Long-term Maintenance Of Sinus Rhythm Research Articles

Left atrial strain as an independent predictor of sinus rhythm maintenance after catheter ablation for paroxysmal atrial fibrillation in HFpEF patients

Abstract Background The early AF treatment by radio-frequency catheter ablation (CA) is very important for improving clinical outcome in patients with history of atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). Left atrial (LA) strain showed to be a useful index to monitor atrial function in AF and HFpEF states. However, the accuracy of LA strain to predict the long-term maintenance of sinus rhythm (SR) in HFpEF patients with paroxysmal AF undergoing CA is still under debate. Aims To define the best echocardiography derived parameters to predict the long-term maintenance of SR in paroxysmal AF patients with high probability of HFpEF undergoing CA. Methods We prospectively enrolled 200 consecutive patients (62 ± 10 years, 58% males) with dyspnea (NYHA≥II), paroxysmal AF and preserved LV ejection fraction (≥50%). All patients had a H2FPEF score suggesting high probability of HFpEF. During sinus rhythm, all patients underwent comprehensive transthoracic echocardiography at baseline, including assessment of left ventricular (LV) global longitudinal strain (GLS), left atrial (LA) reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile strain (LASct) using two-dimensional speckle tracking in apical views. Results After 42+/-8 months follow-up, a total of 34 (17%) patients had a documented recurrence of AF. Patients with AF recurrence had lower LASr (22.2% vs. 28.3%, p < 0.001) and LASct (10.9% vs. 13.2%, p < 0.01) compared to patients who keep on SR. Among speckle tracking derived LA phasic strain indices, LASr showed the largest area under the curve (AUC = 0.8, p < 0.001) and the strongest independent predictive value (LASr > 22%) of long-term maintenance of SR with sensitivity of 80% and specificity of 66% (Figure 1). Other parameters of LA function, LA diameter, maximum or minimum LA volume index, LV GLS or ejection fraction, and indices of LV diastolic function had lower area under the curve. Using multivariable logistic regression, only LASr (OR 0.89, 95% CI 0.81-0.97, p=0.013) was independently associated with long-term SR maintenance while other LA size and function indices were not. Conclusion In HFpEF patients with paroxysmal AF undergoing CA, LASr is more accurate predictor of SR maintenance than other standard echocardiographic parameters in long-term follow-up.

Efficacy of two-stage approach for interventional treatment of coexistent atrial fibrillation and typical atrial flutter for sinus rhythm maintenance in long-term: a prospective controlled clinical trial

Background: Atrial fibrillation (AF) and coexistent typical atrial flutter (AFL) interventional treatment strategy remains unresolved in cardiology and cardiovascular surgery. Results of this approach remain suboptimal. There are several approaches to the interventional treatment of patients with coexistent AF and AFL: simultaneous pulmonary vein isolation (PVI) and cavotricuspid isthmus (CTI) radiofrequency catheter ablation (RFCA), PVI or CTI RFCA only and two-stage approach. To our knowledge, cumulative efficacy of two-stage approach has not been previously reported. The aim. This study aimed to evaluate the efficacy of two-stage approach for interventional treatment of coexistent AF and AFL for sinus rhythm maintenance in long-term. Methods: Patients (pts) (n=34) with AF and AFL aged 41–82 years (11 women) were divided into two groups (1:1): «One-stage Approach» (group 1; n=17): PVI+СTI RFСA and «Two-stage approach» (group 2; n=17): first stage — CTI RFCA (group 2.1); second stage — PVI in case of AF recurrence after RFCA (group 2.2). Primary endpoint (PEP) was defined as any recurrent atrial tachyarrhythmia at the end of follow-up; group 2 events have been considered after PVI. Secondary endpoint (SEP) — recurrent any atrial tachyarrhythmia in groups 1 and 2 after CTI RFCA in group 2. PEP and SEP were evaluated at the end of the «blind period» (3 months after procedure). Results: Registered recurrent atrial tachyarrhythmia in pts who reached PEP or SEP was AF. AFL has not been detected in any cases. PEP was noted in 8 (47.06%) pts in group 1 and 1 (5.88%) pts in group 2. Further, SEP was observed in 3 pts (17.65%) in group 1 and in 4 (23.53%) pts in group 2 (p=0.671). The probability of long-term maintenance of sinus rhythm was significantly higher in «Two-stage approach» than in «One-stage approach» (94.12% and 52.94%, respectively, p=0.001). Significant differences in procedure length and fluoroscopy time have been found. Those were longer in group 1 compared to group 2.1 (p 0.001) and in group 2.2 compared to group 2.1 (procedure duration — p 0.001; fluoroscopy time — p=0.013). No differences were noted in length of procedure and fluoroscopy time between groups 1 and 2.2 (p=0.374 and p=0.028, respectively). Conclusion: The «two-stage approach» for interventional treatment of coexistent AF and AFL results in better long-term arrhythmia-free survival than «one-stage approach» (94.12% and 52.94%, respectively, p=0.001). CTI RFCA alone in pts with coexistent AF and AFL cause 23.53% AF recurrence rate and associated with shorter procedure duration and fluoroscopy time compared to simultaneous PVI and CTI RFCA (p 0.001).

Left atrial strain as an independent predictor of sinus rhythm maintenance after catheter ablation for paroxysmal atrial fibrillation in HFpEF patients

Abstract Funding Acknowledgements Type of funding sources: None. Background The early AF treatment by radio-frequency catheter ablation is very important for improving clinical outcome in patients with history of atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). Left atrial (LA) strain showed to be a useful index to monitor atrial function in AF and HFpEF states. However, the accuracy of LA strain to predict the long-term maintenance of sinus rhythm (SR) in HFpEF patients with paroxysmal AF undergoing catheter ablation is still under debate. Aims To define the best echocardiography derived parameters to predict the long-term maintenance of SR in paroxysmal AF patients with high probability of HFpEF undergoing catheter ablation. Methods We prospectively enrolled (between September 2017 and May 2019) 200 consecutive patients (62 ± 10 years, 58% males) with dyspnea (NYHA≥II), paroxysmal AF and preserved LV ejection fraction (≥50%). All patients had a H2FPEF score suggesting high probability of HFpEF. During sinus rhythm, all patients underwent comprehensive transthoracic echocardiography at baseline, including assessment of left ventricular (LV) global longitudinal strain (GLS), left atrial (LA) reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile strain (LASct) using two-dimensional speckle tracking in apical views. Results After 42+/-8 months follow-up, a total of 34 (17%) patients had a documented recurrence of AF. Patients with AF recurrence had lower LASr (22.2% vs. 28.3%, p < 0.001) and LASct (10.9% vs. 13.2%, p < 0.01) compared to patients who keep on SR. Among speckle tracking derived LA phasic strain indices, LASr showed the largest area under the curve (AUC = 0.8, p < 0.001) and the strongest independent predictive value (LASr > 22%) of long-term maintenance of SR with sensitivity of 80% and specificity of 66% (Figure 1). Other parameters of LA function, LA diameter, maximum or minimum LA volume index, LV GLS or ejection fraction, and indices of LV diastolic function had lower area under the curve. Using multivariable logistic regression, only LASr (OR 0.89, 95% CI 0.81-0.97, p=0.013) was independently associated with long-term SR maintenance while other LA size and function indices were not. Conclusion In HFpEF patients with paroxysmal AF undergoing catheter ablation, LASr is more accurate predictor of SR maintenance than other standard echocardiographic parameters in long-term follow-up. Figure 1: Receiver-operating characteristic curves of left atrial reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile strain (LASct), LA emptying fraction (LAEF), LA expansion index (LAEI), LA end-systolic (LAES) and end-diastolic (LAED) volume index (VI) to predict long-term maintenance of sinus rhythm.

Beat-to-beat variation of P-wave morphology immediately after ablation of persistent atrial fibrillation correlates with long-term clinical outcome

Abstract Funding Acknowledgements Type of funding sources: None. Background P-wave morphology on surface ECG reflects the atrial electrical remodelling, and is regarded as a predictor of ablation outcome for atrial fibrillation (AF). Purpose We sought to investigate whether morphological characteristics of P-waves immediately after a wide circumferential isolation of pulmonary veins (WPVI) in persistent AF (peAF) correlate with long-term maintenance of sinus rhythm (SR). Methods 33 patients (63±10 y, sustained AF 11±7 months) underwent a de-novo WPVI. A second WPVI was performed in patients with recurrent AF in order to provide complete PV disconnection. We defined "success" as patients who remained in SR after one or two procedures, and "failure" otherwise. The average duration and amplitude of the P-waves, and the coefficient of variation (CoV = standard deviation/mean) of the beat-to-beat similarity between ≥30 successive P-waves per patient were computed on ECG lead II during SR after cardioversion. Panel A shows a group of successive P-waves synchronized with regard to their centers of gravity. The similarity between the shapes of two successive synchronized P-waves was assessed using the dynamic time warping distance. Panel B shows the time-evolution of beat-to-beat distance between the P-waves displayed in Panel A. Results Over a mean follow-up of 31±9 months, 21 patients remained free from AF off antiarrhythmics (success group), while 12 patients had AF recurrence after 2 WPVIs (failure group). The clinical characteristics (e.g. age, body mass index, left atrial volume or duration in sustained AF) were similar between groups (p>0.05). The success group displayed significantly lower beat-to-beat variability of P-wave morphology than that of the failure group (p<0.05, Panel C). No significant difference was found in P-wave duration and amplitude between the two groups (p>0.05, Panel D and E). Conclusion Low P-wave beat-to-beat morphological variability immediately after WPVI for persistent AF is associated with long-term maintenance of sinus rhythm.

Effects of Atrial Fibrillation Radiofrequency Ablation in Patients Aged > 75 Years Undergoing Mitral Valve Surgery

Few data exist about the efficacy of radiofrequency (RF) maze procedures in elderly patients with atrial fibrillation (AF) undergoing surgery for mitral valve disease. The aim of the present investigation was to evaluate the effects of AF ablation associated with mitral valve surgery on the recovery and long-term maintenance of sinus rhythm in elderly patients aged > 75 years. Moreover, we evaluated the effects on survival. This study included 96 consecutive patients with AF (42 men and 56 women) aged > 75 years (mean age 78 ± 3) who underwent RF ablation associated with mitral valve surgery (group I). This group was compared to 209 younger patients (mean age 65 ± 8 years) treated in the same period (group II). Baseline clinical and echocardiographic characteristics were similar in the two groups. Four patients died during hospitalization, one aged > 75 years. In surviving patients at the end of the follow-up period, sinus rhythm was present respectively in 64% of the elderly and 74% of younger patients (p = 0.778). The rate of persistence of sinus rhythm without AF recurrences (38% vs. 41%, p = 0.705) was similar in the two groups. After surgery, sinus rhythm was frequently never regained in aged patients (27% vs. 20%, p = 0.231). Elderly patients more frequently needed permanent pacing and had more hospitalizations and a higher number of non-AF atrial tachyarrhythmias. At eight-year follow-up, survival was lower in older patients (48% aged > 75 vs. 79% aged < 75 years). Elderly patients had a similar long-term rate of stable sinus rhythm maintenance in comparison to younger patients after AF radiofrequency ablation associated with mitral valve surgery. However, they needed more frequent permanent pacing and had higher rates of hospitalizations and post-procedural atrial tachyarrhythmias. The effects of survival are difficult to evaluate due to the different life expectancies of the two groups.

Late recurrence of atrial fibrillation and flutter in patients referred for elective electrical cardioversion.

Aim The primary aim was to ascertain long-term rates of atrial fibrillation (AF) recurrence in this all-comer patient population undergoing elective electrical cardioversion (DCR). Secondary aims included procedural DCR success, clinical predictors of long-term maintenance of sinus rhythm (SR) and AF related hospitalizations.Material and Methods A retrospective cohort study was conducted. Consecutive patients (n=316) undergoing elective DCR were included.Results Successful immediate reversion to SR was attained in 266 (84 %) of patients. 224 (84 %) patients were followed up for a median period of 3.5 years (IQR 2.7-4.3). Most patients (150 [67 %]) had recurrence of AF / flutter at a median time of 240 days. Clinical predictors of AF recurrence included a history of AF (HR 0.63, p=0.038) and a dilated left atrium (HR 4.13, p=0.048). Maintenance of SR was associated with fewer unplanned hospitalizations for AF (HR 3.25, p&lt;0.01).Conclusion There was high procedural success post DCR. However, long-term rates of AF recurrence were high, and AF recurrences were associated with increased hospitalizations. These findings underscore the importance of clinical vigilance and multi-modal management as part of a comprehensive and effective rhythm control strategy.

Cryoballoon ablation for atrial fibrillation in patients with heart failure with mildly reduced and preserved ejection fraction.

Limited data are available on the outcomes of cryoballoon ablation (CBA)-based pulmonary vein isolation (PVI) for atrial fibrillation (AF) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) and mildly reduced ejection fraction (HFmrEF). The present study aimed to evaluate the safety and effectiveness of CBA in such patients. Consecutive patients with AF referred for CBA-based PVI from two highly experienced electrophysiology centres were included in this retrospective study. Of 651 patients undergoing CBA, 471 cases were divided into four groups: No HF (n=255), HFpEF (n=101), HFmrEF (n=78), and HF with reduced ejection fraction (n=37). Similar early recurrence of atrial arrhythmia was found among groups (16.2% vs. 15.4% vs. 14.9% vs. 12.2%, P=0.798), and no significant difference of long-term sinus rhythm (SR) maintenance was identified among the HFmrEF, HFpEF, and No HF groups (71.8% vs. 75.2% vs. 79.6%, P=0.334). CBA is safe for patients with HFmrEF and HFpEF with similar complications compared with the No HF group (3.8% vs. 4.0% vs. 3.1%, P=0.814). The reassessment of cardiac function after CBA showed that patients with HF indicated beneficial outcomes. Left atrial diameter (LAD) and left ventricular ejection fraction were significantly improved in the HFmrEF group. There were 41.6% of patients in the HFpEF group who were completely relieved from HF. LAD and New York Heart Association (NYHA) were associated with recurrence in the HFpEF and HFmrEF groups, and the maintenance of SR was an independent predictor of NYHA improvement for all HF groups. Patients with HFmrEF and HFpEF could benefit from CBA with high SR maintenance and significant HF improvement.

Procedural Feasibility and Long-Term Efficacy of Catheter Ablation of Atypical Atrial Flutters in a Wide Spectrum of Heart Diseases: An Updated Clinical Overview.

Atypical atrial flutters (AAFL) are difficult-to-manage atrial arrhythmias, yet potentially amenable to effective radiofrequency catheter ablation (CA). However, data on CA feasibility are only sparingly reported in the literature in different clinical settings, such as AAFL related to surgical correction of congenital heart disease. The aim of this review was to provide an overview of the clinical settings in which AAFL may occur to help the cardiac electrophysiologist in the prediction of the tachycardia circuit location before CA. Moreover, the role and proper implementation of cutting-edge technologies in this setting were investigated as well as which procedural and clinical factors are associated with long-term failure to maintain sinus rhythm (SR) to find out which patients may, or may not, benefit from this procedure. Not only different surgical and non-surgical scenarios are associated with peculiar anatomical location of AAFL, but we also found that CA of AAFL is generally feasible. The success rate may be as low as 50% in surgically corrected congenital heart disease (CHD) patients but up to about 90% on average after pulmonary vein isolation (PVI) or in patients without structural heart disease. Over the years, the progressive implementation of three-dimensional mapping systems and high-density mapping tools has also proved helpful for ablation of these macro-reentrant circuits. However, the long-term maintenance of SR may still be suboptimal due to the progressive electroanatomic atrial remodeling occurring after cardiac surgery or other interventional procedures, thus limiting the likelihood of successful ablation in specific clinical settings.

Pre-treatment with antiarrhythmic drugs for elective electrical cardioversion of atrial fibrillation: a systematic review and network meta-analysis.

Our objective was to compare the efficacy of pre-treatment with different classes of anti-arrhythmic drugs (AADs) in patients with atrial fibrillation (AF) undergoing electrical cardioversion. We performed a systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing different AADs in patients with AF undergoing electrical cardioversion. We grouped AADs into five network nodes: no treatment or rate control, Class Ia, Class Ic, Class III, and amiodarone. Outcomes were (i) acute restoration and (ii) maintenance of sinus rhythm. We searched MEDLINE and EMBASE from inception until June 2020. We used Python 3.8.3 and R 3.6.2 for data analysis. We evaluated the overall certainty of evidence with the GRADE framework. We included 28 RCTs. Compared with no treatment or rate control, Class III AADs [odds ratio (OR): 2.41; 95% credible interval (CrI): 1.37 to 4.62, high certainty] and amiodarone (OR: 2.58; 95% CrI: 1.54 to 4.37, high certainty) improved restoration of sinus rhythm. Amiodarone improved long-term maintenance of sinus rhythm when compared with no treatment or rate control (OR: 5.37; 95% CrI: 4.00-7.39, high certainty), Class Ic (OR: 1.89; 95% CrI: 1.05-3.45, moderate certainty) and Class III AADs (OR: 2.19; 95% CrI: 1.39-3.26, high certainty). Before electrical cardioversion of AF, treatment with Class III AADs or amiodarone improves the acute restoration of sinus rhythm. Amiodarone is most likely to improve the maintenance of sinus rhythm after electrical cardioversion, but Class Ic and Class III AADs are also effective.

Amplitude of fibrillatory wave correlates with long-term maintenance of sinus rhythm after ablation in persistent atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Commission for Technology and Innovation (CTI), Switzerland Background Amplitude of fibrillatory wave (fWA) on surface ECG is regarded as a predictor of ablation outcome for atrial fibrillation (AF). Purpose We sought to investigate whether fWA and its changes during ablation predicts long-term maintenance of sinus rhythm (SR) after wide circumferential isolation of pulmonary veins (WPVI) in persistent AF (peAF). Methods 41 patients (63±10 y, sustained AF 11±7 months) underwent a de-novo WPVI. A second WPVI was performed in patients with recurrent AF in order to provide complete PV disconnection. We defined "success" as patients who remained in SR after one or two procedures, and "failure" otherwise. 60-sec ECG signals devoid of QRST waves were recorded during the index ablation at baseline and at the end of ablation (end_WPVI, before cardioversion or conversion of AF into SR). fWA was computed on leads V1 and V6b (placed on the pts’ back) as the average difference between the upper and lower envelope of atrial ECG signals. Results Over a mean follow-up of 33±9 months, 30 patients remained free from AF (success group), while 11 patients had AF recurrence after 2 WPVIs (failure group). The clinical characteristics (e.g. age, body mass index, left atrial volume or duration in sustained AF) were similar between groups (p &amp;gt; 0.05). The success group displayed significantly higher fWA values at baseline and end_WPVI than that of the failure group (p&amp;lt;0.05, Panel A and B). No significant difference was found between baseline fWA values and those measured at end_WPVI (p &amp;gt; 0.05). Conclusion As fWA is independent of PVs contribution, it is a marker of atrial body remodelling. Low fWA values identify patients with peAF unresponsive to WPVI.

Long-Term Maintenance of Sinus Rhythm Is Associated with Favorable Echocardiographic Remodeling and Improved Clinical Outcomes after Transcatheter Aortic Valve Replacement.

Periprocedural atrial fibrillation (AF) is associated with poor prognosis after transcatheter aortic valve replacement (TAVR). We evaluated the impact of long-term sinus rhythm (SR) maintenance on post-TAVR outcomes. We enrolled 278 patients treated with TAVR including 87 patients with periprocedural AF. Patients with periprocedural AF were classified into the AF-sinus rhythm maintained (AF-SRM) group or the sustained AF group according to long-term cardiac rhythm status after discharge. Patients without AF before or after TAVR were classified into the SR group. The primary clinical outcome was a composite of all-cause death, stroke, or heart failure rehospitalization. The AF-SRM and the SR groups showed significant improvements in left ventricular ejection fraction and left atrial volume index at one year after TAVR, while the sustained AF group did not. During 24.5 (±16.1) months of follow-up, the sustained AF group had a higher risk of the adverse clinical event compared with the AF-SRM group (hazard ratio (HR) 4.449, 95% confidence interval (CI) 1.614–12.270), while the AF-SRM group had a similar risk of the adverse clinical event compared with the SR group (HR 0.737, 95% CI 0.285–1.903). In conclusion, SR maintenance after TAVR was associated with enhanced echocardiographic improvement and favorable clinical outcomes.

Quality of life in patients with long-standing persistent atrial fibrillation after surgical ablation and simultaneous coronary artery bypass grafting

Aim. To analyze quality of life (QOL) of patients with coronary artery disease (CAD) in combination with long-standing persistent atrial fibrillation (AF) in the long-term postoperative period, depending on chosen surgical strategy for concomitant pathology.Material and methods. The analysis of QOL changes in the long-term postoperative period (12 and 24 months) in 116 patients with CAD and concomitant long-term persistent AF who selectively underwent biatrial (BA) or isolated left atrial (LA) ablation with simultaneous on-pump coronary artery bypass grafting. To assess QOL, a non-specific Medical Outcomes Study 36-Item Form Health Status Survey (SF-36) questionnaire was used. Patients were questioned in preoperative and long-term postoperative periods (12 and 24 months).Results. All SF-36 parameters significantly improve after open surgical treatment in the long-term postoperative period (24 months) with both treatment strategies (BA and LA ablation) for AF. In the BA ablation group, 74% of patients did not have arrhythmia after 12 months, and only 38,5% of patients in the LA ablation group belonged to European Heart Rhythm Association (EHRA) score class 1 (p=0,001). After 24 months, a comparison revealed a significant diff erence between the two groups in arrhythmia symptoms (p=0,014), with maintaining the advantage of the BA ablation group. After 12 and 24 months, none of the patients in both compared groups had severe class IV angina.Conclusion. SF-36 parameters were improved 24 months after surgical treatment of CAD and long-standing persistent AF, regardless of the ablation strategy. Elimination of angina symptoms and long-term maintenance of sinus rhythm can improve the QOL of patients in the long-term postoperative period.

Dynamics of Intraprocedural Dominant Frequency Identifies Ablation Outcome in Persistent Atrial Fibrillation.

Background: The role of dominant frequency (DF) in tracking the efficiency of a stepwise catheter ablation (step-CA) in persistent atrial fibrillation (peAF) remains poorly studied. We hypothesized that the DF time-course during step-CA displays divergent patterns between patients in whom a step-CA successfully restores long-term sinus rhythm (SR) and those with recurrence.Methods: This study involved 40 consecutive patients who underwent a step-CA for peAF (sustained duration 19 ± 11 months). Dominant frequency was computed on electrograms recorded from the right and left atrial appendages (RAA; LAA) and the coronary sinus before and during the step-CA synchronously to the 12-lead ECG. Dominant frequency was defined as the highest peak within the power spectrum.Results: Persistent atrial fibrillation was terminated by a step-CA in 28 patients [left-terminated (LT)], whereas 12 patients remaining in AF after ablation [not left-terminated (NLT)] were cardioverted. Over a mean follow-up of 34 ± 14 months, all NLT patients had a recurrence. Among the 28 LT patients, 20 had a recurrence, while 8 remained in SR throughout follow-up. The RAA and V1 DF had the best predictive values of the procedural failure to terminate AF (area under the curve; AUC 0.84, p < 0.05). A decision tree model including a decrease in LAA DF ≥ 6.61% during the first 20 min following pulmonary vein isolation (PVI) and a baseline RAA DF <5.6 Hz predicted long-term SR restoration with a sensitivity of 83% and a specificity of 93% (p < 0.05).Conclusion: This study found that high baseline DF values are predictive of unfavorable ablation outcomes. The reduction of the LAA DF at early ablation steps following PVI is associated with procedural AF termination and long-term SR maintenance.

Successful Reversal of Severe Tachycardia-Induced Cardiomyopathy with Cardiogenic Shock by Urgent Rhythm or Rate Control: Only Rhythm and Rate Matter.

Background and objectives Severe forms of Tachycardia-induced cardiomyopathy (TIC) with cardiogenic shock are not well described so far, and efficiency of catheter ablation in this setting is unknown. Methods We retrospectively included consecutive patients admitted to the Intensive Cardiac Care Unit for acute heart failure with cardiogenic shock associated with atrial arrhythmia and managed by ablation. Result Fourteen patients were included, each with cardiogenic shock and two needing the use of extracorporeal membrane oxygenation. Successful ablation was performed in the acute setting or over the following weeks. Two patients experienced relapses of arrhythmias and were treated by new ablation procedures. At 7.5 ± 5 months follow-up, all patient were alive with stable sinus rhythm. The left ventricular Ejection Fraction dramatically improved (21 vs. 54%, p = 0.001) as well as the end-diastolic left ventricular diameter (61 vs. 51 mm, p = 0.01) and NYHA class (class IV in all vs. median 1, p = 0.002). Conclusion Restoration and maintenance of sinus rhythm in severe TIC with cardiogenic shock and atrial arrhythmias lead to a major increase or normalization of LVEF, reduction of ventricular dimensions, and improvement in functional status. Ablation is efficient in long-term maintenance of sinus rhythm and may be proposed early in refractory cases.

Supraventricular tachycardias in the first year of life: what is the best pharmacological treatment? 24\xa0years of experience in a single centre

BackgroundSupraventricular tachycardias (SVTs) are common in the first year of life and may be life-threatening. Acute cardioversion is usually effective, with both pharmacological and non-pharmacological procedures. However, as yet no international consensus exists concerning the best drug required for a stable conversion to sinus rhythm (maintenance treatment). Our study intends to describe the experience of a single centre with maintenance drug treatment of both re-entry and automatic SVTs in the first year of life.MethodsFrom March 1995 to April 2019, 55 patients under one year of age with SVT were observed in our Centre. The SVTs were divided into two groups: 45 re-entry and 10 automatic tachycardias. As regards maintenance therapy, in re-entry tachycardias, we chose to start with oral flecainide and in case of relapses switched to combined treatment with beta-blockers or digoxin. In automatic tachycardias we first administered a beta-blocker, later combined with flecainide or amiodarone when ineffective.ResultsThe patients’ median follow-up time was 35 months. In re-entry tachycardias, flecainide was effective as monotherapy in 23/45 patients (51.1%) and in 20/45 patients (44.4%) in combination with nadolol, sotalol or digoxin (overall 95.5%). In automatic tachycardias, a beta-blocker alone was effective in 3/10 patients (30.0%), however, the best results were obtained when combined with flecainide: overall 9/10 (90%).ConclusionsIn this retrospective study on pharmacological treatment of SVTs under 1 year of age the combination of flecainide and beta-blockers was highly effective in long-term maintenance of sinus rhythm in both re-entry and automatic tachycardias.

Echocardiography markers of myocardial deformation as independent predictors of sinus rhythm maintenance after catheter ablation for paroxysmal atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Speckle Tracking Echocardiography (STE) provides a comprehensive and quantitative assessment of myocardial function. However, the accuracy of STE-derived indices to predict maintenance of sinus rhythm (SR) following radio-frequency catheter ablation (CA) is still under debate. Therefore, the aim of the present study is to define the accuracy of STE-derived parameters to predict long-term maintenance of SR in patients with paroxysmal AF undergoing CA. Methods We prospectively enrolled 218 consecutive patients (age: 62 ± 10 years, 30% females) with paroxysmal AF undergoing first-CA. All patients with preserved ejection fraction (EF ≥ 50%) underwent comprehensive transthoracic echocardiography at baseline, including assessment of left ventricular (LV) global longitudinal strain (GLS), left atrial (LA) reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile strain (LASct) using two-dimensional STE in apical views. Results At 12 months follow up, a total of 39 (18%) patients had a documented recurrence of AF. Among imaging parameters, LASr &amp;gt; 23% showed the largest area under the curve (0.80) to predict long-term maintenance of SR with sensitivity of 79% and specificity of 72%. Other parameters of LA function, LA diameter, maximum or minimum LA volume index, LV GLS or ejection fraction, and indices of LV diastolic function had lower area under the curve (Figure 1). Using multi-variable logistic regression, LASr (OR 1.19, 95% CI 1.10-1.23, p &amp;lt; 0.001) and LASct (OR 1.21, 95% CI 1.07-1.37, p = 0.002) were independently associated with long-term SR while maximum or minimum LA volume index was not. Conclusion In patients with paroxysmal AF undergoing radio-frequency CA, preserved LA reservoir and contractile strain is independently associated with long-term maintenance of SR, whereas LA diameter or volumes were not. LA strain may therefore be useful in management of patients with paroxysmal AF. Figure 1: Receiver-operating characteristic curves of left atrial reservoir strain (LASr), LA conduit strain (LAScd), LA contractile strain (LASct), LA emptying fraction (LAEF), LA expansion index (LAEI), LA end-systolic (LAES) and end-diastolic (LAED) volume index (VI) to predict long-term maintenance of sinus rhythm. Abstract Figure.

Early assessment of left atrial function after cardioversion predicts recurrence of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background The restoration of sinus rhythm (SR) improves the mechanical function of the heart. Purpose To assess left atrial (LA) function before and within 24 hours after successful electrical cardioversion (EC) and its prognostic value for atrial fibrillation (AF) recurrence during 24 months follow-up. Methods Prospective study involved 71 patients with non-valvular AF (mean age 64 ± 13 years, 61% male). All patients underwent echocardiography before and after EC. We analysed standard parameters in two-dimensional echo, pulse-wave Doppler and tissue Doppler echocardiography. Using speckle-tracking method we assessed peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS). Results During follow-up we noticed AF recurrence in 48 (68%) patients. Median time to AF recurrence was 2.4 (IQR 1 to 6.9) months. Left ventricular ejection fraction as well as E/E’ and PALS assessed during AF were statistically insignificant as potential predictors in univariate regression model. Receiver operating characteristic curve analysis revealed that left atrial volume index &amp;gt;37 ml/m² (AUC = 0.811, p &amp;lt; 0.0001), E/A ratio &amp;gt;2.1 (AUC = 0.828, p &amp;lt; 0.0001), A wave ≤0.4 m/s (AUC = 0.662, p = 0.01), mean E/E’ ratio during sinus rhythm &amp;gt;8.5 (AUC = 0.815, p &amp;lt; 0.0001), mean A’ wave of ≤5.5 cm/s (AUC = 0.848, p &amp;lt; 0.0001), PALS-SR ≤14.1% (AUC = 0.767, p &amp;lt; 0.0001), PACS ≤4.3% (AUC = 0.883, p &amp;lt; 0.0001) were the optimal cut-off values for predicting AF recurrence. Conclusions The assessment of LA and diastolic function conducted within 24 hours after successful cardioversion predicts long-term maintenance of sinus rhythm.

Transcatheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy: Long-term results and clinical outcomes.

Radiofrequency transcatheter ablation (RFCA) for atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM) has been proven feasible. However, the long-term results of RFCA and its impact on clinical course of HCM are unknown. The aim of this study was to analyse clinical outcomes and long-term efficacy of RFCA in a multicentre cohort of patients with HCM and concomitant AF. Patients with HCM and AF consecutively undergoing RFCA were included. Ablation failure was defined as recurrence of AF, atrial tachycardia, or flutter lasting more than 3 min and occurring after the blanking period. Overall, 116 patients with symptomatic AF refractory to antiarrhythmic drugs were included. Over a median follow-up of 6.0 years (interquartile range: 3.0-8.9 years) recurrence rate after a single RFCA was 32.3 per 100 patient/years with 26% of patients free from AF relapses at 6-year follow-up. Among patients experiencing AF recurrence, 51 (66%) underwent at least one redo-procedure. The overall recurrence rate considering redo-procedures was 12.6 per 100 patients/years with 53% of patients free from AF relapses at 6 years. At last follow-up, with an average of 1.6 procedures, 67 (61%) patients were in sinus rhythm (SR). Patients remaining in SR showed better functional status compared with those experiencing arrhythmic recurrences (NYHA Class 1.6 ± 0.1 vs. 2.0 ± 0.1, p = .009). RFCA of AF in HCM patients is an effective and safe strategy favoring long-term SR maintenance, reduction of atrial arrhythmic events, and improved functional status. However, most patients need repeat procedures and continuation of antiarrhythmic drugs.

Delayed Recurrence of Atrial Fibrillation and Flutter in Patients Referred for Electrical Cardioversion: A 5-year Study in a Real-World Setting

Atrial fibrillation (AF) and atrial flutter are common cardiac arrhythmias treated with electrical cardioversion (DCR) to restore sinus rhythm (SR). The primary outcome of the study was to ascertain the long-term maintenance of SR in this all-comer patient population undergoing elective DCR. Secondary outcomes involved reporting on periprocedural safety, predictors of long-term (greater than 1 year) maintenance of SR and clinical outcomes including mortality or hospitalisation of heart failure or AF.

Prevalence and Clinical Significance of Latent Brugada Syndrome in Atrial Fibrillation Patients Below 45 Years of Age.

Aim: This study aims to describe prevalence and clinical significance of latent Brugada syndrome (BrS) in a young population with atrial fibrillation (AF).Methods: Between September 2015 and November 2017, among 111 AF patients below 45 years of age, those without pre-existing pathologies and/or known risk factors were selected for the study. Based on baseline 12-lead−24-h Holter electrocardiogram (ECG), previous class 1C antiarrhythmic drug therapy, or ajmaline testing, patients were stratified as latent type 1 BrS or not.Results: Within the 78 enrolled patients, 13 (16.7%; group 1) revealed a type 1 BrS ECG pattern, while 65 (83.3%; group 2) did not. Mean age was 37 ± 8 vs. 35 ± 7 (p = 0.42), and males were 7 (54%) vs. 54 (83%) (p = 0.02) in the two groups, respectively. Family history of BrS was significantly more common within group 1 patients (2, 15% vs. 0; p = 0.03), and 4 (31%) patients experienced syncope in group 1 vs. 5 (8%) in group 2 (p = 0.02). After a mean follow-up of 42 ± 18 months from the index AF event, more than 80% of the patients, in both study groups, were in sinus rhythm.Conclusion: In young patients with AF without pre-existing pathologies and/or known risk factors, latent BrS should be suspected. Syncope and a family history of BrS emerge as easily identifiable factors related to BrS. Long-term sinus rhythm maintenance appears satisfactory, either in the presence or not of BrS.