Long-term Persistent Atrial Fibrillation Research Articles

First experience of treating patients with atrial fibrillation using thoracoscopic isolation with left atrial appendage excision in the North-Western State Medical University named after I.I. Mechnikov

The given article describes the first experience of a thoracoscopic isolation of pulmonary veins and left atrial appendage excision in the North-Western State Medical University named after I.I. Mechnikov. The clinical case features a woman with a long history of paroxysmal atrial fibrillation, severe left atrium dilation, failure in a pace control drug therapy and no effect of radiofrequency catheter isolation of pulmonary veins. Additionally, there outlined the advantages and the significance of employing the method of thoracoscopic ablation in patients with symptomatic paroxysmal and long-term persistent atrial fibrillation, — in case if antiarrythmic drugs and radiofrequency catheter ablation proved ineffective, as well as in patients with a long-term persistent atrial fibrillation along with a severe left atrium dilation.

The expression of selected microRNAs enables identification of patients with functional atrial tricuspid regurgitation. New insights into TR pathophysiology

Abstract Background Functional tricuspid regurgitation (FTR) is a powerful and independent predictor of patients’ morbidity and mortality. Atrial FTR (A-FTR) is a recently defined phenotype associated with permanent atrial fibrillation. In A-FTR, the underlying pathophysiological factors behind tricuspid annulus (TA) enlargement and the subsequent development of atrial TRF are still unclear, given that despite RA enlargement, a significant fraction of patients presenting long-term persistent atrial fibrillation (AF) will fail to develop significant TR during follow-up. Different microRNAs (miRNAs) have been studied as regulators and diagnostic biomarkers in mitral and aortic valve disease, but no study has been focus on FTR so far. Purpose Our current study aims to identify and validate a selection of circulating miRNAs as potential regulators of A-FTR Methods Consecutive patients with severe A-FTR and patients with non-valvular permanent atrial fibrillation (AF without TR) undergoing anticoagulant therapy were prospectively recruited. The experimental design included a first screening phase in 16 subjects ((8 A-FTR and 8 AF controls) to identify candidate miRNAs differentially expressed in a miRNA qPCR panel containing 192 specific miRNAs, and a second validation phase in which selected miRNAs were screened for further validation by qRT-PCR in 80 additional patients (40 TR and 40 AF). Results The initial screening revealed 16 differentially expressed miRNAs in atrial FTR vs. AF subjects matched by age, gender and atrial dimensions (figure 1). In the validation phase, the expression of miR-29b-3p, miR-152-3p, miR-30e-5p, miR-186-5p, miR-126-5p and miR-148a-3p (p<0.05) were significantly different in A-FTR compared to AF. Among all, miR-186-5p, miR-152-3p and miR-30e-5p yielded the highest predictive values for the detection of A-FTR with areas under the curve of 0.96 (0.92-0.99), 0.90 (0.83-0.97) and 0.87 (0.79-0.95) respectively (p<0,001 for all, figure 2). Conclusions Patients with atrial FTR exhibited different miRNA fingerprint compared to patients with permanent AF without TR but similar degree of atrial enlargement. Additionally, our study identified 3 novel miRNAs as potential diagnostic biomarkers of A-FTR: miR-186-5p, miR-152-3p and miR-30e-5p which excellent accuracy. Whether the differential expression of such miRNAs precedes or follows the development of FTR or the subsequent leaflet adaptation or growth, will be further explored in future studies.Table and volcano plot of miRNAmiRNA ROC curves in A-FTR

Predictors of pacing-induced cardiomyopathy detection and outcomes demonstration after conduction system pacing upgrade on patients with long-term persistent atrial fibrillation.

To identify the predictors of pacing-induced cardiomyopathy (PICM) and illustrate the safety and feasibility of conduction system pacing (CSP) upgrade on patients with long-term persistent atrial fibrillation (AF). All patients with long-term persistent AF and normal left ventricular ejection fraction (LVEF) ≥50% were consecutively enrolled from January 2008 to December 2017, and all the patients with atrioventricular block (AVB) and high right ventricular pacing (RVP) percentage of at least 40%. The predictors of PICM were identified, and patients with PICM were followed up for at least 1 year regardless of CSP upgrade. Cardiac performances and lead outcomes were investigated in all patients before and after CSP upgrade. The present study included 139 patients, out of which 37 (26.62%) developed PICM, resulting in a significant decrease in the left ventricular ejection fraction (LVEF) from 56.11±2.56% to 38.10±5.81% (p<.01). The median duration for the development of PICM was 5.43 years. Lower LVEF (≤52.50%), longer paced QRS duration (≥175ms), and higher RVP percentage (≥96.80%) were identified as independent predictors of PICM. Furthermore, the morbidity of PICM progressively increased with an increased number of predictors. The paced QRS duration (183.90±22.34ms vs. 136.57±20.71ms, p<.01), LVEF (39.35±2.71%vs. 47.50±7.43%, p<.01), and left ventricular end-diastolic diameter (LVEDD) (55.53±5.67mm vs. 53.20±5.78mm, p=.03) improved significantly on patients accepting CSP upgrade. CSP responses and complete reverse remodeling (LVEF ≥50% and LVEDD<50mm) were detected in 80.95% (17/21) and 42.9% (9/21) of patients. The pacing threshold (1.52±0.78V/0.4ms vs. 1.27±0.59V/0.4ms, p=.16) was stable after follow-up. PICM is very common in patients with long-term persistent AF, and CSP upgrade was favorable for better cardiac performance in this patient population.

Hybrid ablation of atrial fibrillation: long-term outcomes from a single center prospective experience

Abstract Funding Acknowledgements Type of funding sources: None. Background/introduction Hybrid ablation of atrial fibrillation (AF) is emerging as a new technique for rhythm control with good clinical outcomes, especially in patients with non-paroxysmal AF. However, the role of hybrid AF in redo procedures is not clear. Moreover, long term clinical outcomes studies are lacking. Purpose The aim of this study is to define the long-term clinical outcomes of hybrid AF ablation in a large cohort from a single high-volume center. Furthermore, a correlation between the timing of hybrid AF and the outcomes is aimed. Methods All consecutive patients undergoing to hybrid AF ablation between 2014 and 2020 were enrolled in a prospective fashion. Hybrid ablation was performed in a one-step procedure consisting of: 1) Bilateral thoracoscopic epicardial ablation and 2) Percutaneous mapping and ablation. Pulmonary veins and posterior wall isolation was performed in all patients. Additional lesion set was performed based on physician judgement and clinical indication, including the following: superior vena cava isolation, bicaval line, anterior or posterior mitral line, cavotricuspid isthmus. Hybrid ablation time was analyzed as first hybrid procedure or redo hybrid after previous failed percutaneous procedure. The primary endpoint was defined as freedom from any atrial tachyarrhythmias (ATas) ≥ 30 seconds after a 90-day post-ablation blanking period. Results A total of 120 patients were included, 92 (76.7%) patients with persistent or long-term persistent AF and 28 patients (23.3%) with paroxysmal AF. Hybrid ablation was the first procedure in 85 (70.8%) patients and the second or third procedure (redo or re-redo) in 35 (29.2%) patients. Compared to patients with a second or third hybrid procedure, patients with a first hybrid procedure had more often persistent AF [81 patients (95.3%) vs 11 patients (31.4%), p&amp;lt;0.001]. At a mean follow-up of 52.1 months ± 29.0 there were 36 (30%) ATas recurrences, Figure 1. There was no significant difference in ATas free survival between patients with a first hybrid procedure and patients with a second or third hybrid procedure (69.4% vs 71.4%, Log-Rank p=0.81), Figure 2. Patients with a second hybrid procedure had higher ATas free survival compared to patients with a third hybrid procedure (86.4% vs 46.2%, Log-Rank p=0.01) Conclusion In a large cohort undergoing to hybrid AF ablation, the recurrence rate was 30% at a long-term follow-up of more than 4 years. Timing is of utmost clinical importance as delaying hybrid approach might be associated with worse clinical outcome.

СВЯЗЬ ПОЛИМОРФНОГО ВАРИАНТА RS989692 ГЕНА НЕПРИЛИЗИНА (MME) С УРОВНЕМ НАТРИЙУРЕТИЧЕСКИХ ПЕПТИДОВ И ЕГО КЛИНИЧЕСКОЕ ЗНАЧЕНИЕ У ПАЦИЕНТОВ С СЕРДЕЧНОЙ НЕДОСТАТОЧНОСТЬЮ И ФИБРИЛЛЯЦИЕЙ ПРЕДСЕРДИЙ

Background. The variability in the activity of natriuretic peptides (NUPs) is determined genetically, as evidenced by the association of polymorphic variants encoding brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) with an increased risk of cardiovascular (CV) disease. The aim of the study. To determine the frequency of alleles and genotypes of the SNP rs989692 of the neprilysin gene (MME). To determine the association of SNP rs989692 in MME with the concentration of NUP and soluble neprilysin and to evaluate its prognostic value in relation to the development of adverse cardiovascular events in patients with heart failure (HF) associated with a left ventricular ejection fraction (LVEF) &lt;50% and persistent or long-term persistent atrial fibrillation (AF). Material and methods. The main group included 152 patients with HF, the control group included 35 individuals without CV disease. The levels of ANP, BNP, NT-proBNP and soluble neprilysin were determined for all patients. The genetic study of the SNP rs989692 in the MME gene was carried out by polymerase chain reaction. The endpoint: hospitalization due to HF progression. The composite endpoint: hospitalization due to HF progression, new onset or progressive exertional angina pectoris, myocardial infarction. Results. The frequency distribution of genotypes and alleles of the SNP rs989692 in MME did not differ significantly between the control and experimental groups. The levels of ANP, BNP and neprilysin in patients with HF in combination with AF did not differ depending on the SNP rs989692 in MME genotype. Patients with HF associated with LVEF &lt;50%, AF and TT genotype rs989692 in MME had higher levels of NT-proBNP (those with CC genotype – 964 [655.1; 1724] pg/ml, those with TC genotype – 1074.1 [857; 1944] pg/ml, those with the TT genotype – 2992 [886; 4885] pg/ml, p&lt;0.05). The presence of the homozygous TT genotype in patients with HF combined with LVEF &lt;50% and AF was associated with an increased risk of developing adverse CV events, OR=1.9 [95% CI from 1.2 to 3.09]. Conclusion. Patients with HF associated with LVEF &lt;50% in combination with permanent or long-term persistent AF with homozygous TT genotype rs989692 of the MME gene have higher levels of NT-proBNP and a higher risk of developing adverse cardiovascular events.

Hybrid Ablation of Atrial Fibrillation: A Contemporary Overview.

Electrical isolation of pulmonary veins (PVI) is the cornerstone of invasive treatment of atrial fibrillation (AF). However, arrhythmia-free survival of a PVI only approach is suboptimal in patients with persistent and long-term persistent AF. Hybrid AF ablation has been developed with the aim of combining the advantages of a thoracoscopic surgical ablation (direct visualization of anatomical structures to be spared and the possibility to perform epicardial lesions) and endocardial ablation (possibility to check line block, confirm PVI, and possibility to perform cavotricuspid isthmus ablation). Patient selection is of utmost importance. In persistent and long-term persistent AF, hybrid AF ablation demonstrated promising results in terms of AF free survival. It has been associated with a relatively low complication rate if performed in centers with expertise in hybrid procedures and experience with both surgical and endocardial ablation. Different techniques have been described, with different approaches and lesion sets. The aim of this review is to provide a state-of-the-art overview of hybrid AF ablation.

Evaluation of atrial contractility and remodeling after the Maze-3 procedure with combined heart interventions

Highlights. The most important goal of atrial fibrillation surgical treatment is to eliminate the arrhythmia in order to restore atrial contractility and improve their transport function. Our study showed positive dynamics of atrial contractility and remodeling after the maze-3 procedure against the background of a regular heart rhythm restoration. The study of sinus rhythm predictors maintenance and recovery of atrial transport function will help to make patient selection more personified.Aim. Evaluation of atrial contractility and remodeling after the maze-3 procedure with combined interventions on the heart.Methods. The analysis of 217 combined surgical interventions was carried out, where a maze-3 was used to treat atrial fibrillation (AF). The operations were performed in our center from 2012 to 2016. Key points of the study: rhythm after surgery and echocardiographic control in the long-term follow-up in order to determine the dynamics of atrial contractility and volumes. The average follow-up period was 47 (1–100) months. 40 (18.4%) patients had paroxysmal, 38 (17.5%) persistent, 139 (64.1%) long-term persistent AF. The mean AF duration before surgery was 27.4 months (1–200 months). The indications for the maze-3 procedure were: ineffectiveness of antiarrhythmic therapy, the need to perform combined cardiac procedures. We used standard statistical research methods with one – and multivariate logistic regression.Results. In the long-term follow-up, sinus rhythm (SR) persists in 79% of patients. In the long-term follow-up, in this group of patients, the left atrial contractility was restored from 76% to 91%, while the biatrial contractility increased from 82 to 96%. Shorter AF duration before surgery was a positive predictor of SR recovery and atrial contractility (p = 0.005), while pulmonary artery pressure and patient age negatively affected these indicators (p = 0.041 and p = 0.038, respectively). The presence of SR early after surgery was not a significant predictor of AF freedom. At the same time, according to the long-term observations, patients maintaining a regular atrial heart rate had positive indicators of atrial systolic function restoration and a positive dynamics of a decrease in atrial volumes.Conclusion. SR and restoration of left atrial contractility are two interrelated goals of the maze procedure. The negative factors associated with the failure of surgical treatment of AF are increased pressure in the pulmonary artery, long-term AF before surgery, and the age of patients.

Mid-term success rate of single stage hybrid ablation of persistent and long-term persistent atrial fibrillation.

Single stage thoracoscopic radiofrequency ablation (RFA) is a treatment method for persistent and long-term persistent atrial fibrillation (AF) offering the possibility for patients otherwise inconsolable by conventional catheter RFA. We present a pilot group of patients after the introduction of the new method at our clinical center. Patients group: A total of 52 patients aged 61.82 ± 9.7 years underwent single stage hybrid ablation (thoracoscopic isolation of pulmonary veins and box lesion followed by catheter verification of the surgical procedure effectivness) for symptomatic persistent and long-term persistent AF with significantly dilated left atrium 57.9 ± 11.0mm in the period September 2016-March 2019. The median duration of the procedure was 232 minutes and the median duration of hospitalization was 10 days. At discharge, 52 patients (100%) had sinus rhythm. 48 of 52 patients (92.3%) had a 6-month follow-up. 41 of 48 (85.4%) and 38 of 44 (86.4%) of patients were AF free at 3-month and 6-month follow-up, respectively. Acute complications were: one left atrial perforation resolved successfully by suture and one transient ischaemic attack without permanent sequelae. Late complications involved one massive pulmonary embolization and an atrioesophageal fistula. There was no periprocedural myocardial infarction or stroke with permanent sequelae. Hybrid thoracoscopic-catheter ablation performed during one procedure is an effective and relatively safe mini-invasive method of treatment for long-term persistent atrial fibrillation.

The Chinese expert recommendations on the clinical use of dronedarone

Dronedarone, a class Ⅲ antiarrhythmic drug, is a deiodinated benzofuran derivative of amiodarone. It has similar antiarrhythmic effects with amiodarone, but much lesser adverse effects than amiodarone, particularly in those outside the heart. It is suggested to use dronedarone for the rhythm control of atrial fibrillation/flutter, for it has been shown to prevent the recurrence of atrial fibrillation/flutter and reduce rehospitalization in patients with paroxysmal or persistent atrial fibrillation/flutter. Dronedarone is not recommended for the rhythm control in patients with long-term persistent atrial fibrillation or permanent atrial fibrillation, and atrial flutter or atrial fibrillation patients with reduced ejection fraction. Liver function, electrolyte tests and an electrocardiogram should be performed before and after the drug initiation. Potential interactions with other kinds of drugs have to be taken into consideration as well.

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.

Thoracoscopic ablation for symptomatic atrial fibrillation improves quality of life

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

Features of the expression of fibroblast growth factor in patients with idiopathic atrial fibrillation and verified myocarditis

Abstract Introduction Myocarditis and inflammatory changes in the myocardium can be one of the causes of the development and progression of atrial fibrillation (AF). The biomarker FGFβ is involved in the processes of angiogenesis, repair of heart tissues and stimulates fibroblasts. Purpose To assess the dynamics and to identify the relationship of fibroblast growth factor (FGFβ) expression and myocardial inflammatory diseases revealed by the results of histological examination of endomyocardial biopsy in patients with various forms of idiopathic AF. Methods Subjects were 40 patients (41.0±9.2 y.o.) with idiopathic AF, the arrhythmic history constituted 4.9±3.9 years. The patients were divided into 3 groups: 1–with paroxysmal AF (n=15), 2–persistent (n=12), 3–long-term persistent (n=13) depending on the form of AF. All patients underwent radiofrequency ablation (RFA) of the pulmonary veins and endomyocardial byopsy with histologic and immunohistochemical studies. In 1st group active lymphocytic myocarditis (ALM) were found in 40% patients (n=6); in 2d and 3d groups – 66.7% (n=8 in each gr.). All other patients showed signs of lymphocytic infiltration (LI). The serum levels of FGFβ determined all patients in prior to intervention (T1) and in 6 months after RFA (T2). Results Comparative analysis showed, in patients with morphologically verified ALM, the FGFb levels in 6 months after RFA in 1st gr. was significantly higher than in 3d gr. (p=0.036). In patients gr.1 with ALM the levels of FGFb was higher (at stages T1 and T2) than in patients with LI (p=0.055 and p=0.06, respectively). In 1st gr., a positive association between the levels of FGFb (T1) and the degree of activity of inflammatory processes caused in 6 months after RFA (R=0.95 p=0.005) were identified. In 1st gr., the relationship between the degree of activity of inflammatory processes and fibrotic changes (R=−0.77 p=0.009) and an association of FGFb with the value of cardiac ejection fraction was obtained (R=0.90 p=0.037). In 2d gr., strong correlations of FGFb with the degree of activity of inflammatory processes (R=0.79 p=0.019) and ejection fraction (RT1=0.73 p=0.039, RT2=0.96 p=0.0002) were revealed. In 3d gr., the FGFb levels was significantly higher in patients with LI than with ALM (14.74 [13.28; 14.80] and 6.92 [5.65; 9.90] pg/ml, respectively; p=0.048). In 3d gr., the severity of fibrotic changes was associated with FGFb expression (RT1=−0.73 p=0.041, RT2=−0.85 p=0.008). Conclusion The relationships of FGFb with the degree of activity of inflammatory processes in groups with paroxysmal and persistent AF were revealed. In patients with active lymphocytic myocarditis, the FGFb level was significantly higher in paroxysmal AF than in long-term persistent AF. Our study showed, increased expression of FGFb is associated with inflammatory processes of active lymphocytic myocarditis, and may be due to intense proliferation and differentiation of fibroblasts in paroxysmal AF. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Cardiology Research Institute, Tomsk NRMC

The Pathophysiological Link between Right Atrial Remodeling and Functional Tricuspid Regurgitation in Patients with Atrial Fibrillation: A Three-Dimensional Echocardiography Study

Atrial fibrillation (AF) itself may lead to functional tricuspid regurgitation (FTR) through tricuspid annulus (TA) dilation. However, the pathophysiological determinants of TA enlargement in AF patients remain to be clarified. The objectives of this study were (1) to compare the TA size and function in AF patients versus healthy subjects; (2) to identify the determinants of TA remodeling in patients with AF and FTR; and (3) to assess the relationships among right heart structures and severity of FTR in AF patients. Eighty-three consecutive patients with long-term persistent AF and FTR (61±9.9years, 67% women) were prospectively enrolled and compared with 83 sex and body surface area-matched healthy subjects. Heart chamber size and function and TA geometry were analyzed using three-dimensional echocardiography. Among AF patients, 33%, 34%, and 33% had mild, moderate, and severe FTR, respectively. Right atrial (RA) dilation was detected in 93% of AF patients, while only 27% and 12% of them showed dilated or dysfunctional right ventricle (RV), respectively. End-diastolic TA area had the strongest correlation with the minimum volume of the RA (RAVmin r=0.6981, P<.0001) but only mild correlation with RV end-diastolic volume and sex (r=0.3405, P=.0019; r=0.2914, P=.0075). At multivariable analysis, only RAVmin was independently associated with TA area in AF patients (r=0.665, P<.0001). The RAVmin and TA area were the only predictors of FTR severity. In patients with AF, RA dilation seems to be more important than RV dilation to determine TA enlargement and subsequent FTR development. The RAVmin and TA area were directly correlated to FTR severity.

Delayed sinus rhythm restoration after thoracoscopic left atrium fragmentation (а report of two cases)

The article presents two clinical cases of delayed restoration of the sinus rhythm in patients with long-term persistent atrial fibrillation after the procedure of thoracoscopic radiofrequency fragmentation of the left atrium. The necessity of continuing attempts to restore the sinus rhythm up to the end of the "blind period" (90 days) is discussed.

Association of actin-myosin interaction biomarkers and fibrosis with myocardial inflammatory changes in patients with idiopathic atrial fibrillation

Abstract Introduction Myocarditis and inflammatory changes in the myocardium are causes of the development and progression of atrial fibrillation (AF). Inflammatory processes may also lead to the development of fibrosis, electrical and structural myocardial remodeling, adversely affecting the effectiveness of interventional treatment. Purpose To assess the dynamics and to identify relationships between serum levels of tropomyosin I, myosin light chain kinase (MLCK), myosin heavy (MYH7) and light chains (CMLC), transforming growth factor (TGF-β1) and myocardial inflammatory changes in patients with idiopathic AF. Methods Subjects were 40 patients (41.0±9.2 y.o.) with idiopathic AF (arrhythmic history constituted 4.9±3.9 years). Paroxysmal AF (ParAF) was detected in 37% (n=15), persistent AF (PerAF)–30% (n=12), and long-standing persistent (LPerAF)–33% (n=13). All patients underwent radiofrequency ablation (RFA) of the pulmonary veins and endomyocardial byopsy with histologic and immunohistochemical studies. Depending on the results of histological study, the patients were divided into 2 groups: 1–with active lymphocytic myocarditis (ALM) (n=22); 2–with lymphocytic infiltration (IL) (n=18). Blood for biomarkers evaluation was collected prior to RFA and in 6 months after RFA. Results In patients with ALM levels of biomarkers significant differed depending on the form of AF. In patients with PerAF, the levels of MYH7, MLCK and tropomyosin I were significantly lower than in patients with ParAF (p&amp;lt;0.005). In 6 months the levels of MLCK, tropomyosin I, and CMLC significantly differed in patients with ALM depending on the form of AF (p&amp;lt;0.05). In patients with PerAF in the group 1, the concentrations of MYH7, CMLC, and tropomyosin I were lower, than the group 2 (p&amp;lt;0.05). In 6 months in patients with PerAF, the TGF-β1 levels also differed between groups 1 and 2 (Me: 24.09 and 40.34 ng/ml, p&amp;lt;0.05). The content of TGF-β1 before the RFA and in 6 months in patients with PerAF was associated with the development of infiltration in 6 months after RFA (R=0.696, p=0.025). In LPerAF patients we showed correlation between the content of TGF-β1 and the severity of fibrosis in 6 months after RFA (R=0.607, p=0.047). At LPerAF TGF-β1 content correlated with degree of fibrosis in 6 months after RFA (R=0.607, p=0.047). The relationship between the form of AF and the inflammatory changes were identified (r=0.32, p=0.049). Thus, in patients with LPerAF and PerAF, ALM was diagnosed in 69% and 50% of cases, while in patients with ParAF the frequency of ALM detection constituted 33%. Conclusion Our study showed that ALM was detected in 55% of patients, and IL–in 45% of cases. Significant differences in the levels of MYH7, MLCK, CLCK, tropomyosin I in patients with PerAF and various forms of inflammatory myocardial changes were revealed. The content of the TGF-β1 is reduced in ALM in patients with PerAFP. The incidence of ALM was higher in patients with long-term persistent AF. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Cardiology Research Institute, Tomsk NRMC

Short-term and mid-term effects of radiofrequency ablation in mitral valve surgery in patients with different left atrial sizes.

BackgroundTo evaluate the efficacy of atrial fibrillation radiofrequency ablation (AFRA) in patients with chronic valvular atrial fibrillation (AF) with different left atrial sizes [left atrial diameter (LAD) >45 or ≤45 mm].MethodsBetween May 2016 and January 2019, 264 patients who underwent cardiac operations with modified bipolar AFRA in the Department of Cardiovascular Surgery, PLA General Hospital, were enrolled. The clinical data of the patients were analysed, and inclusion and exclusion criteria were implemented. A propensity score was given for two groups of different left atrial sizes: group A (75 patients with LAD >45 mm) and group B (75 patients with LAD ≤45 mm). Preoperative general data, operative indicators, postoperative mortality, complications, and sinus rhythm recovery were analysed and compared between the two groups.ResultsThe rates of sinus rhythm recovery in group A (LAD >45 mm) at 1 week, 6 months, 1 year, and 2 years after surgery were 84.0%, 81.33%, 73.33%, and 69.33%, respectively, compared with 90.67.0%, 88.00%, 86.67%, and 84.00% at 1 week, 6 months, 1 year, and 2 years after surgery, respectively, in group B (LAD ≤45 mm). The difference between the two groups was statistically significant at the two points in time of 1 year, and 2 years (P<0.05). Warfarin anticoagulation, the standard therapy, was applied after surgery. No new cerebrovascular events occurred in either group during short- and medium-term postoperative follow-up.ConclusionsMitral valve surgery using improved Cox-Maze IV bipolar radiofrequency ablation was effective in treating chronic long-term persistent valvular AF and had an excellent sinus rhythm recovery rate. However, the larger the LAD, the less likely a patient was to maintain sinus rhythm as time passed after surgery.

P4762What do atrial fibrillation ablation procedural volume differences across European centers reflect? An ESC EORP registry: atrial fibrillation long-term

Abstract Background Data from the European Atrial Fibrillation (AF) Ablation Long-Term Registry suggest that there are significant differences in the volume of AF ablation procedures performed across different centers even in the same country. If these differences in AF ablation volume between centers reflect regional, socioeconomic, infrastructural/technical or other disparities has not been addressed till now. Purpose The aim of this study was to investigate patient and non-patient related differences among European AF ablation centers according to the volume of AF ablations performed. Methods Data for this analysis originate from the European AF Ablation Long-Term Study, a prospective registry designed to describe the clinical epidemiology of patients undergoing AF ablation. Based on 25th and 75th percentiles of AF ablation numbers performed, the participating centers were classified into high volume (HV) (≥250 procedures/year), medium volume (MV) (&lt;250 and ≥58/year) and low volume (LV) (&lt;58/year). Patient (demographics, comorbidities) and non-patient (center infrastructure, procedural characteristics) related differences were assessed. Results A total of 91 centers in 26 European countries enrolled 3368 patients. There were no significant differences concerning regional distribution, hospital/cardiology facilities or services provided among centers with the exception of electrophysiology procedures and labs which were more abundant in HV centers (p=0.02 and &lt;0.001 respectively). HV and MV centers ablate twice more cases of long-standing persistent and persistent AF compared to LV centers, in which paroxysmal AF reaches 78.9% of all cases (Figure A). Accordingly, first AF ablation procedure was far more frequent in LV centers compared to MV and HV (85.8% vs 76.0% vs 76.1% respectively, p&lt;0.001). Even though HV centers ablate significantly more high risk patients (CHA2DS2-VASc score ≥2 51.4% in HV vs 46.5% in MV vs 37.2% in LV, p&lt;0.001) (Figure B) with accompanying comorbidities, applying more elaborate ablation techniques, fluoroscopy time and radiation dose were higher among patients undergoing AF ablation in LV centers (p&lt;0.001 for all). Despite the above-mentioned dissimilarities, Kaplan-Meier survival analysis, based on adjusted data, demonstrated non-significant differences in complication rate (p=0.402) or AF recurrence rate (p=0.363) among HV, MV and LV centers. Conclusions Volume of AF ablations in a center is not correlated with regional or infrastructural characteristics. The higher volume in HV centers consists mainly by more long-term persistent AF and higher risk patients, suggesting that differences in volume reflect differences in experience and personnel's commitment towards AF ablation.

P5985New aspects of management of patients with long-term persistent atrial fibrillation before extracardiac interventions

Abstract Surgery in patients with atrial fibrillation is always an additional risk of thromboembolic complications. In the modern era of direct oral anticoagulants, the risk of bleeding is much lower, due to the lack of need for a Bridge, but at the same time, there is no clear position on the strategy of management of patients with long-term current atrial fibrillation in the tactics of rhythm control or heart rate control. In our clinic we examined 772 before surgical intervention high risk. Of these, atrial fibrillation was diagnosed in 366 patients. 121 patients had a persistent or long-persistant form of arrhythmia. To determine the tactics, we performed a transesophageal echocardiographic study to assess intracardiac hemorheology. 109 studies were performed. 35 patients received rivaroxaban, 29 dabigatran, 19 apixaban, 26 patients did not receive anticoagulant therapy. Disorders of intracardiac hemorheology that do not allow to perform a planned cardioversion, such as blood clots and spontaneous contrast 3–4 degrees, were detected in 78% of patients not receiving anticoagulant therapy, 56% of patients receiving dabigatran, 52% of patients receiving rivaroxaban and 38% of patients receiving apixaban. Among patients with disorders of intracardiac hemorheology, unreasonably reduced doses were taken by 78% of patients. Patients with thrombotic disorders proposed to enter the perioperative period in accordance with the strategy of heart rate control and correction doses of anticoagulant therapy. Thus, based on our observations, we recommend transesophageal echocardiography before elective surgery in all patients with persistant AF to determine the feasibility of restoring the sinus rhythm before surgery.

Morphological study of telocytes in the left atrium in patients with long-term persistent atrial fibrillation

The telocytes were found in the human atria in 2005. Atrial fibrillation (AF) is the most common heart rhythm disorder, accompanied by inflammation and fibrosis, however, the morphological analysis of telocytes in this pathology has not yet been performed. Aim . To make morphological analysis of left atrial telocytes in patients with longterm persistent AF. Material and methods . The study was based on the left atrial (LA) wall of 10 patients with AF, 10 without AF (autopsy material) and LP fragments of 2 patients with AF (surgical material). A histological, immunohistochemical, and ultrastructural study, telocyte culture isolation, and confocal laser microscopy were performed. Results. The presence of telocytes in the LA was confirmed. Morphometric analysis revealed that the average number of telocytes in the LP was significantly less by 3 times in patients with AF than without it (2,7±1,1 vs 8,2±3,0 with x400). Correlation analysis revealed significant negative associations of the number of telocytes with AF, fibrosis, lipomatosis, and inflammation. Conclusion. The development of inflammation and fibrosis in AF is accompanied by the loss of telocytes.

Features of Atrial Fibrillation in Patients with Arterial Hypertension and Extracardial Disorders

Aim. To study the features of the progression of atrial fibrillation (AF) in patients with arterial hypertension (HT) and comorbid extracardiac diseases.Material and methods. In the observational cohort study 308 men 45-65 years old with AF and HT were observed Most patients also had the following comorbid extracardiac diseases: diabetes mellitus (DM; n=40), diffuse toxic goiter (DTG; n=42); hypothyroidism (HTH; n=59), abdominal obesity (AO; n=64), and chronic obstructive pulmonary disease (COPD; n=47). The comparison group consisted of 56 patients with AF and HT only. Clinical, anthropometric, laboratory parameters, levels of NT-proBNP and galectin-3, results of ECG, daily monitoring of ECG and blood pressure wereassessed initially and after 12 months.Results. Persistent AF (29.6-65.2%) and long-term persistent AF (16-31.3%) were more common in groups with extracardiac diseases compared with the AF+HT group (20.4% and 14.2%, respectively). Permanent form of AF was statistically significantly more common in the DM (11.1%), AO (14.8%) and HTH (6.2%) groups compared with the AF+HT group (0.6%). A comparative assessment of risk factors (smoking and alcohol) did not show significant differences in prevalence in the groups (22-44%). An assessment of the levels of fibrosis and remodeling markers found a statistically significant increase in the level of galectin-3 in groups of patients with concomitant extracardiac diseases and an increase in the NT-proBNP level, relative to reference values in all groups except DTG.Conclusion. Patients with AF in combination with HT and comorbid extracardiac diseases have a more rapid AF progression.