Paroxismal Atrial Fibrillation Research Articles

Respiratory disturbance index as a predictor of atrial fibrillation

Abstract Background Obstructive sleep apnea (OSA) is a risk factor for development of atrial fibrillation (AF). Recent pacemakers have specific algorithms for detecting of OSA based on impedance measurement. Purpose The aim was to determine the burden of AF in patients with high respiratory disturbance index (RDI). It was also intended to determine if the onset of continuous positive airway pressure (CPAP) reduced the AF burden. Methods Retrospective observational study carried out through the analysis of the patient records. It included patients with pacemakers evaluated in an outpatient clinic during the first 8 months of 2018. All had the RDI algorithm. AF burden was assessed according to automatic mode switch (AMS) duration. The percentage of nights with an RDI>20/h was analysed to assess the risk of OSA. Results 108 patients were included (mean age=70.3±9.0 years; 56.5% men). The most prevalent indication for cardiac pacing was atrioventricular node dysfunction (59.3%). The average percentage of nights with an RDI>20/h was 44.2%. The average follow-up (FU) period was 4.1 years. Of all cardiovascular risk factors, diabetes mellitus was the only one associated with a higher incidence of AF at FU (p=0.044). Considering just the patients with an RDI >20/h in more than 20% of nights (RDI20%), male gender was associated with higher rate of major adverse cardiovascular events [(acute myocardial infarction, stroke, acute heart failure and death) (p=0.019)]. Considering patients with AF prior to pacemaker implantation (n=34), 76% of patients had an RDI >20/h in more than 20% of nights (mean of 58.1%). 23 of these patients had long standing persistent AF at the end of FU (vs 17 at the beginnig of FU). Considering patients who developed AF after pacemaker implantation (n=24), 58% of patients had an RDI>20/h in more than 20% of nights (mean of 45.3%). Most patients had paroxismal AF (83%). Patients with prior paroxysmal AF or those who developed AF during FU (n=37) had a higher burden of AF at the end of FU when they had RDI >20/h in more than 50% of nights (mean burden of 24.66% vs 14.69%, p=0.005). There was no statistically significant correlation between the percentage of nights with RDI >20/h and the Apnea Hypopnea Index (AHI) value. Patients who underwent polysomnography (n=30) had a mean AHI of 16/h (which corresponds to moderately severe OSA). 63% of patients who were referred from the pacemaker consultation to pneumology and performed polysomnography started CPAP. CPAP use was not associated with a statistically significant reduction in any endpoints or AF burden. Conclusion A high RDI was associated with onset of de novo AF and higher AF burden in patients with paroxysmal AF. Thus, there is a rationale for early diagnosis and treatment of OSAS to prevent and reduce AF progression. In this study, CPAP was not shown to significantly reduce this endpoint, probably due to reduced polysomnography and CPAP treatment. Funding Acknowledgement Type of funding sources: None.

Real-time local impedance monitoring to assess tissue lesion during pulmonary vein isolation: a new tool for AF ablation

Abstract Background Contact force catheter ablation is the gold standard for treatment of atrial fibrillation (AF). Local tissue impedance (LI) evaluation has been recently studied to evaluate lesion formation during radiofrequency ablation. Purpose Aim of the study was to assess the outcomes of an irrigated catether with LI alghorithm compared to contact force (CF)-sensing catheters in the treatment of symptomatic AF. Methods A prospective, single-center, nonrandomized study was conducted, to compare outcomes between CF-AF ablation (Group 1) and LI-AF ablation (Group 2). For Group 1 ablation was performed using the Carto 3© System with the SmartTouch SF catheter and, as ablation target, an ablation index value of 500 anterior and 400 posterior. For Group 2, ablation was performed using the Rhythmia™ System with novel ablation catheter with a dedicated algorithm (DirectSense) used to measure LI at the distal electrode of this catheter. An absolute impedance drop greater than 20Ω was used at each targeted. According to the Close Protocol, ablation included a point by point pulmonary vein isolation (PVI) with an Inter-lesion space ≤5 mm in both Groups. Procedural endpoint was PVI, with confirmed bidirectional block. Results A total of 116 patients were enrolled, 59 patients in Group 1 (CF) and 57 in Group 2 (LI), 65 (63%) with a paroxismal AF and 36 (37%) with a persistent AF. Baseline patients features were not different between groups (P=ns). LI-Group showed a comparable procedural time (180±89 vs 180±56, P=0.59) but with a longer fluoroscopy time (20±12 vs 13±9 min, P=0.002). Wide antral isolation was more often observed in CF-Group (95% vs 80%, P=0.022), while LI-Group 2 required frequently additional right or left carina ablation (28% vs 14%, P=0.013). The mean LI was 106±14Ω prior to ablation and 92.5±11Ω after ablation (mean LI drop of 13.5±8Ω) during a median RF time of 26 [19–34] sec for each ablation spot. No steam pops or complications during the procedures were reported. The acute procedural success was 100%, with all PVs successfully isolated in all study patients. Regarding safety, only minor vascular complications were observed (5%), without differences between groups (p=0.97). During follow up, 9-month freedom from atrial fibrillation/atrial flutter/atrial tachycardia recurrence was 86% in Group 1 and 75% in Group 2 (P=0.2). Conclusions An LI-guided PV ablation strategy seems to be safe and effective, with acute and mid-term outcomes comparable to the current contact force strategy. LI monitoring could be a promising complementary parameter to evaluate not only wall contact but also lesion formation during power delivery. Procedural Outcomes Funding Acknowledgement Type of funding source: None

P1288 Male gender and left atrial volume index predict non valvular atrial fibrillation recurrence. The NeAfi echo registry

Abstract Background In non-valvular atrial fibrillation (AF) patients, risk stratification scores such as CHA2DS2VASc and HASBLED allow the prediction of thromboembolic and bleeding risks, respectively. However, no risk score for the prediction of AF recurrence has been yet validated. Purpose To evaluate the mayor anthropometric and echocardiographic determinants of AF recurrence in non-valvular paroxysmal AF patients at 1 year follow-up. Methods Among 395 consecutive adult patients with non valvular AF enrolled in the Neapolitan Atrial Fibrillation (NeAfi) Echo registry, 177 (F/M = 87/90, age = 66.5± 11.9 years) had paroxismal AF and underwent 1-year follow-up. Fifteen patients had AF recurrence. Anthropometric parameters and blood pressure (BP) were recorded and CHA2DS2VASc and HASBLED scores were calculated. At baseline, patients underwent a comprehensive echo-Doppler exam, including quantification of left atrial (LA) size measurements, peak atrial longitudinal strain (PALS) and left ventricular (LV) global longitudinal strain (GLS). Binary logistic regression analysis was used to establish a mathematical model of the relationship between the variables and AF recurrence. The covariates for regression analysis were chosen as potential confounding factors based on their significance in independent T test analyses for continuous variables of chi-square for dichotomous variables, or on their biological plausibility. Results AF recurrence was higher in male than in female patients (14.4 vs 2.3%, p = 0.008). Patients with AF recurrence had similar body mass index, systolic and diastolic BP and heart rate compared to those without. The two groups were similar for LV end-systolic and end-diastolic volumes, ejection fraction, LV mass index, diastolic indexes, pulmonary artery systolic pressure and GLS. LA diameter (p = 0.235) and PALS (p = 0.375) were also similar between the two groups, whereas LA volume index (LAVi) was greater in patients experiencing AF recurrence (45.5 ± 15.7 vs. 36.7 ± 10.4 ml/m², p = 0.003). Binomial multiple regression analysis model explained 25% (Nagelkerke R²) of the variance in AF recurrence and correctly classified 95.0% of cases. Males were 8.9 times more likely to exhibit AF recurrence than females (p = 0.04). Greater LAVi was associated with an increased likelihood of exhibiting AF recurrence (OR = 1.07, p = 0.03), whereas CHA2DS2VASc >1 in men and >2 in women, HASBLED >3 and greater LA diameter or lower PALS did not add significant information to the model. Conclusions Male gender and, with a lower extent, LAVi appear to be major determinants of AF recurrence in non-valvular paroxysmal AF. The quantification of PALS does not seem to add valuable information in the prediction of recurrent AF.

IMMEDIATE RESULTS OF THORACOSCOPIC ABLATION FOR TREATMENT OF PATIENTS WITH LONE ATRIAL FIBRILLATION

Background. Atrial fibrillation remains the most common sustained arrhythmia, with an expected increase in our aging population. In addition to the significant morbidity that is secondary to hemodynamic compromise and tachycardia-induced cardiomyopathy, stroke remains the most feared complication, with a 5-fold increased risk. New surgical approaches show promising results and perfect safety for treatment patients with different types of atrial fibrillation.Subject: to describe surgical technique and to evaluate the short-term efficacy and safety of radiofrequency thoracoscopic ablation (Dallas Lesion Set) in patients with lone atrial fibrillation.Material and Methods. Epicardial bipolar radiofrequency ablation was performed on the beating heart through a bilateral endoscopic approach in 127 consecutive patients with lone atrial fibrillation. This included isolation of the pulmonary veins using a clamp; isolation of the posterior left atrial wall, including a trigonal line to the aortic noncoronary sinus using a linear ablation device; and clip or resection of the left atrial appendage. Paroxismal atrial fibrillation was registered in 7% of patients; persistent and persistent long-standing atrial fibrillation was registered in 54 and 39% of patients respectively.Results. Mean duration of atrial fibrillation was 60 (24; 120) months. Mean operation time was 146.7±29.1 minutes. Complications rates were 24% during the learning curve period and 3.9% beyond this period. Freedom from atrial fibrillation and others rhythm disturbances was achieved in 90.5% of patients at discharge. Conclusion. Endoscopic radiofrequency ablation on the beating heart demonstrated high success rates in patients with all types of atrial fibrillation. The rates of complications and procedure-related morbidity decreased at times beyond the learning curve period.

RF42 LONG TERM RESULTS OF SEPTAL MYECTOMY IN OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY: OUR THIRTY YEAR HISTORY.

Background and aim: The objective of this study was to evaluate the early and long-term results of surgical myectomy in a consecutive series of patients operated for obstructive hypertrophic cardiomyopathy (HOCM). Methods: Between January-1989 and March-2014, 79 patients (mean age 50 ± 22 years, 48% males) with HOCM underwent surgical myectomy at our Institution. Nine patients had a history of paroxismal atrial fibrillation (11.3%). Sixty-three patients were symptomatic for dyspnoea (79.7%), twenty-one patients (26.5%) for angina, and twenty-one patients experienced a syncope (26.5%). The mean left ventricular outflow tract gradient was 59 ± 28 mmHg and mean preoperative LVEF was 66% ± 8%. Systolic anterior motion was present in 67 patients (76%) and mitral regurgitation ≥ 2 + in 51 (57%). Results: Mitral valve repair and replacement was performed in 7 (8.7%) and 11 (13.7%) patients.In-hospital mortality was 1.2%. Echocardiography performed at discharge showed a mean left ventricular outflow tract gradient and LVEF of 11 ± 10 and 61% ± 6% respectively. Systolic anterior motion was present in 13 patients (14%) and residual mitral regurgitation ≥ 2 + in 6 patients (7.5%). During follow up (mean 129 ± 73 months)overall mortality and cardiac-related mortality were 16.4% and 5% respectively. In six cases an ICD was implanted (7.6%) and only 3 patients were severely symptomatic for dyspnea. At 15 years freedom from all cause and cardiac death were respectively 63 ± 8% and 89 ± 10%, freedom from recurrence of NYHA class > II were 89 ± 11%. Freedom from reintervention was 100%. Conclusions: In our experience, long-term follofxRF42

Učestalost atrijalne fibrilacije u bolesnika sa koronarnom bolešću

The incidence of atrial fibrillation in patients with coronary artery disease Dušan Miljković Health Center Varvarin Introduction: Atrial fibrillation(AF) is the most common and widespread long-term cardiac arrhythmia in adults.The aim was to examine the frequency of AF in ambulatory patients with coronarography confirmed coronary disease. Methods: The trial included 264 patients (57.5±9.4 years) with coronary artery disease, 204(77,3%) men and 60(22.7%) women. All clinical examinations were performed, continuous ECG control, laboratory, echocardio-graphic diagnostics and coronarography. Results: The incidence of AF in patients with coronary artery disease is 9.85%, paroxismal AF 4.17%, persistent and permanent AF 5.68%. There was no significant difference in the incidence of singl-vessel disease (p>0.05), two-vessel disease (p>0,05), three-vessel disease (p>0.05) and LM disease (p>0.05) among patients with coronary artery disea-se and without AF. Patients with persistent AF and coronary disease have significantly higher incidence of LCX (p<0.05) and RCA (p<0.01) than those without AF. There was no significant difference in the incidence of proximal segments of LCX (p>0.05) and RCA (p>0.05) between patients with and without AF with coronary artery disease. Conclusion: Three-vessel coronary disease, low ejection fraction left ventricle and secondary ischemic heart dise-ase followed by cardiac insufficiency are major factors contributing to the development of AF in stable coronary disease.

Abstract 13474: Incremental Value of Left Atrial Conduction Time for Predicting Atrial Fibrillation in Patients Receiving Cardiac Pacing

Background: Atrial fibrillation (AF) is a relatively common complication of cardiac pacing. Prolonged LA electromechanical conduction time (EMT) has been proposed for prediction of new- onset AF. We sought to investigate the incremental benefit of EMT for predicting AF over conventional predictors in pts undergoing pacing. Methods: We prospectively followed 127 pts with preserved ejection fraction, absence of chronic or known paroxismal AF, and a pacemaker implantation because of atrioventricular block in the PROTECT-PACE trial for 2 years. Reliable recognition of AF episodes was based on pacemaker monitoring. Echocardiography was performed just after the implantation. EMT was measured as the time interval from the onset of the P wave to the peak of the late diastolic wave from the septal and lateral mitral annulus on tissue Doppler echocardiography. We also assessed LA volume index (LAVI) and CHADS2 score. Results: 24 patients (19%) had new onset AF. Septal EMT was significantly longer in pts with AF than that in pts without AF (130±31 vs 112±31 ms, p=0.01). Larger LAVI and prolonged septal EMT were significantly associated with AF. In sequential logisitic models, LAVI added to the model power of CHADS2 score, and the model based on CHADS2 score and LAVI was significantly improved by adding septal EMT (Figure). Conclusion: EMT provides incremental value over the conventional risks for predicting a first episode of AF in patients receiving cardiac pacing.

Atrioesophageal fistula secondary to pulmonary vein cryo-ablation

We report the case of a 31-year-old man with paroxismal atrial fibrillation treated with pulmonary vein isolation (PVI) with cryo-balloon. Early after discharge he presented a transient mild haemoptysis and fever. Four weeks later he was re-admitted for recurring fever, headache, and absence seizures. Brain-CT scan showed multiple bilateral hemispheric emboli ( Panel …

Seven years results in percutaneous closure of atrial septal defect and patent foramen ovale (single center experience)

Cardiologia CROATICA Background: The aim of this report is to present 7 years results in percutaneous closure of atrial septal defect (ASD) and patent foramen ovale (PFO) in Magdalena hospital, and to assess the safety and efficacy of this procedure. Methods: From April 2007 to March 2013, we performed transcatheter ASD and PFO closure in 58 consecutive symptomatic patients (pts). There were 34 percutaneous closures of ASDs and 24 percutaneous closure of PFOs. Indication for ASD closure was significant left-to-right shunt associated with RV overload and mild to moderate pulmonary artery hypertension. Diameter of ASDs were in range from 12 to 28 mm (average diameter 17 mm). For all pts. we used Occlutech Figulla Flex ASD and PFO Closure Device (I and II generation) sized from 15 to 30 mm. Closure of PFO was clinically indicated for secondary prevention in pts. with previous cryptogenic cerebrovascular events due to presumed paradoxical embolism. Pre-procedurally thromboembolic events were: 19 ischemic strokes (79%), and 5 transient ischemic attacks (20.8%). All procedures were performed with conscious sedation anesthesia under fluoroscopic and transesophageal echocardiography (TEE) guidance. Aspirin and clopidogrel were recommended at least for for 20 weeks after procedure for all patients. Results: Primary success of percutaneous closure was achived in all patients. The in-hospital complications were: self-limited supraventricular arrhythmia in 2 pts (3.4%); paroxismal atrial fibrillation in 1 pts (1.7%); minimal groin hematoma in 1 pts (1.7%). Control TEE pefomed after 20 weeks revealed mild residual shunt due to the lack of complite epitelisation of ocluder in 3 pts (5.1%), and aspirin and clopidogrel were recommended for another 20 weeks. No device malfunction, erosion, valvular regurgitation or thrombus formation were occurred so far.

Abstract 3735: Utility A Second 24-hours Holter Monitoring For The Diagnosis Of Paroxismal Atrial Fibrillation After An Acute Stroke

OBJETIVE: to assess the utility of a second 24-hours Holter monitoring for the diagnosis of paroxysmal atrial fibrillation (PAF) in patients with suspected cardioembolic ischemic stroke. METHODS: prospective study of ischemic stroke patients (brain infarction/TIA) treated in a Stroke Center (June 2010-February 2011). A first 24-hours Holter monitoring was performed if PAF was suspected and, if it was negative, a second 24-hours Holter monitoring was performed. Variables analyzed: demographic data, vascular risk factors, stroke severity and etiological subtype, presence of carotid plaques by duplex ultrasound, enlarged left atrial by transthoracic/transesophageal echocardiography and presence of chronic/acute brain infarctions by neuroimaging (CT/MRI). RESULTS: 219 patients included, mean age 69.8 (SD 13.5) years, 55.3% male. 17.8% have previous atrial fibrillation (AF). In 14 (6.4%) patients AF was diagnosed by ECG on admission or by serial ECG in the Stroke Unit. 24-hours Holter was performed in 101 patients to assess the presence of PAF, 85 cases during hospitalization and 16 at the outpatient clinic. This 24-hours Holter diagnosed PAF in 28.7% (29/101) of patients. A second 24-hours Holter was performed at the outpatient clinic in 21 cryptogenic brain ischemia patients. The mean time from the first to the second Holter was 143.3 (SD 72.2) days. This second 24-hours Holter detected PAF in 2 (9.5%) patients. CONCLUSION: a second 24-hours Holter monitoring at the outpatient clinic could detect PAF in almost 10% of cryptogenic ischemic stroke patients.

Effect of Omega-3 Fatty Acids on the Prevenction of Recurrences of Atrial Fibrillation

The effects of Omega-3 fatty acids (n-3) on cardiac membrane stabilization are well known. Reduction of ventricular arrhythmias and sudden death has been reported; fewer data exist regarding the effects of n-3 on atrial arrhythmias. Objective of this preliminary report is to evaluate the reduction of atrial arrhythmias after treatment with n-3 in pts with DDD pace-makers (PM). we examined 40 pts with paroxismal atrial fibrillation (PAF) recorded at the periodic (every four months) PM controls. The PMs were implanted more than 1 year earlier for AV block (14 pts), synus bradicardia (8 pts), bradi-tachy syndrome (16 pts) and CHF (biventricular, 2 pts); the underlying cardiac pathologies were hypertensive disease in 24 pts, mitral regurgitation in 28, stable CAD in 16. All pts had bipolar atrial and ventricular leads with proper sensing function; the PMs were programmed in DDD or DDDr mode with minimum rate of 70 to 85 bpm. At the study entry, all pts were treated with n-3 (1 gr/d); no changes in PM programming and in the previous pharmacological therapy were allowed. The PM memories were interrogated after 4 months of treatment to evaluate the number and burden of PAF episodes; the percentage reduction of PAF burden (D burden) was calculated. At this point, the treatment was discontinued and the pts were evaluated 4 months later. Statistical analyses were performed with the T-Student test. 2 pts early discontinued the treatment complaining adverse drug effects (abdominal pain and diarrhoea). They were included in the intention-to-treat analysis. The patient population showed a dramatic reduction in episodes and burden of PAF during the treatment period. The episodes of PAF in the pre-treatment period resulted 450 ± 1190, and the PAF burden 3,92% of time; in the treatment period resulted respectively 147±346 (p = 0,07) and 1,01% (p = 0,042), with a mean PAF burden reduction of 69%. After the withdrawal of drug, the PAF episodes raised to 488±1687 (p = 0,100) and the PAF burden to 2,8% (p = 0,005). Even after the exclusion from analysis of the 9 pts with non sustained-PAF (<30 sec), the treatment reduced the PAF episodes (559 vs 172, p=0,079) and burden (5,17% vs 1,39%, p=0,042). our data suggest a powerful effect of n-3 in reduction of PAF in these pts, without significant adverse effects. Although we expected a beneficial effect, we were extremely surprised of the magnitude of these results, so that we started a multicentric, double blinded trial on the atrial anti-arrhythmic effects of n-3.

Multiple Lines Ablation Of Atrial Fibrillation: A Surgical Like Approach

A hundred pts with (38) and without (62) structural heart disease were submitted to ablation of atrial fibrillation (AF) with left atrial linear lesions, with irrigated tip radiofrequency catheter, including encircling of pulmonary veins, roof, left isthmus, posterior wall between the two encirclings. If AF was still inducible with a 5 sec 250 bpm atrial burst a septal line (mitral anulus- right inferior pulmonary vein) and if still inducible anterior line (mitral anulus right superior pulmonary vein) were added. Visit, ECG and Holter were performed after a month and once every three months. After a follow up of 250 (137 days, success rates were 84%, and 88% with drugs. A three months echocardiografic evaluation showed a preserved atrial contractility and mitral flow. Recurrences were left atrial flutter in 23,1% and AF in 76,9%. In patients with recurrences the burden of AF was significantly decreased. The presence of structural heart disease was not predictive of the outcome, whereas the presence of permanent vs persistent vs paroxismal AF was predictive (p=0,01). Procedures were complicated by tamponade in 3% of cases.

Synchronized biventricular pacing after av node ablation in CHF patients

Background atrioventricular junctional (AVJ) ablation with PM implantation has been shown to improve quality of life (QoL) in selected patients(pts) with drug resistant atrial fibrillation (AF). However,after the procedure,some pts worsen because of asinchronous ventricular stimulation. History during the last 9 years,among 1986 pts who referred to our Institution for AF, 28 pts underwent ablate and pace procedure by right ventricular single lead.The long term follow up(FU) of 36 months demonstrated an improvement of QoL in all but 4 pts who developed a progressive, irreversible heart failure. Methods from january 2001 to july 2002, 12 consecutive pts (6F,6M of mean age of 70.2 years) with dilated cardiomyopathy and chronic, non controlled high rate AF, were recruited. Eight pts had chronic persistant AF and 4 pts had chronic paroxismal AF. After AVJ ablation, a biventricular device was implanted : Medtronic Insync in 9 pts and Insync biventricular ICD in 3 pts. The NYHA functional class, the QRS duration, the mean heart rate, left ventricular ejection fraction (LVEF) and LV end diastolic dyameter (LVEDD) by 2D echocardiography, 6 minutes walking test(6'WT), the score of Minnesota questionnaire and the score of palpitation symptoms were evaluated at baseline and at 1, 3, 6 and 12 months FU in every pts. Results the mean FU was 7.2+/− 4 months.The results have been quite terrific as shown as follow. One pt,3 months after the procedure, in spite of wide clinical improvements, died suddenly on ecg Holter monitoring that demonstrated a ventricular fibrillation as the cause of death. In pts with paoxismal AF, a trend of reduction of numbers and duration of episodes of AF was observed. View this table: Conclusions these results demonstrated that the AVJ ablation combined with biventricular pacing is an effective tecnique to improve QoL in AF in congestive heart failure pts, mostly by relief of symptoms of palpitations and by means of the resinchronization therapy. The clinical results are not correlated to the QRS duration and to the LVEDD.Also the number of episodes of paroxismal AF seems to be lowered by the resnchronization therapy.However, life threatening ventricular arrhythmias have to be considered in pts without previous episodes.

A35-1 Is the paroxismal atrial fibrillation radiofrequency catheter ablation a safe procedure?

A35-1 Is the paroxismal atrial fibrillation radiofrequency catheter ablation a safe procedure?

A35-1 Is the paroxismal atrial fibrillation radiofrequency catheter ablation a safe procedure?

A35-1 Is the paroxismal atrial fibrillation radiofrequency catheter ablation a safe procedure?

Oral flecainide for prevention of paroxismal atrial fibrillation: Predictive value of the response to transesophageal atrial stimulation

Oral flecainide for prevention of paroxismal atrial fibrillation: Predictive value of the response to transesophageal atrial stimulation