Onset Of Atrial Arrhythmias Research Articles

Real-time prognostic biomarkers for predicting in-hospital mortality and cardiac complications in COVID-19 patients.

Hospitalized patients with Coronavirus disease 2019 (COVID-19) are highly susceptible to in-hospital mortality and cardiac complications such as atrial arrhythmias (AA). However, the utilization of biomarkers such as potassium, B-type natriuretic peptide, albumin, and others for diagnosis or the prediction of in-hospital mortality and cardiac complications has not been well established. The study aims to investigate whether biomarkers can be utilized to predict mortality and cardiac complications among hospitalized COVID-19 patients. Data were collected from 6,927 hospitalized COVID-19 patients from March 1, 2020, to March 31, 2021 at one quaternary (Henry Ford Health) and five community hospital registries (Trinity Health Systems). A multivariable logistic regression prediction model was derived using a random sample of 70% for derivation and 30% for validation. Serum values, demographic variables, and comorbidities were used as input predictors. The primary outcome was in-hospital mortality, and the secondary outcome was onset of AA. The associations between predictor variables and outcomes are presented as odds ratio (OR) with 95% confidence intervals (CIs). Discrimination was assessed using area under ROC curve (AUC). Calibration was assessed using Brier score. The model predicted in-hospital mortality with an AUC of 90% [95% CI: 88%, 92%]. In addition, potassium showed promise as an independent prognostic biomarker that predicted both in-hospital mortality, with an AUC of 71.51% [95% Cl: 69.51%, 73.50%], and AA with AUC of 63.6% [95% Cl: 58.86%, 68.34%]. Within the test cohort, an increase of 1 mEq/L potassium was associated with an in-hospital mortality risk of 1.40 [95% CI: 1.14, 1.73] and a risk of new onset of AA of 1.55 [95% CI: 1.25, 1.93]. This cross-sectional study suggests that biomarkers can be used as prognostic variables for in-hospital mortality and onset of AA among hospitalized COVID-19 patients.

Electrocardiographic findings and incidence of new-onset atrial arrhythmia among patients with severe leptospirosis who underwent veno-venous extracorporeal membrane oxygenation

Abstract Funding Acknowledgements Type of funding sources: None. Background Leptospirosis is a zoonotic disease caused by Leptospira species that remains endemic in the Philippines. In severe cases, patients present with multiple organ system failure such as acute renal failure and acute respiratory distress syndrome(ARDS) requiring renal replacement therapy, mechanical ventilation, and novel treatment modalities such as extracorporeal membrane oxygenation(ECMO). Cardiac complications such as atrial arrhythmia also occur in cases of severe leptospirosis leading to worse outcomes. There is limited data on the electrocardiographic findings in patients with severe leptospirosis undergoing ECMO along with the incidence of new-onset atrial arrhythmia while managed on this intervention with unique hemodynamic system. Purpose To determine the baseline electrocardiographic(ECG) findings and incidence of new onset atrial arrhythmia among patients with severe leptospirosis during veno-venous(V-V) ECMO. Methods A cross-sectional study among patients with severe leptospirosis and ARDS who underwent V-V ECMO was conducted at a tertiary hospital in the Philippines. Primary outcome was defined as the presence or absence of new-onset atrial arrhythmia during ECMO. Secondary outcomes included in-hospital mortality, length of hospital stay, duration of mechanical ventilation, duration of ECMO, and development of thrombotic events. Results Among 31 patients included, 90.3%(n=28) were male and median age was 33.48±10.0 years. The most common ECG finding was atrial fibrillation with an incidence of 32.3%(n=10), half of which occurred before ECMO, while the other half were noted after cannulation. During ECMO, the incidence of new-onset atrial arrhythmia was found to be at 19.4% (n=6). Patients with new-onset atrial arrhythmia had higher white blood cell, total bilirubin, creatinine, APACHE-II Scores, use of dopamine, lower platelet count and PaO2/Fio2 ratio. Two patients(33.33%) died among those with new-onset atrial arrhythmia, while five patients(20%) died in the other group. There was no noted thrombotic events such as stroke among groups and no difference on the duration on ventilator, ECMO and hospital stay. Conclusions Atrial arrhythmias are under-reported complications during veno-venous ECMO among patients with severe leptospirosis. This study demonstrated a higher mortality among patients with new-onset atrial arrhythmia during ECMO for severe leptospirosis.

Readmission in patients undergoing percutaneous patent foramen ovale closure in the United States

Current estimates suggest that a patent foramen ovale (PFO) may exist in up to 25% of the general population and is a potential risk factor for embolic, ischemic stroke. PFO closure complications include bleeding, need for procedure-related surgical intervention, pulmonary emboli, device malpositioning, new onset atrial arrhythmias, and transient atrioventricular block. Rates of PFO closure complications at a national level in the Unites States remain unknown. To address this, we performed a contemporary nationwide study using the 2016 and 2017 Nationwide Readmissions Database (NRD) to identify patterns of readmissions after percutaneous PFO closure. In conclusion, our study showed that following PFO closure, the most common complications were atrial fibrillation/atrial flutter followed by acute heart failure syndrome, supraventricular tachycardia and acute myocardial infarction.

Abstract 9968: Classification and Treatment of Post-Operative Atrial Arrhythmias in Pulmonary Thromboendarterectomy Surgery

Background: Atrial arrhythmias (AA) are common after cardiac surgeries including pulmonary thromboendarterectomy (PTE) surgery. However, the arrhythmia classification, treatment and impact of these AA after PTE surgery is unclear. Hypothesis: We hypothesized that most AA after PTE are paroxysmal and have a significant impact on post-operative outcomes. Methods: We reviewed the charts of 883 consecutive patients who were referred to University of California San Diego for PTE. Demographics, lab results and imaging were extracted from chart review. Predictors and outcomes were analyzed using a multivariate backward logistic regression model or independent samples t test respectively. Results: A total of 158 patients (18%) of patients developed an atrial arrhythmia. Paroxysmal atrial fibrillation (AF) was most common (72%, n=113). Persistent AF occurred in 8% of patients (n=12) and atrial flutter occurred in 21% (n=33) after PTE. The average days to onset of AA was 5.6 +/-4.4 days. Strongest predictors of AA (shown in attached figure) were chronic obstructive pulmonary disease (OR 2.8, p=<0.01) and epicardial pacing requirement (OR 4.6, p=<0.01). Patients who developed an AA had significantly prolonged post-operative length of stays (LOS) (14.7 days vs 11.9 days, p=<0.01) compared to those who did not. Amiodarone was given in 73% (n=115) of patients and cardioversion was performed in 15% (n=23) of AA patients. Conclusions: AA are common after PTE surgery. Paroxysmal atrial fibrillation was seen most commonly. Patients who had COPD or required epicardial pacing were at highest risk of developing an AA. AA have a significantly prolonged post-operative LOS. The majority of patients received antiarrhythmic therapy with amiodarone (73%) and a minority underwent cardioversion (15%)

Abstract 10583: A Novel Functional Variant, P.Gln419Pro, Residing Outside the SCN5A -Encoded Na V 1.5 Voltage-Sensing Domain Causes Multifocal Ectopic Purkinje-Related Premature Contractions

Background: Multifocal ectopic Purkinje-related premature contractions (MEPPC), the most recent addition to the spectrum of SCN5A -mediated cardiac channelopathies, is characterized by frequent premature ventricular complexes (PVCs) originating from the Purkinje system, atrial arrhythmias, and a predilection for PVC-mediated dilated cardiomyopathy. MEPPC-causative variants tend to cluster within the voltage sensing domain (VSD) of Na v 1.5. Objective: To describe the clinical and cellular electrophysiological phenotype associated with a novel, putative MEPPC-causative SCN5A variant (p.Gln419Pro-SCN5A) that resides outside the VSD of Na v 1.5. Methods: p.Gln419Pro-SCN5A was identified in a 21-year-old male with a history of frequent, multifocal PVCs and atrial tachycardia. Subsequently, three p.Gln419Pro-SCN5A-positive relatives, each with early onset atrial arrhythmias and/or frequent, multifocal PVCs, were identified. All individuals had structurally normal hearts by echocardiography and/or cardiac magnetic resonance imaging. p.Gln419Pro-SCN5A was engineered by site directed mutagenesis and heterologously expressed in TSA201 cells. The standard whole-cell patch clamp technique was used to measure SCN5A wild-type (WT) and p.Gln419Pro-SCN5A sodium currents. Results: Analysis of the current-voltage relationship revealed that neither peak sodium current densities nor late inward sodium current were impacted by p.Gln419Pro-SCN5A. However, p.Gln419Pro-SCN5A significantly shifted V 1/2 in inactivation by -4.6 mV from -84.5±0.7 mV (WT, n=10) to -89.1±0.4 mV (Gln419Pro, n=12, p<0.05 vs. WT) and V 1/2 in activation by -11.6 mV from -30.9±1.3 mV (WT, n=10) to -42.5±1.0 mV (Gln419Pro, n=12, p<0.05 vs. WT) leading to a larger hyperpolarized window current. Flecainide dramatically reduced PVC burden in p.Gln419Pro-SCN5A-positive patients. Conclusions: p.Gln419Pro-SCN5A represents only the fifth MEPPC-causative variant described to date and the first associated with a classic MEPPC phenotype localizing outside Na v 1.5’s VSD. As class I antiarrhythmic drugs are highly efficacious in MEPPC, this clinical entity merits consideration in all young patients found to have a high burden of Purkinje-related PVCs.

B-PO05-204 LATE ONSET ATYPICAL ATRIAL FLUTTER IN A TRANSPLANTED HEART

Cardiac denervation, allograft rejection and vasculopathy increase the risk of cardiac arrhythmias and pose management challenges in a heart transplant patient. To discuss the management of atrial arrhythmia in a transplanted heart. N/A A 71-year-old Caucasian woman with a history of orthotopic heart transplant in 2001, paroxysmal atrial fibrillation, and transplant vasculopathy status post left circumflex artery stent presented with palpitations. External monitoring revealed supraventricular tachycardia. Twelve lead ECG confirmed an atrial flutter with variable block. Echocardiography showed normal ventricular function. Cardiac biopsy showed focal moderate cellular allograft rejection. Left heart catheterization did not show significant coronary obstruction. The finding of graft rejection prompted commencement of steroids. Following steroid therapy, repeat biopsy was negative for rejection; however, atrial arrhythmia persisted requiring multiple cardioversions. Antiarrhythmic drug therapy caused intolerable side effects. An electrophysiology study revealed atypical mitral flutter in the donor atria. Catheter ablation of the anterior mitral line terminated the flutter. Allograft rejection causes inflammation and fibrosis leading to slowing of conduction in the atria forming the substrate for intra-atrial arrhythmia. Bi-atrial anastomosis might have increased the risk of transmitral flutter in the donor heart. Catheter ablation should be considered for late onset atrial arrhythmia in transplant patients.

Accelerometry-assessed physical behaviour and the association with clinical outcomes in implantable cardioverter-defibrillator recipients: a systematic review

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Eurostars Introduction Patients at a high risk of sudden cardiac death (SCD) benefit from an implantable cardioverter defibrillator (ICD). However, they remain at a high risk of (inappropriate) shocks, heart failure, mortality and psychological distress. Consumer-level wearable accelerometry as method for recording physical behaviour (PB) has gained popularity over the past years, but so far the clinical potential is largely underinvestigated. The identification of patterns in PB and the association with clinical outcomes may provide a means to improve ICD therapy. Purpose This review addresses the evidence concerning PB in ICD patients and aims to characterise PB patterns associated with clinical outcomes. Methods A systematic review of studies focussing on accelerometer-assessed PB in patients older than 18 years equipped with an ICD, or patients at a high risk of SCD (e.g. advanced heart failure) was performed. PB could be assessed using a wearable accelerometer or an embedded accelerometer in the ICD (i.e. device-measured physical activity (D-PA)). Papers presenting quantitative data in English language peer reviewed journals published between January 2000 and September 2020 were identified via the OVID MEDLINE and OVID EMBASE databases. A study protocol describing study selection, data charting and summarisation of results was developed apriori. Study selection was conducted by two independent reviewers and a third reviewer in case of disagreement. Results A total of 4219 studies were identified, of which 51 were deemed appropriate for this review. Of these studies, 29 examined D-PA (n = 169.742 patients), 19 examined wearable accelerometery (n = 1.601) and 3 validated wearable accelerometry against D-PA (n = 106). The main findings were that (i) a low level of physical activity (PA) after implantation of the ICD and (ii) a decline in physical activity were both associated with an increased risk of ICD shocks, hospitalization and mortality. Second, PB was affected by cardiac factors (e.g. onset of atrial arrhythmias, ICD shocks) and non-cardiac factors (e.g. seasonal differences, pandemic lockdown). Third, PB was related to left ventricular ejection fraction, physical and cognitive function and quality of life. The evidence regarding wearable accelerometry compared to D-PA was scarce and heterogeneous. Conclusion This review demonstrated the potential of PB as an identifier of clinical deterioration in an ICD population. Accelerometer-assessed PB data could improve early warning systems and facilitate preventive and pro-active strategies, especially considering the nature of PB as modifiable risk factor. We suggest two directions for future research: (i) prospective collection of wearable accelerometry data in an ICD population to identify the most clinically relevant behavioural metrics (ii) investigation of preventive measures that can be undertaken once changes in PB are observed. Abstract Figure. Accelerometry-derived physical behaviour

Cardiac arrhythmias in patients with COVID-19: Lessons from 2300 telemetric monitoring days on the intensive care unit

BackgroundPatients with COVID-19 seem to be prone to the development of arrhythmias. The objective of this trial was to determine the characteristics, clinical significance and therapeutic consequences of these arrhythmias in COVID-19 patients requiring intensive care unit (ICU) treatment. Methods and resultsA total of 113 consecutive patients (mean age 64.1 ± 14.3 years, 30 (26.5%) female) with positive PCR testing for SARS-CoV2 as well as radiographically confirmed pulmonary involvement admitted to the ICU from March to May 2020 were included and observed for a cumulative time of 2321 days. Fifty episodes of sustained atrial tachycardias, five episodes of sustained ventricular arrhythmias and thirty bradycardic events were documented.Sustained new onset atrial arrhythmias were associated with hemodynamic deterioration in 13 cases (35.1%). Patients with new onset atrial arrhythmias were older, showed higher levels of Hs-Troponin and NT-proBNP, and a more severe course of disease.The 5 ventricular arrhythmias (two ventricular tachycardias, two episodes of ventricular fibrillation, and one torsade de pointes tachycardia) were observed in 4 patients. All episodes could be terminated by immediate defibrillation/cardioversion. Five bradycardic events were associated with hemodynamic deterioration. Precipitating factors could be identified in 19 of 30 episodes (63.3%), no patient required cardiac pacing. Baseline characteristics were not significantly different between patients with or without bradycardic events. ConclusionRelevant arrhythmias are common in severely ill ICU patients with COVID-19. They are associated with worse courses of disease and require specific treatment. This makes daily close monitoring of telemetric data mandatory in this patient group.

New-onset atrial arrhythmias associated with mortality in black and white patients hospitalized with COVID-19.

BackgroundSpecific details about cardiovascular complications, especially arrhythmias, related to the coronavirus disease of 2019 (COVID‐19) are not well described.ObjectiveWe sought to evaluate the incidence and predictive factors of cardiovascular complications and new‐onset arrhythmias in Black and White hospitalized COVID‐19 patients and determine the impact of new‐onset arrhythmia on outcomes.MethodsWe collected and analyzed baseline demographic and clinical data from COVID‐19 patients hospitalized at the Tulane Medical Center in New Orleans, Louisiana, between March 1 and May 1, 2020.ResultsAmong 310 hospitalized COVID‐19 patients, the mean age was 61.4 ± 16.5 years, with 58,7% females, and 67% Black patients. Black patients were more likely to be younger, have diabetes and obesity. The incidence of cardiac complications was 20%, with 9% of patients having new‐onset arrhythmia. There was no significant difference in cardiovascular outcomes between Black and White patients. A multivariate analysis determined age ≥60 years to be a predictor of new‐onset arrhythmia (OR = 7.36, 95% CI [1.95;27.76], p = .003). D‐dimer levels positively correlated with cardiac and new‐onset arrhythmic event. New onset atrial arrhythmias predicted in‐hospital mortality (OR = 2.99 95% CI [1.35;6.63], p = .007), a longer intensive care unit length of stay (mean of 6.14 days, 95% CI [2.51;9.77], p = .001) and mechanical ventilation duration(mean of 9.08 days, 95% CI [3.75;14.40], p = .001).ConclusionOur results indicate that new onset atrial arrhythmias are commonly encountered in COVID‐19 patients and can predict in‐hospital mortality. Early elevation in D‐dimer in COVID‐19 patients is a significant predictor of new onset arrhythmias. Our finding suggest continuous rhythm monitoring should be adopted in this patient population during hospitalization to better risk stratify hospitalized patients and prompt earlier intervention.

Amiodarone Use in Lung Transplant Recipients with New Onset Atrial Arrhythmias

Purpose Atrial arrhythmias occur in 16-46% of patients after lung transplant, and most of these are atrial fibrillation or flutter. Standard therapy is described as rate control with correction of electrolyte imbalances and optimization of fluid status. Amiodarone is generally considered first line therapy for atrial arrhythmias but is often avoided in lung transplant patients because of its association with pulmonary fibrosis. This paper describes the outcomes for frequent use of amiodarone in a cohort of lung transplant recipients. Methods This study reviews the medical records of 255 lung transplant patients at a single center from 2014 to 2018. Atrial arrhythmias were managed initially with rate control, but amiodarone was administered to the majority if there was not immediate resolution of the dysrhythmia. Standard dosing was administered. Outcomes included resolution of the dysrhythmia within 48 hours of onset, time on the ventilator, recurrence of the dysrhythmia during hospitalization, length of hospital stay, and patient survival. Results There were 102 patients with post lung transplant atrial arrhythmia (40%), and 79% of these patients were treated with intravenous amiodarone. Patients at risk for post-transplant atrial arrhythmia included those patients who were older, male, and had a higher body mass index (p Conclusion In this cohort, intravenous amiodarone therapy in lung transplant patients with new onset atrial arrhythmias did not result in any identifiable pathology. Clinical outcomes for these two study groups were similar. These results suggest that amiodarone can be safely used in this population.

Genetic Testing for Early Onset Atrial Arrhythmias Changes Clinical Management

Genetic Testing for Early Onset Atrial Arrhythmias Changes Clinical Management

Efficacy and safety of catheter ablation in patients with new-onset atrial arrhythmia after surgical excision of left atrial myxoma

Objective: To evaluate the safety and efficacy of catheter ablation in patients with new-onset atrial arrhythmia after surgical excision of left atrial myxoma. Methods: Nine patients with new onset atrial arrhythmia and a prior history of left atrial myxoma, who received surgical myxoma excision and catheter ablation between September 2014 and November 2019, were included in the present study. Baseline characteristics, procedural parameters during catheter ablation, severe perioperative adverse events, recurrence rate of arrhythmia and clinical prognosis were analyzed. Kaplan Meier survival analysis was used to define the maintenance rate of sinus rhythm after catheter ablation in this patient cohort. Results: Nine patients were included. The average age was (55.8 ± 9.1) years old (3 male), there were 3 patients (3/9) with paroxysmal atrial fibrillation (PAF) and 6 patients (6/9) with atrial flutter or atrial tachycardia (AFL or AT). Ablation was successful in all patients, there were no perioperative complications such as stroke, pericardial effusion, cardiac tamponade, vascular complications or massive hemorrhage. During a mean follow-up time of 40.0 (27.5, 55.5) months, sinus rhythm was maintained in six patients (6/9) after the initial catheter ablation. The overall sinus rhythm maintenance rate was 2/3. In addition, 1 out of the 3 AF patients (1/3) developed recurrence of AF at 3 month after ablation, and 2 out of the 6 AFL or AT patients (2/6) developed late recurrence of AF or AFL (19 months and 29 months after ablation), two out of three patients with recurrent AFs or AFL received repeated catheter ablation and one patient remained sinus rhythm post repeat ablation. Meanwhile, there was no recurrence of atrial myxoma, no death, stroke, acute myocardial infarction and other events during the entire follow-up period. Conclusions: Catheter ablation is a safe and feasible therapeutic option for patients with new-onset atrial arrhythmia after surgical excision of left atrial myxoma.

CHA2DS2-VASc and readmission with new-onset atrial fibrillation, atrial flutter, or acute cerebrovascular accident

BackgroundAlthough risk factors for atrial fibrillation (AF) and atrial flutter (AFL) are known, identifying patients who will develop AF/AFL within the near future remains challenging. We sought to evaluate if the CHA2DS2-VASc risk score (CVRS) can identify hospital readmissions with AF, AFL, or acute cerebrovascular accident (CVA) among hospitalized patients without prior history of AF/AFL. MethodsUsing the Nationwide Readmission Database, a study cohort included patients without prior AF/AFL or new diagnosis of AF/AFL at the index hospitalization from 2012 to 2014. Patients were stratified based on the CVRS into three groups: Low (CVRS ≤1), Intermediate (CVRS 2–5), and High (CVRS ≥6).The primary outcome of interest was 180-day readmission rate with a primary or secondary diagnosis of AF/AFL. Secondary outcomes of interest were acute CVA and 6-month mortality rate. ResultsA total of 17,820,640 patients were included in our study. Over a 6-month follow up duration from the index hospitalization, the overall re-admission rate for new onset atrial arrhythmias (AF/AFL) was 3.48% (n = 620,986), acute CVA 0.13% (n = 22,522), and all-cause mortality 0.31% (n = 55,632). When compared to other groups, patients with a higher CVRS were readmitted more frequently for AF/AFL [odds ratio (OR) 2.43; 95% confidence interval (CI) 2.41–2.45, P < .0001), acute CVA (OR 3.96; 95%CI 3.85–4.08, P < .0001), and all-cause mortality (OR 2.19; 95%CI 2.14–2.24, P < .0001). ConclusionIn this large contemporary cohort, a CHADS2VA2SC score ≥ 6 identified patients without known prior atrial arrhythmias at an elevated risk of developing AF/AFL or acute CVA within 6 months of hospitalization.

Incidence of Primary, Dilated Rather Than Tachycardia-Induced Cardiomyopathy among Patients Presenting with New Onset Atrial Arrhythmia and Heart Failure with Reduced Ejection Fraction

Background Tachycardia-induced cardiomyopathy (CMP) is an established cause of left ventricular (LV) systolic dysfunction and heart failure (HF) that is reversible upon treatment of the tachyarrhythmia. The incidence of a primary, dilated CMP among patients (pts) presenting with presumed tachycardia-induced CMP, and the features that distinguish them are not well established. Methods We examined the records of 476 consecutive pts presenting with new atrial fibrillation or flutter (AF) and a rapid ventricular rate (RVR) coupled with acute HF with reduced LV ejection fraction (HFrEF - LVEF≤ 45%). We sought to determine the number of pts with a sustained, presumed primary CMP (persistent LVEF ≤ 45%) rather than one that is reversible. Pts with clinically relevant coronary artery disease, severe valvular disease or other suspected/known cause of CMP were excluded. Clinical variables, ECGs and follow up echocardiography were examined to establish: 1) the number of pts with improvement in LVEF vs. those with persistently depressed LVEF (LVEF ≤ 45%); and 2) variables associated with improvement or persistence of LV systolic dysfunction. Results 92 pts were identified matching our entry criteria having a mean LVEF of 31.2±9.2%. Among these, 37 (40%) exhibited persistent LV systolic dysfunction (LVEF 34.3 ± 8.2%) after a follow-up of 27 ± 35 months. The LVEF normalized in the remaining 55 pts (LVEF 57.1±4.2%) supporting probable tachycardia-induced CMP. We observed no significant differences among clinical, laboratory or ECG variables between those pts whose LVEF normalized vs. those with a persistent CMP. Echocardiographic data from the index hospitalization demonstrated that pts with persistent CMP had an increased left atrial volume index (LAVI) compared to those with normalization in their LVEF (51.6 ± 19.2 ml/m2 vs 37.7 ± 10.4 ml/m2, respectively, p Conclusion The incidence of persistent LV systolic dysfunction was present in 40% of pts presenting with AF with RVR and acute HFrEF supporting that a substantial number have a primary CMP rather than a reversible, tachycardia-induced CMP. These data support early intervention in these pts with guideline directed medical therapy. Greater LAVI on echocardiography may help identify pts with a primary CMP presenting with a new atrial tachyarrhythmia, heart failure and a reduced LVEF.

Prognostic and functional implications of left atrial late gadolinium enhancement\xa0cardiovascular magnetic resonance

BackgroundLeft atrial (LA) late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging is indicative of fibrosis, and has been correlated with reduced LA function, increased LA volume, and poor procedural outcomes in cohorts with atrial fibrillation (AF). However, the role of LGE as a prognostic biomarker for arrhythmia in cardiac disease has not been examined.MethodsIn this study, we assessed LA LGE using a 3D LGE CMR sequence to examine its relationships with new onset atrial arrhythmia, and LA and left ventricular (LV) mechanical function.ResultsLA LGE images were acquired in 111 patients undergoing CMR imaging, including 66 patients with no prior history of an atrial arrhythmia. During the median follow-up of 2.7 years (interquartile range (IQR) 1.8–3.7 years), 15/66 (23%) of patients developed a new atrial arrhythmia. LA LGE ≥10% of LA myocardial volume was significantly associated with an increased rate of new-onset atrial arrhythmia, with a hazard ratio of 3.16 (95% CI 1.14–8.72), p = 0.026. There were significant relationships between LA LGE and both LA ejection fraction (r = − 0.39, p < 0.0005) and echocardiographic LV septal e’ (r = − 0.24, p = 0.04) and septal E/e’ (r = 0.31, p = 0.007).ConclusionsElevated LA LGE is associated with reduced LA function and reduced LV diastolic function. LA LGE is associated with new onset atrial arrhythmia during follow-up.

Myocyte Remodeling Due to Fibro-Fatty Infiltrations Influences Arrhythmogenicity.

The onset of cardiac arrhythmias depends on the electrophysiological and structural properties of cardiac tissue. Electrophysiological remodeling of myocytes due to the presence of adipocytes constitutes a possibly important pathway in the pathogenesis of atrial fibrillation. In this paper we perform an in-silico study of the effect of such myocyte remodeling on the onset of atrial arrhythmias and study the dynamics of arrhythmia sources—spiral waves. We use the Courtemanche model for atrial myocytes and modify their electrophysiological properties based on published cellular electrophysiological measurements in myocytes co-cultered with adipocytes (a 69–87 % increase in APD90 and an increase of the RMP by 2.5–5.5 mV). In a generic 2D setup we show that adipose tissue remodeling substantially affects the spiral wave dynamics resulting in complex arrhythmia and such arrhythmia can be initiated under high frequency pacing if the size of the remodeled tissue is sufficiently large. These results are confirmed in simulations with an anatomically accurate model of the human atria.

Percutaneous closure of patent foramen ovale vs. medical treatment for patients with history of cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials.

Patients with history of cryptogenic stroke are more likely to have a patent foramen ovale (PFO) and should be managed with antithrombotic agents, while the alternative option is percutaneous closure of PFOs. Our aim was to perform a meta-analysis of randomized controlled trials (RCTs) comparing percutaneous closure vs. medical treatment for patients with PFO and prior cryptogenic stroke. Medline, Scopus and Cochrane databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. New ischemic stroke was defined as the primary endpoint. A sensitivity analysis was performed for Amplatzer device. Subgroup analyses were performed for different patient and PFO characteristics for the composite endpoints as defined by the included RCTs. In total of 3440 patients were included in this meta-analysis. Closure devices were superior to medical therapy for prevention of recurrent ischemic strokes (HR = 0.29; CI: 0.02-0.56), but were associated with increased risk of new onset of atrial fibrillation (AF) and atrial flutter (RR = 4.67; CI: 2.22-9.81). However, in the sensitivity analysis for Amplatzer device, there was no difference between the two groups in new onset of atrial arrhythmias. Closure devices were superior across all different subgroups when compared to medical treatment with the exception of patients with a small shunt. This meta-analysis shows that closure devices for patients with PFO and history of cryptogenic stroke can significantly decrease the risk of a new ischemic stroke. The use of Amplatzer device was not associated with increased risk of newly diagnosed atrial arrhythmias.

Impact of atrial arrhythmias on outcome in adults with congenital heart disease

BackgroundAdults with congenital heart disease (ACHD) are affected by atrial arrhythmias (AA). To elucidate the impact of AA on prognosis, we aimed to determine the impact of AA on death, heart failure and stroke in ACHD patients in a prospective nationwide clinical registry. MethodsAll patients aged ≥18years included in the CONCOR registry per October 1st 2015 were analysed. Prior AA was defined as atrial fibrillation, atrial flutter or unspecified AA before inclusion in CONCOR and new-onset AA as a first documented AA during follow-up. The outcomes were death, first stroke and first admission for heart failure (HF). ResultsThe study cohort comprised 14,224 patients (baseline median age 33.6 [IQR 23–47], male 49.5%, AA n=1501, complex defect 10.3%, repaired defect 58.9%). Median follow-up was 6.5years [IQR 3–10]. Adjusting for age, sex, repair status and defect severity, patients with prior AA had higher mortality and more HF admissions, but no increased risk of stroke compared to those without AA (HR=2.11; 95% CI=1.79–2.49; p<0.001, HR=4.06; 95% CI=2.66–6.19; p<0.001 and HR=1.09; 95% CI=0.71–1.68; p=0.698, respectively). New-onset AA during follow-up was significantly associated with stroke (HR=2.04; 95% CI=1.05–3.96; p=0.036). ConclusionsACHD patients with prior AA have a 2-fold increased risk of death and a 4-fold increased risk of heart failure, but no increased risk for stroke compared to those without AA. Defect severity and age appear to be more important risk factors for stroke than prior AA. Stroke risk is increased only after conversion of new onset AA.

Initial clinical experience with the GORE® CARDIOFORM ASD occluder for transcatheter atrial septal defect closure.

To report the initial clinical experience with a novel atrial septal defect (ASD) closure device, the GORE® CARDIOFORM ASD Occluder (GCO). Transcatheter closure has become the treatment of choice for secundum ASD. A wide range of occluder devices are available, but concern has been raised about the risk of cardiac erosion associated with rigid devices and future access to the left atrium METHODS: Retrospective chart review of patients treated with the GCO at three Canadian centers. Primary outcomes were procedural success and residual shunting at follow-up, as well as 30-day major adverse events. Secondary outcomes included new onset atrial arrhythmias, wire frame fractures (WFF), and all cause mortality. Clinical, echocardiographic, procedural data, and follow-up outcome variables were collected in each participating hospital. Between February and December 2015, 26 patients (5 children and 21 adults) underwent transcatheter ASD closure with the GCO and were included in the study cohort. Procedural success was achieved in 22 of 26 patients (85%) and no major procedural complications were observed. Two patients (8%) presented new onset atrial tachyarrhythmia during early follow-up (0-30 days). Follow-up echocardiography (median of 119 days [IQR: 92-146]) demonstrated no residual shunt in all implanted patients. After a median clinical follow-up of 174 days (IQR: 135-239), one patient died of an unrelated cause, there were no documented major adverse cardiovascular events. Fluoroscopic imaging of the device was performed in 20 patients (91%), and WFF was noted in five cases. No clinical consequence or device dysfunction was observed in these patients. In this first-in-man multicenter study, the GCO was safe and effective for ASD closure, with no major adverse events or residual shunt at follow-up. © 2017 Wiley Periodicals, Inc.

Atrial arrhythmogenicity in aged Scn5a+/∆KPQ mice modeling long QT type 3 syndrome and its relationship to Na+ channel expression and cardiac conduction

Recent studies have reported that human mutations in Nav1.5 predispose to early age onset atrial arrhythmia. The present experiments accordingly assess atrial arrhythmogenicity in aging Scn5a+/∆KPQ mice modeling long QT3 syndrome in relationship to cardiac Na+ channel, Nav1.5, expression. Atrial electrophysiological properties in isolated Langendorff-perfused hearts from 3- and 12-month-old wild type (WT), and Scn5a+/∆KPQ mice were assessed using programmed electrical stimulation and their Nav1.5 expression assessed by Western blot. Cardiac conduction properties were assessed electrocardiographically in intact anesthetized animals. Monophasic action potential recordings demonstrated increased atrial arrhythmogenicity specifically in aged Scn5a+/ΔKPQ hearts. These showed greater action potential duration/refractory period ratios but lower atrial Nav1.5 expression levels than aged WT mice. Atrial Nav1.5 levels were higher in young Scn5a+/ΔKPQ than young WT. These levels increased with age in WT but not Scn5a+/ΔKPQ. Both young and aged Scn5a+/ΔKPQ mice showed lower heart rates and longer PR intervals than their WT counterparts. Young Scn5a+/ΔKPQ mice showed longer QT and QTc intervals than young WT. Aged Scn5a+/ΔKPQ showed longer QRS durations than aged WT. PR intervals were prolonged and QT intervals were shortened in young relative to aged WT. In contrast, ECG parameters were similar between young and aged Scn5a+/ΔKPQ. Aged murine Scn5a+/ΔKPQ hearts thus exhibit an increased atrial arrhythmogenicity. The differing Nav1.5 expression and electrocardiographic indicators of slowed cardiac conduction between Scn5a+/ΔKPQ and WT, which show further variations associated with aging, may contribute toward atrial arrhythmia in aged Scn5a+/ΔKPQ hearts.