Paroxysmal AFib Research Articles

Smart watch applications in atrial fibrillation detection: Current state and future directions.

Atrial fibrillation (Afib) is a prevalent chronic arrhythmia associated with severe complications, including stroke, heart failure, and increased mortality. This review explores the use of smartwatches for Afib detection, addressing the limitations of current monitoring methods and emphasizing the potential of wearable technology in revolutionizing healthcare. Current Afib detection methods, such as electrocardiography, have limitations in sensitivity and specificity. Smartwatches with advanced sensors offer continuous monitoring, improving the chances of detecting asymptomatic and paroxysmal Afib. The review meticulously examines major clinical trials studying Afib detection using smartwatches, including the landmark Apple Heart Study and ongoing trials such as the Heart Watch, Heartline, and Fitbit Heart Study. Detailed summaries of participant numbers, smartwatch devices used, and key findings are presented. It also comments on the cost-effectiveness and scalability of smartwatch-based screening, highlighting the potential to reduce healthcare costs and improve patient outcomes. The integration of wearable technology into healthcare can lead to earlier diagnosis, improved patient engagement, and enhanced cardiac health monitoring. Despite ethical considerations and disparities, the potential benefits outweigh the challenges. This review calls for increased awareness, collaboration with insurance companies, and ongoing research efforts to optimize smartwatch accuracy and encourage widespread adoption of Afib detection. With insights from major trials, this review serves as a comprehensive reference for healthcare professionals and policymakers, guiding future strategies in the early diagnosis and management of atrial fibrillation.

Pulmonary hypertension is associated with increased recurrence of atrial fibrillation post-pulmonary vein isolation: a multicenter study insights

Abstract Background Pulmonary vein isolation (PVI) has become an essential therapeutic approach for managing paroxysmal and persistent atrial fibrillation. Besides the fact its application increases, a substantial proportion of patients will suffer from arrhythmia recurrence. Objectives This study aims to determine the clinical and echocardiographic factors that predict fibrillation recurrence following pulmonary vein isolation. Methods In this prospective, multicenter study carried out across 14 medical centers in Israel, we included a cohort of 1002 patients who underwent pulmonary vein isolation from 2019 to 2022. The study involved an assessment of patients' baseline characteristics, electrocardiographic and echocardiographic data, laboratory results, details of the procedure, and their clinical outcomes. We monitored these clinical outcomes for one year after the ablation procedure, focusing mainly on the recurrence of atrial fibrillation, which was verified using electrocardiographic evidence during the post-blanking period. A multivariable analysis revealed the clinical and echocardiographic predictors for atrial fibrillation recurrence post-PVI. Results Our study evaluated 1002 patients with an average age of 64.4 ±11.3 years, including 37.5% females (376 patients). The cohort predominantly, about two-thirds, had paroxysmal AFIB, with an average arrythmia duration of 4.1 years. Frequent pre-existing conditions included ischemic heart disease in 17.3% and congestive heart failure in 13.8% of the patients. Additionally, diabetes was present in a quarter of the cohort, with 9% having a prior cerebrovascular event. The median LVEF was 60 (IQR 53-60), and the average left atrial diameter was 42.6 mm±8.8. The median pulmonary artery pressure was noted at 31 (IQR 25-38), with 13% of patients exhibiting elevated levels above 45 mmHg. Within the first year after the ablation, 11.7% of patients experienced AFIB recurrence in the post-blanking period. Our multivariate COX analysis established clinical and echocardiographic models for predicting post-PVI AFIB recurrence. Gender was a significant predictor, with women showing a higher recurrence rate (HR 1.85, 95% CI 1.29-2.7, P<0.01), in addition to persistent AFIB and a non-sinus rhythm at the time of the procedure. Echocardiographic predictors of recurrence included a left atrial diameter greater than 40 mm (HR 2.16, 95% CI 1.3-3.6, P<0.01) and pulmonary hypertension, notably when pulmonary artery pressure exceeded 55 mmHg, which correlated with almost a fourfold increase in AFIB recurrence risk within the first-year post-procedure (HR 4.25, 95% CI 1.57-11.5, P<0.01). Conclusions Pulmonary hypertension, especially with pulmonary artery pressure above 55 mmHg, significantly elevates the risk of atrial fibrillation recurrence post-pulmonary vein isolation, underscoring its importance in patient prognosis and management.

Inter-patient variability of local cycle length and duty cycle distribution of the atrial fibrillation substrate beyond pulmonary vein isolation

Abstract Appropriate targets for catheter ablation of atrial fibrillation (AFib) beyond pulmonary vein isolation (PVI) are still controversially discussed. Various approaches such as ablation of complex fractionated atrial electrograms (EGMs), areas with spatio-temporal dispersion, and areas with increased rotor density have not been reproducible or failed to improve clinical success rates. The local cycle length (CL) and duty cycle (DC) distribution during AFib offer novel measures to characterize the atrial substrate. This study aims at providing first insights into the inter-individual variability of observed CL and DC distributions, their interdependence, and their correlation to the duration of AFib episodes to improve the individual characterization of the AFib substrate and tailor ablation strategies in future. In patients with recurrence of AFib despite PVI, a high-resolution 3D map was recorded at baseline during AFib. Intracardiac EGMs were preprocessed to improve local signal quality and far field suppression. EGMs were recorded with the multipolar, basket-shaped high-density mapping catheter. Local CL and DC distribution were visualized using a scatter plot and histograms. CL quantifies the time between subsequent local activations, DC quantifies the fraction of CL with local EGM activity, and the confidence (conf) feature quantifies the spatiotemporal consistency of EGM morphology. Only EGMs with conf > 0.6 are analysed. Feature calculation does not only take into account single EGMs but a weighted conglomerate of all acquisitions within a series of beats. Adjustable CL and DC thresholds allow highlighting regions within the 3D map for individual spatial analysis. 14 patients (7x paroxysmal AFib, 7x persistent AFib) were enrolled. All subjects underwent repeat ablation after PVI due to recurrence of AFib. CL and DC histograms were of highly individual shape. The most prevalent feature value varied from 158ms to 263ms for CL and from 38% to 96% for DC; histogram widths (inter-quartile-range) from 10ms to 34ms and from 26% to 36%, respectively. Normal distributions, multimodal distributions, and skewed distributions exhibiting a dominant peak were observed for CL. Both the most prevalent CL and the width of the distribution were highly individual. DC was observed to be normally to equally distributed with mostly broad bandwidths. Linear regression revealed a positive dependency between the most prevalent CL and the width of CL distributions. The most prevalent value and the width of both CL and DC did not differ significantly for the paroxysmal and persistent subgroup. Compare figure for detailed results. CL and DC distributions can help to characterize the highly individual type of AFib. The presented results suggest that there will not be a one-size-fits-all ablation approach for the AFib substrate. Further research is needed to identify clusters of similar pattern and individually adjust the ablation strategy.

Temporal stability of local cycle length and duty cycle distribution during atrial fibrillation

Abstract Appropriate targets for catheter ablation of atrial fibrillation (AFib) beyond pulmonary vein isolation (PVI) are still controversially discussed. Since available parameters to analyze the vulnerable substrate are very limited, there is the need to define and understand tailored features. Mapping during AFib can be particularly challenging due to its non-repetitive nature. Amongst others, temporal stability despite changing activation sequences is an essential requirement for features applied to AFib maps. The local cycle length (CL) and duty cycle (DC) offer novel measures to characterize the atrial substrate during AFib. This study aims at providing first insights into the temporal stability of CL and DC during AFib in order to assess the suitability of both features for the characterization of the individual substrate and tailor ablation strategies in future. In patients with recurrent AFib after PVI, two high-resolution 3D electro-anatomical maps were recorded sequentially during AFib before any ablation. Intracardiac electrograms (EGMs) were preprocessed to improve local signal quality and far field suppression. EGMs were recorded with a multipolar, basket-shaped high-density mapping catheter. Local CL and DC distribution were visualized using scatter plots and histograms. CL quantifies the time between subsequent local activations, DC quantifies the fraction of CL with local EGM activity, and the confidence (conf) feature quantifies the spatiotemporal consistency of EGM morphology. Only recordings with conf > 0.6 are analyzed. Feature calculation is based on a weighted conglomerate of all acquisitions within a series of beats. Adjustable CL and DC thresholds allow highlighting regions within the 3D map for individual spatial analysis. Both the global distributions and the local occurrence of CL and DC were compared in order to assess temporal stability. Four patients (2x paroxysmal AFib, 2x persistent AFib) were enrolled. All subjects underwent repeat ablation after PVI due to recurrence of AFib. Table 1 summarizes mapping parameters for both AFib maps in individual patients. Despite differences in mapping time and the number of EGMs, CL and DC histograms were significantly similar when comparing maps within one patient. For individually selected ranges of CL and DC in the upper left corner of the scatter plot (short CL and high DC), localization of corresponding areas was comparable in both 3D maps. An example is shown for patient I in the left and central column of the figure. CL and DC distributions were temporally stable features for all patients in this study cohort. Localization of EGMs of given CL and DC range within the 3D maps were comparable but not identical for arbitrarily selected ranges. CL and DC can therefore be considered valid features for substrate characterization during AFib. Further studies will need to investigate how ablation strategies can be derived from individual CL and DC distributions.

Evaluation of the Diagnostic Performance and Efficacy of Wearable Electrocardiogram Monitoring for Arrhythmia Detection after Cardiac Surgery.

Postoperative atrial fibrillation (A-fib) is a serious complication of cardiac surgery that is associated with increased mortality and morbidity. Traditional 24-hour Holter monitors have limitations, which have prompted the development of innovative wearable electrocardiogram (ECG) monitoring devices. This study assessed a patch-type wearable ECG device (MobiCARE-MC100) for monitoring A-fib in patients undergoing cardiac surgery and compared it with 24-hour Holter ECG monitoring. This was a single-center, prospective, investigator-initiated cohort study that included 39 patients who underwent cardiac surgery between July 2021 and June 2022. Patients underwent simultaneous monitoring with both conventional Holter and patchtype ECG devices for 24 hours. The Holter device was then removed, and patch-type monitoring continued for an additional 48 hours, to determine whether extended monitoring provided benefits in the detection of A-fib. This 72-hour ECG monitoring study included 39 patients, with an average age of 62.2 years, comprising 29 men (74.4%) and 10 women (25.6%). In the initial 24 hours, both monitoring techniques identified the same number of paroxysmal A-fib in 7 out of 39 patients. After 24 hours of monitoring, during the additional 48-hour assessment using the patch-type ECG device, an increase in A-fib burden (9%→38%) was observed in 1 patient. Most patients reported no significant discomfort while using the MobiCARE device. In patients who underwent cardiac surgery, the mobiCARE device demonstrated diagnostic accuracy comparable to that of the conventional Holter monitoring system.

Atrial Arrhythmia in Sickle Cell Anemia: A Missing Piece to Prevent Cerebrovascular Complications?

Background: Although Sickle Cell anemia (SCA) patients carries an increased risk of stroke and an important left atrial (LA) remodeling, the reality of atrial arrythmia (AA) has never been prospectively assessed. Purpose: The aim of this study was to identify the prevalence and predictors of atrial arrhythmia in SCA patients among Drepacoeur registry. Methods: From January 2019 to November 2022, consecutive adult patients with SCA were referred to the physiology department to specifically analyze cardiac function and were prospectively included. They underwent a 24-hour electrocardiogram monitoring (ECG-Holter), transthoracic echocardiography, and laboratory tests on the same day. The primary end point was the occurrence of AA, defined by the presence of excessive supraventricular ectopic activity (ESVEA) on ECG-holter (i.e. >720 premature atrial contractions [PACs] or any run ≥ 20 PACs), recent history of paroxysmal atrial fibrillation (AFib), of persistant AFib. Results: Overall, 130 patients were included. Mean age was 45±12 years, 48% were male. AA was observed in 34 (26%) patients (17 with more than 720 PACs/day, 6 with at least a run ≥ 20 PACs, 11 with recent history of paroxysmal AFib and 5 with persistant AFib). Ageing (52±9 vs. 42±12 years, P=0,004), LA dilation (LAV i, 71±24 vs. 52±14 ml/m², P<0.001) and history of stroke without underlying cerebral vasculopathy (23% vs. 7%, P=0.04) were independently associated with AA. Age and LAV i correlated with PAC load on ECG-holter (R=0,56, P<0,001 and R=0,33, P<0.001 respectively). Interestingly n age over 47 years or a LAV i >55ml/m² could predict AA with a positive prective value of 33% and a negative one of 92%. Conclusion: Atrial arrythmia is common in adult SCA patients and is associated with ageing, LA remodeling and considerably increases the risk of ischemic stroke. This study provides tools for early detection of AA and prevent cardiac and cerebrovascular dramatic complications in this highly vulnerable population.

0982 Atrial fibrillation diagnosed from a home-based sleep study in a patient with REM behavior disorder

Abstract Introduction Atrial fibrillation (A-Fib) is the most common form of cardiac arrhythmia and is a major cause of stroke. Obstructive sleep apnea (OSA) is an established risk factor of A-Fib, but sleep disruption with frequent awakenings was recently identified as another risk factor, independent from OSA. Home sleep apnea test (HSAT) is widely used to diagnose OSA with low cost and short wait time, and HSAT that uses peripheral arterial tonometry (PAT) can reveal cardiac arrhythmia. Here we report a case of A-Fib detected by PAT-based HSAT in a patient with REM sleep disorder. Report of case(s) A 60-year-old man with hypertension, depression, anxiety, tobacco and alcohol use disorders presented to sleep clinic for frightening vivid dreams and violent dream enactments that gradually developed over the last two years. A diagnostic polysomnography study showed mild OSA, normal heart rhythm, and no epoch of REM sleep without atonia (RSWA). In the following four years, he used CPAP therapy, imagery rehearsal therapy, high-dose melatonin, doxepin and hydroxyzine. However, the frightening dreams and dream enactments persisted despite full adherence to CPAP. To reassess OSA, the patient took a PAT-based HSAT, which showed not only mild OSA, but one episode of irregularly irregular PAT-derived pulsation variations that lasted three hours and started and stopped abruptly. We therefore ordered longitudinal cardiac monitoring, which showed multiple asymptomatic episodes of A-Fib during nighttime. After treatments for A-Fib were started, a polysomnography study with effective CPAP titration showed one episode of A-Fib with rapid ventricular response that lasted 2.5 hours during non-REM sleep, and multiple epochs of RSWA. The diagnosis of REM sleep behavior disorder (RBD) was thus established. Conclusion We reported concurrent developments of RBD and asymptomatic paroxysmal A-Fib in a man in his early sixties. Our case suggests a potential association between RBD and A-Fib, which has not been studied but is conceivable, given that RBD causes frequent awakenings with surges of sympathetic activity. Our case also highlights the advantage of PAT in capturing not only OSA but cardiac arrhythmia. Clinical interpreters of PAT-based HSAT can seize the opportunity to diagnose A-Fib and prevent stroke. Support (if any)

Elevated fibrosis burden as assessed by MRI predicts cryoballoon ablation failure.

Late-gadolinium enhancement magnetic resonance (LGE-MRI) imaging is increasingly used in management of atrial fibrillation (AFib) patients. Here, we assess the usefulness of LGE-MRI-based fibrosis quantification to predict arrhythmia recurrence in patients undergoing cryoballoon ablation. Our secondary goal was to compare two widely used fibrosis quantification methods. In 102 AF patients undergoing LGE-MRI and cryoballoon ablation (mean age 62 years; 64% male; 59% paroxysmal AFib), atrial fibrosis was quantified using the pixel intensity histogram (PIH) and image intensity ratio (IIR) methods. PIH segmentations were completed by a third-party provider as part of the standard of care at our hospital; Image intensity ratio(IIR) segmentations of the same scans were carried out in our lab using a commercially available software package. Fibrosis burdens and spatial distributions for the two methods were compared. Patients were followed prospectively for recurrent arrhythmia following ablation. Average PIH fibrosis was 15.6 ± 5.8% of the left atrial (LA) volume. Depending on threshold (IIRthr ), the average IIR fibrosis (% of LA wall surface area) ranged from 5.0 ± 7.2% (IIRthr = 1.2) to 37.4 ± 10.9% (IIRthr = 0.97). An IIRthr of 1.03 demonstrated the greatest agreement between the methods, but spatial overlap of fibrotic areas delineated by the two methods was modest (Sorenson Dice coefficient: 0.49). Fourty-two patients (41.2%) had recurrent arrhythmia. PIH fibrosis successfully predicted recurrence (HR 1.07; p = .02) over a follow-up period of 362 ± 149 days; regardless of IIRthr , IIR fibrosis did not predict recurrence. PIH-based volumetric assessment of atrial fibrosis was modestly predictive of arrhythmia recurrence following cryoballoon ablation in this cohort. IIR-based fibrosis was not predictive of recurrence for any of the IIRthr values tested, and the overlap in designated areas of fibrosis between the PIH and IIR methods was modest. Caution must therefore be exercised when interpreting LA fibrosis from LGE-MRI, since the values and spatial pattern are methodology-dependent.

In patients with paroxysmal atrial fibrillation left atrial strain paramethers, left atrial function index and poor glycaemic control can be predictors of arrhythmia recurrence

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left atrial (LA) systolic dysfunction is present in early stages of atrial fibrillation (AFib) prior to left anatomical changes and is influenced by left ventricular systolic function. We evaluate weather left atrial function index (LAFI), left atrial strain parameters (LASP) and glycemic control can be a predictor of AFib recurrence after medical or electrical conversion patients with paroxysmal AFib. Material and method We evaluate 150 patients who underwent medical or electrical conversion for paroxysmal AFIb, for a period of 2 years. LA systolic function was appreciated with the echocardiography determined LA emptying volume = Maximum LA volume (LAV max)-minimum LA volume (LAV min), LA emptying fraction= {[LAV max-LAV min]/LAV max]x100}, and LAFI = LA emptying fraction x LVOT-VTILA max index. Left atrial strain (LAS) was assessed as reservoir strain[normal value(NV) 39%], conduit strain(NV 23%) and contractile strain(NV 17%). Flow mediated vasodilation was recorded at the level of brachial artery. Recurrent AFib was recorded in 75 patients (50%), time11,5 ± 10 month. Results Univariate analysis revealed as markers for arrhythmia recurrence low LAFI, reduced LA ejection force, altered LASP, high BMI, poor glycemic control (cut-off value for hemoglobin HbA1C 7%), high BMI, decreased index of flow mediated vasodilatation (FMD). On multivariate analysis poor glycemic control, reduced LAFI, altered LASP and larger LA diameter had a higher risk of AFib than patients with higher LAFI and good glycemic control (p < 0,004). Conclusion In patients with paroxysmal atrial fibrillation, reduced left atrial function index, altered left atrial strain parameters, larger left atrium, altered endothelial dysfunction appreciated by flow mediated vasodilatation, and poor glycemic control can be predictors of arial fibrillation recurrence.

Capacities of atrial fibrillation detection after stroke: a French nationwide survey

Abstract Background Atrial fibrillation (AFib) is a major contributor to recurrent but preventable ischemic Stroke (IS)/TIA. However, majority of stroke patients suffer from paroxysmal asymptomatic AFib, which implies stroke health system to implement accurate AFib detection strategies to large scale population. Current practices of AFib screening methods provided by Stroke Units (SU) organization and network in France are currently unknown and uncovered by dedicated guidelines. Purpose To assess the methodology of Afib screening in French SU. Methods A French Nationwide survey was led (September-November 2020) with on-line structured questionnaires sent to individual targeted stroke-physicians (SP) and heads of SU in France.We analyzed qualitative and quantitative availability and current use of AFib detection tools during acute inhospital and outpatient subacute and chronic post-IS phases. Results 67% of 140 heads of SU and 33% of SP responded across all continental and overseas French regions.Main clinical characteristics that lead to search Afib are: TIA/IS recurrence under antiplatelet therapy (97%), patient's age (74%), proximal occlusion of a major cerebral artery (72%). Afib is highly suspected when there is: recent brain IS in multiple vascular territories (100%), previous IS in another vascular territory (98%), left atrial enlargement (96%), burst of supraventricular tachycardia <30s (94%). In-hospital cardiac monitoring is considered to be mandatory by 90% of SU teams but only 1/3 of those possess telemetry out of intensive care unit. Outpatient cardiac monitoring is considered of major interest/necessary by 100% of SP. When first line 24-hour Holter monitor is normal and Afib is highly suspected, 75% of the SP required outpatient noninvasive monitoring (NIM) for at least 7 days and more than half required insertable cardiac monitor (ISC). ISC are implanted each year by SU for <10 patients in 44% and <50 patients in 94%. The delay IS-ICM implantation is <1 month in 10%, 1–3 months in 52%, 3–6 months in 29% and >6 months in 9%. Accessibility to outpatient monitoring modalities is graded: fairly easy for 24/48h-Holter (85%) and ISC (68%); rather difficult/impossible for 3–7 days NIM (51%), 8–21 days NIM (75%) or e-ECG tools (99%). Main obstacles to monitoring abilities development in SU were lack of: manpower (80%), efficient network with cardiologists (56%), familiarity of techniques (42%); and technical equipment cost (44%). 96.5% of SU teams deem necessary practice decision support flowchart with cardiologist partnership but 19% use for it. Conclusion The survey raises concern about lack of a systematic strategy and shortcomings for Afib detection capacities. These results are a call to establish practice-guidelines and to promote an improvement plan for AFib detection (selection of the patients, tools and prioritization of the exams) after TIA/IS in France which will require a strong collaboration between neurologists and cardiologists. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer

White matter integrity of watershed areas is potentially influenced by hypoperfusion in the presence permanent atrial fibrillation

Aim. To test a hypothesis of hypoperfusion-induced white matter changes in patients with atrial fibrillation (AFib) and to present statistics to compute sample size for the upcoming studies.Material and methods. We included 30 inpatients with AFib and investigated them with magnetic resonance imaging (MRI) with standard sequencies and diffusion tensor imaging (DTI). DTI data were analyzed with conventional ROI analysis in the Olea Sphere software and with watershed areas (WSA) mask in the FSL toolbox after nonlinear transformation of images to the Montreal Neurological Institute (MNI) space. Wilcoxon test was used to compare diffusion characteristics across subgroups.Results. Median age of participants was 73 years (69-78), 18 (60%) patients had moderate signs of small vessel disease with Fazekas score of one. Twenty-one patients had paroxysmal AFib. Analysis of WSA revealed decreased white matter integrity in the parieto-occipital cortical WSA with a pattern of significantly increased mean diffusivity (p=0,039), and marginally significant decrease in fractional anisotropy (p=0,056). Rank-based effect size across areas under comparison was either small (0,2) or negligible, and with statistical power in the range of 0,05-1.Conclusion. Atrial fibrillation could have pathophysiologically feasible mechanism to affect white matter integrity in the watershed areas.

Diagnostic accuracy of MicroRNA 208b level with respect to different types of atrial fibrillation

MicroRNAs (miRNA) are prerequisite for cardiovascular functions. miRNA miR-208 b is a cardio-specific miRNA with tissue (atrial) levels elevated in atrial fibrillation (AFib) and blood levels significantly elevated in myocardial infarction. We calculated serum levels of miR-208 b in paroxysmal and persistent AFib, embolic cerebrovascular accident patients with AFib as possible etiology and controls. There was a statistically significant change of miR-208 b levels in paroxysmal (p = 0.044) and persistent (p = 0.040) AFib patients, but not for embolic CVA patients. miR-208 b could serve as a new serum marker for paroxysmal AFib.

Intravascular Lymphoma in Patient With Celiac Disease With Multi Glandular Involvement

Case Presentation: The patient is a 60 year old male with a past medical history of celiac disease, paroxysmal Afib, iron deficiency, and CAD who presented with lightheadedness, dizziness, and fatigue. Notable workup revealed that the patient had Afib with RVR, a TSH of 0.189, Free t4 0.51an LDH of 2726, hemoglobin of 8.7, AST of 155, ALT of 19, WBC of 4.5, and serum iron of 20. The patient’s cardizem dose was adjusted and repeat transthoracic echocardiogram was unremarkable compared to history. The patient presented again with complaints of abdominal distension, postural dizziness, occasional night sweats, and fevers. Repeat workups revealed pancytopenia, proteinuria, hypotension, and anasarca most pronounced in the lower extremity and scrotum. Ultimately, a kidney biopsy revealed an intravascular B cell non-Hodgkin lymphoma (IVBCL). Notable repeat labs include a CRP of 44 and a failed ACTH stimulation test. A brain MRI revealed a 6mm pituitary microadenoma. The patient placed on an R-CHOP regiment and is scheduled for repeat MRI to rule out pituitary involvement. Discussion: IVBCL’s are a rare form of diffuse B cell lymphoma and remain a diagnostic challenge due to the variety of involved systems including skin, CNS, and endocrine. IVBCL is also known to not produce a mass or lymphadenopathy. Celiac disease is a known risk factor for non-Hodgkin’s lymphoma. A literature search reveals a few case reports with common themes of increased LDH and inflammatory markers, anemia, and hepatic and renal dysfunction. Postural hypotension can also be a presenting symptom due to IVBCL’s ability to infiltrate neurovascular tissue to cause autonomic neuropathy. However, in this case, the patient’s history of primary adrenal insufficiency makes this unlikely. Hypothyroidism secondary to pituitary and thyroid involvement was suspected due to TSH level suppressed enough for central hypothyroidism. Repeated MRI showed resolution of Pituitary Microadenoma post Chemo therapy.Sylvain Raoul Simeni Njonnou, Bruno Couturier, Yannick Gombeir, Sylvain Verbanck, France Devuyst, Georges El Hachem, Ivan Theate, Anne-Laure Trepant, Virginie De Wilde, Frédéric-Alain Vandergheynst, “Pituitary Gland and Neurological Involvement in a Case of Hemophagocytic Syndrome Revealing an Intravascular Large B-Cell Lymphoma”, Case Reports in Hematology, vol. 2019, 6 pages, 2019. https://doi.org/10.1155/2019/9625075Catassi C, Fabiani E, Corrao G, et al. Risk of Non-Hodgkin Lymphoma in Celiac Disease. JAMA. 2002;287(11):1413Khan MS, McCubbin M, Nand S. Intravascular Large B-Cell Lymphoma: A Difficult Diagnostic Challenge. J Investig Med High Impact Case Rep. 2014 Mar 6;2(1):2324709614526702.Pearce C, Hope S, Butchart J. Intravascular lymphoma presenting with postural hypotension. BMJ Case Rep.Published 2018 Jan 29.

3D transesophageal echocardiography assists in evaluating the morphology, function, and presence of thrombi of left atrial appendage in patients with atrial fibrillation

BackgroundLeft atrial appendage (LAA) is significantly more likely to form thrombi in patients with atrial fibrillation (AFib). Two-dimensional transesophageal echocardiography (2D TEE) is considered the gold standard for assessing and studying LAA morphology and anatomy. However, 2D TEE can only visualize one plane at any given time. Real-time three-dimensional echocardiography (RT-3D TEE) imaging can preserve spatial and temporal resolution, which is a safe, accurate, and reproducible imaging modality. There are few reports of the usage of RT-3D TEE to study LAA in AFib patients. In our research, RT-3D TEE helps to provide detailed LAA information and identifying the presence or absence of thrombi from pectinate muscles in paroxysmal and long-standing AFib patients.MethodsLAA morphology was analyzed in detail by 2D TEE and RT-3D TEE in 320 patients with paroxysmal or long-standing AFib. The LAA flow pattern, as maximal LAA emptying flow velocity (LAAeV), was retrieved from 2D and 3D TEE imaging. LAA morphological parameters, spontaneous echo contrast (SEC), and thrombi were also detected by 2D and 3D TEE in all patients. In addition, LAA lobes and types were classified according to the morphology by 3D TEE, and the relationship between LAA types and the incidence of thrombi was evaluated.ResultsLong-standing AFib had greater enlargement of LAAs (orifice diameters and area), significantly more severe SEC, and a higher thrombi clot incidence rate by 3D-TEE compared with paroxysmal AFib patients (P<0.05). In addition, cauliflower morphology in long-standing AFib patients was associated with a higher LAA thrombus (OR 2.1, 95% CI: 1.1–8.5, P=0.031) and increased prevalence of SEC. Moreover, the uncertainty of thrombi detection was significantly decreased by 3D TEE compared with 2D TEE (P<0.001), and the certainty of thrombi detection by 3D TEE also decreased slightly (P=0.06).ConclusionsRT-3D TEE is a safe and real-time option for the evaluation of LAA morphology and function. Long-standing AFib has greater LAA and SEC, as well as a higher incidence of thrombi than the paroxysmal group. Cauliflower LAA type was associated with a higher prevalence of SEC and thrombi.

Cryoablation may be superior to drug therapy for initial management of AFib

Results from two studies published in the New England Journal of Medicine support the use of catheter cryoballoon ablation over antiarrhythmic therapy as initial therapy for patients with symptomatic, paroxysmal atrial fibrillation (AFib). The research was based on two trials, known as EARLY-AF and STOP AF First, which both showed that initial use of cryoablation resulted in a significantly lower rate of AFib recurrence compared with drug therapy without increasing the risk for serious adverse events. “We can now offer pulmonary vein isolation–based ablation with greater confidence as first-line therapy for selected patients with paroxysmal atrial fibrillation, particularly those who are disinclined to take antiarrhythmic drugs,” said Joseph E. Marine, MD, from the division of cardiology at Johns Hopkins University School of Medicine, in an accompanying editorial. “The new data will inform shared decision-making discussions with all patients with paroxysmal atrial fibrillation.” The EARLY-AF (Early Aggressive Invasive Intervention for Atrial Fibrillation) trial included 303 adult patients with symptomatic, paroxysmal, untreated AFib who were randomized to catheter ablation with a cryothermy balloon (n = 154) or antiarrhythmic drug therapy (n = 149) as their initial rhythm control. Patients were followed for 12 months. The primary endpoint was the first documented recurrence of any atrial tachyarrhythmia (i.e., AFib, atrial flutter, or atrial tachycardia) lasting 30 seconds or longer between 91 and 365 days after catheter ablation or initiation of an antiarrhythmic drug. At 1 year, documented recurrence occurred in 42.9% of patients who underwent cryoablation compared with 67.8% in the antiarrhythmic group (hazard ratio 0.48 [95% CI 0.35–0.66]). The occurrence of serious adverse events was similar among the two groups: 3.2% of patients in the cryoablation group and 4.0% of patients in the antiarrhythmic group. The STOP AF First (Cryoballoon Catheter Ablation in Antiarrhythmic Drug Naive Paroxysmal Atrial Fibrillation) trial included 203 adult patients with paroxysmal AFib who had not previously received rhythm-control therapy. They were randomized to treatment with a class I or III antiarrhythmic (n = 99) or cryoballoon ablation (n = 104). The results were similar to those of the EARLY-AF trial. A higher percentage of patients in the cryoballoon ablation group had treatment success, defined as freedom from initial failure of the procedure or atrial arrhythmia recurrence after a 90-day period. The estimated percentage of treatment success at 12 months was 74.6% in the ablation group compared with 45.0% in the drug therapy group. Serious adverse events occurred in 14% of patients in both treatment groups. AFib is common, affecting approximately 0.4% to 1% of the general U.S. population, and recurrence rates are high, especially in individuals who are not receiving preventive treatments. Current guidelines by the American Heart Association/American College of Cardiology/Heart Rhythm Society and European Society of Cardiology have generally recommended the use of antiarrhythmic drugs as initial therapy for maintenance of sinus rhythm in patients with AFib. However, these medications tend to have limited efficacy and substantial adverse effects. Once an initial course of treatment fails, catheter ablation is superior to antiarrhythmic drug therapy for preventing further recurrences of atrial arrhythmias. Results of the EARLY-AF and STOP AF First trials could result in some modifications to these current recommendations, with catheter cryoballoon ablation used as initial management to prevent AFib recurrences in select patients. In his editorial, Marine noted that clinicians should consider the populations included in these trials when applying the data in clinical practice. As in the trials, most patients will need to have normal left ventricular function, normal left atrial size, and few coexisting conditions to be eligible for cryoablation. The results cannot be readily extrapolated to patients with persistent AFib, significant structural heart disease, or substantial coexisting conditions that may reduce the efficacy and safety of ablation. Clinicians will need to discuss with patients the benefits and risks of cryoablation compared with initial use of antiarrhythmic therapy. A shared clinical decision-making approach may be beneficial.

Сравнительный анализ результатов измерения артериального давления автоматическими тонометрами у пациентов с фибрилляцией предсердий

Aim: to specify indications for use of distinct types of blood pressure monitors (mechanical, automatic with arrhythmia detector and upper arm cuff, and automatic with arrhythmia detector and wrist cuff) in patients with atrial fibrillation (AFib). Patients and Methods: 202 patients (mean age 61.8 ± 1.3 years) with paroxysmal AFib of any origin occurred no more than 1 month ago and atrial tachysystole were enrolled. All patients had a history of hypertension of various severity. This study was conducted in three units, i.e., ICU, ED, and therapeutic department. Blood pressure (BP) measurements were performed at 8 a.m., 12 p.m., and 4 p.m. using various types of BP monitors in turn, i.e., mechanical BP monitor (whose readings were considered reference values), automatic BP monitor OMRON M2 BASIC HEM-7121-ALRU (OMRON M2 BASIC) with upper arm cuff, automatic BP monitor OMRON RS2 HEM-6121-Ru (OMRON RS2) with wrist cuff, and automatic BP monitors of other manufacturers with upper arm cuff (B1 and A1) or wrist cuff (B2 and A2). Results: in patients with AFib of any severity, BP readings measured by automatic BP monitors OMRON M2 BASIC and OMRON RS2 demonstrate no significant differences compared to BP readings measured by mechanical BP monitor. Meanwhile, BP readings measured by BP monitors of other manufacturers (A1, A2, B1, and B2) were significantly different from reference values. The more severe was arrhythmia, the more significant the differences were. Conclusions: automatic BP monitors OMRON M2 BASIC and OMRON RS2 that provide as accurate as possible BP readings can be recommended for measuring BP in patients with AFib of any severity in ED, outpatient wards, and at home (self-control). KEYWORDS: hypertension, atrial fibrillation, blood pressure measurement, blood pressure variability, blood pressure monitor. FOR CITATION: Vertkin A.L., Sycheva A.S., Kebina A.L. et al. Measurement of blood pressure using automatic monitors in patients with atrial fibrillation: a comparative analysis. Russian Medical Inquiry. 2021;5(4):189–195 (in Russ.). DOI: 10.32364/2587-6821-2021-5-4-189-195.

Abstract 12785: The American College of Cardiology's NCDR Afib Ablation Registry: A Summary of Initial Data Including Patient Characteristics, Procedural Characteristics, and Adverse Events

Introduction: The American College of Cardiology developed the National Cardiovascular Data Registry (NCDR) AFib Ablation Registry to assess prevalence, demographics, procedural management and outcomes of patients undergoing atrial fibrillation (AFib) ablation procedures. The objective of this registry’s first presentation is to summarize initial AFib Ablation Registry data regarding patient characteristics, procedural characteristics, and in-hospital adverse events and outcomes in those undergoing AFib ablation enrolled in the registry. Methods: Data were tabulated and summarized with simple proportions for categorical data, and mean ± standard deviation for continuous data. Results: A total of 31,345 patients who underwent AFib ablation were included in the registry (mean age 65.0 ± 10.4, 65.2% male, 57.6% paroxysmal AFib), with ablations performed at 120 hospitals, by 501 physicians. The mean CHA2DS2-VASc score of was 2.6 ± 1.6, and mean HAS-BLED score was 1.1 ± 0.9. Successful pulmonary vein isolation was able to be achieved in all veins in 94.5% of patients. The prevalence of any complication during procedural admission was 3.1%; the most common were hematoma (0.5%) and pericardial effusion requiring intervention (0.42%). The mean length of stay during the index admission (days) was 1.4 ± 7.6, and in-hospital death prevalence was 0.04% [FIGURE] . Conclusions: In conclusion, the NCDR AFib Ablation Registry is a large, national, multi-center, prospective cohort study to describe events outside the clinical trial or research setting, demonstrating successful pulmonary vein isolation in the majority of patients and a low prevalence of adverse events. Future studies from the registry will be able to help support and develop evidence-based guidelines for AFib ablation treatment and optimize patient outcomes.

Abstract 13318: Omega-3 Ethyl Esters and Atrial Fibrillation or Flutter in Patients With Coronary Artery Disease: Results From a Randomized Trial

Introduction: Statins have led to significant reductions in cardiovascular disease (CVD) events; however, a high level of residual cardiovascular risk remains. The REDUCE-IT trial showed additional benefit with icosapent ethyl to statins in reducing CVD morbidity and mortality. However, the safety of omega-3 ethyl esters with regards to atrial fibrillation (Afib) in patients with coronary artery disease (CAD) remains unclear. Hypothesis: We hypothesize that omega-3 ethyl esters may influence the risk of Afib or flutter in patients with CAD. Methods: In total, 285 CAD patients on statins were randomized to high dose omega-3 ethyl esters (1.86 g of Eicosapentaenoic acid [EPA] and 1.5 g of Docosahexaenoic acid [DHA]) or no omega-3 for 30 months. The incidence and recurrence of Afib or flutter was compared in those on EPA/DHA plus statin to statin alone (control). Results: A total of 240 patients were included in the analysis and no difference in baseline characteristics was observed (Table A). In total, 19 patients were in Afib or flutter during the trial: 12 in EPA/DHA and 7 in control (9.5% vs. 6.1%, respectively, p=0.33). The incidence of new onset Afib or flutter within 30 months was 7.2% and 4.9% in patients receiving omega-3 ethyl esters compared to controls, respectively (p=0.48). No significant difference in recurrence of Afib occurred among patients with a history of paroxysmal Afib receiving omega-3 ethyl esters compared to control (26.7% vs. 16.7%, respectively, p=0.53) (Table B). Conclusions: EPA/DHA did not increase the incidence of Afib or flutter in patients with established CAD. Further studies are warranted to better understand the effects of omega-3 ethyl esters on the cardiac conduction system.

P421Efficacy of radiofrequency ablation and drug therapy of atrial fibrillation in patients with heart failure

Abstract Objective to compare the efficacy of radiofrequency ablation (RFA) and drug therapy in patients with atrial fibrillation (AFib) and heart failure (HF) within 12-month follow-up. Materials and methods 130 patients (men-75%, average age-62.8 ± 11.8 years) with AFib and HF with left ventricular ejection fraction (LVEF)&amp;lt;50% were included in a prospective study. In 107 (82%) of the included patients, intermediate LVEF was detected (40-49%). At the time of inclusion, paroxysmal AFib (PaAFib) was recorded in 60 (46%) of patients and persistent AFib (PeAFib) in 70 (54%). AFib RFA was performed in 65 patients, 65 patients continued to receive optimal antiarrhythmic therapy. Prior to the intervention and after 12 months, all patients underwent transthoracic echocardiography and quality of life (QoL) assessment using the SF-36 questionnaire. Results the freedom from AFib within 12 months follow-up period was registred in 49 (75%) of patients in the RFA group and 26 (40%) in the drug therapy group. After 12 month follow-up period we revealed increase of LVEF (p &amp;lt; 0.001), decrease of anteroposterior size (p &amp;lt;0.001) and volume (p &amp;lt; 0.001) of left atrium (LA), improvement of mental (p = 0.008) and physical (p = 0.048) health components according to the SF-36 questionnaire in the RFA group. In the group of drug rhythm control, after 12 months there was only the improvement of mental (p = 0.006) and physical p = 0.016) health components and it was much less than in RFA group (р&amp;lt;0.001). Similar results were received in patients who were free from Afib within 12 months in both groups. Conclusions in patients with AFib and HF with LVEF &amp;lt; 50%, restoration and maintenance of sinus rhythm using RFA was accompanied by an increase in LVEF, decrease of LA size, and an improvement of QoL. In the group of drug therapy, there was a lower freedom from AFib and there was the slight improvement only in QoL.

P1407Efficacy of radiofrequency ablation of paroxysmal and persistent atrial fibrillation in heart failure patients

Abstract Background radiofrequency ablation (RFA) is considered to be one of the most preferred treatments for atrial fibrillation (AFib) in patients with heart failure (HF). Objective to study the effectiveness of AFib RFA in patients with HF, to compare the effectiveness of the procedure in patients with paroxysmal (PaAFib) and persistent (PeAFib) AFib. Materials and methods 65 patients with AF and HF with LVEF &amp;lt; 50%, who underwent RFA were included in a prospective study. All patients underwent transthoracic echocardiography and quality of life assessment using the SF-36 questionnaire before RFA and after 12 months. AFib was recorded in 42 (65%) of patients, AFL in 23 (35%). Thirty (46%) patients had PaAfib (Group 1), and 35 (54%) PeAFib (Group 2). Results In 45 (69%) patients sinus rhythm (SR) was restored during RFA, in 15 (23%) SR was restored by electrical cardioversion. In 5 (8%) patients with PaAFib revealed SR at the time of RFA. Twelve month follow-up period revealed 49 (75%) patients who were free from AFib: 23 (77%) patients with PaAFib and 26 (74%) with PeAFib. After 12 month follow-up we revealed the improvement in LVEF (p &amp;lt; 0.001 in both groups), decrease of anteroposterior size of left atrium (LA) (p &amp;lt; 0.001 in both groups) and LA volume (p &amp;lt; 0.001 in both groups), improvement in the mental (p = 0.008 in Group 1; p = 0.006 in Group 2) and physical component of health according to the SF-36 questionnaire (p = 0.036 in Group 1; p = 0.049 in Group 2). There were no significant differences between two groups of follow-up period. Conclusions AFib RFA significantly improves the course of heart failure and the quality of life of patients, leads to decrease of left atrium size and increase of LVEF. The effectiveness of RFA does not depend on the type of arrhythmia in HF patients.