lung transplant recipients without known AA were reviewed retrospectively. Mean follow-up was 28 ± 17 months. Electrophysiology studies (EPS) were performed in 25 patients with AA. ResultsThe highest incidence of new-onset AA after lung transplantation occurred within 30 days after transplantation (25% of all patients). In multivariable analysis, post-operative AA was associated with double-lung transplantation (odds ratio: 2.79; p = 0.005) and lower mean pulmonary artery pressure (odds ratio: 0.95; p = 0.027). Patients with post-operative AA had longer hospital stays (21 days vs. 12 days; p < 0.001). Post-operative AA was independently associated with late AA (hazard ratio: 13.52; p < 0.001) but not mortality (hazard ratio: 1.55; p = 0.14). On EPS, there were 14 patients with atrial flutter alone and 11 with atrial flutter and fibrillation. Among all EPS patients, 20 (80%) had multiple AA mechanisms, including peritricuspid flutter (48%), perimitral flutter (36%), right atrial incisional re-entry (24%), focal tachycardia from recipient pulmonary vein (PV) antrum (32%), focal PV fibrillation (24%), and left atrial roof flutter (20%). Left atrial mechanisms were present in 80% of EPS patients (20 of 25) and originated from the anastomotic PV antrum. ConclusionsPost-operative AA was independently associated with longer length of stay and late AA but not mortality. Pleomorphic PV antral arrhythmogenesis from native PV antrum is the main cause of AA after lung transplantation.

Supraventricular arrhythmias late after orthotopic cardiac transplantation: electrocardiographic and electrophysiological characterization and radiofrequency ablation

Cardiac transplantation (CTX) is an effective treatment for end-stage heart disease. Cardiac arrhythmias are increasingly recognized and associated with significant morbidity and mortality. We aim to describe the clinical and electrophysiological characteristics of patients with atrial arrhythmias occurring late after CTX. Sixteen patients with prior CTX who presented with late atrial arrhythmias for electrophysiological studies (EPS) were identified at two cardiac transplant centres. Among 859 patients, 16 (mean age 52 ± 14 years, 11 of 16 were men) patients underwent EPS for atrial arrhythmias presenting 8.6 ± 5.7 years following CTX. Among 16 patients, 14 underwent cardiac alone and 2 included lung transplantation. There were no cases of cardiac rejection. Arrhythmias were due to counterclockwise cavotricuspid-dependent atrial flutter (AFL) in 10 of 16, atrial tachycardia (AT) in 6 (1 patient had AFL and AT), and 1 due to atrioventricular nodal re-entrant tachycardia. Recipient-donor atrial electrical connection was seen in two of six AT and in no cases of AFL. In two cases, a focal AT was mapped to the remnant atrium conducting 2 : 1 or at variable block to the donor atrium. In four cases a focal/micro re-entrant AT originated within the vicinity of the interatrial suture scar. All cases were successfully ablated with radiofrequency energy; however, one case of AFL required a repeat ablation. Patients remained free of arrhythmia at 34 ± 15 months post-ablation. Typical AFL and AT are the most frequent supraventricular arrhythmias occurring late following CTX. Focal ATs may originate in low-voltage or border zones immediately adjacent to the atrio-atrial anastomosis. Radiofrequency ablation is an effective treatment strategy with high long-term success.

Arrhythmias After Heart Transplantation: Mechanisms and Management

Heart transplantation (HT) has significantly altered the treatment paradigm for end-stage heart disease. With current surgical techniques and postoperative immunosuppression, 1-year survival after HT is ≈90%, 5-year survival is ≈70%, and median survival exceeds 10 years.[1][1]–[3][2] These

Predictive model for late atrial arrhythmia after closure of an atrial septal defect

ObjectivesTo develop a quantitative event-free prediction model of late atrial arrhythmia after atrial septal defect (ASD) repair. BackgroundThe clinical management of ASD is driven by risk factors that determine the occurrence of late atrial arrhythmia. MethodsData from ASD type secundum patients, included in the Belgian Congenital Heart Disease Registry, were analyzed. Based on review of the literature, age at repair, gender, pulmonary hypertension, atrial arrhythmia before and within one month after repair were included in the model. Using Cox-regression analysis, a weighted risk score was derived, which was validated using the Brier score. ResultsA total of 155 patients (117 women; median age at follow-up 53.9years, range 18.0–78.8) having 349 follow-up years was included. Thirty-nine patients (25.2%) presented with late atrial arrhythmia. Multivariate analysis showed that a mPAP≥25mmHg (HR 4.39; 95%CI 2.17–9.09; P<0.0001), the presence of atrial arrhythmia before (HR 3.52; 95%CI 1.75–7.14; P=0.002) and≤1month after repair (HR 6.62; 95%CI 2.38–20.00; P<0.0001) and gender (HR 2.18 95%CI 1.11–4.35) were associated with late atrial arrhythmia. A risk score (0 to 28 points) to predict atrial arrhythmia free survival was derived for follow-up times ranging from one to 5years. Mean Brier score for the model was 0.10. ConclusionsWe formulated a well validated risk model to predict arrhythmia-free survival in ASD patients undergoing ASD repair. Further research is needed whether this model can be used for individual clinical risk stratification and whether the model can be adapted for application in other congenital heart defects.