Periprocedural Atrial Fibrillation Research Articles

Evaluation of efficacy and safety of simplified procedure for the percutaneous closure of patent foramen ovale: the Ile De France Foramen Ovale Permeable(IDFFOP) prospective, multicenter cohort study

Abstract The superiority of device closure over medical therapy for the prevention of recurrent stroke in patients with cryptogenic stroke and patent foramen ovale (PFO) was reported in several meta –analyses of randomized controlled trials. The growing number of PFO procedures requires to find alternatives to conventional guidance by transoesophageal echocardiography (TOE) needing general anesthesia. The aim of our study was to assess prospectively the efficacy and safety of a simplified procedure based on trans thoracic echocardiography (TTE) and local anesthesia rather than TOE during PFO closure. Methods Design and study oversight. The IDFFOP study was a French prospective, multicenter cohort study performed in four centers expert in TTE-guided device deployment. All patients had a stroke history, a PFO and a large or moderate right to left shunt defined by the number of microbubbles in the left atrium ( large shunt > 30, moderate : 10 to 30 microbubbles). A(Risk of Paradoxical Embolism) score>5 was required to confirm PFO imputability in stroke history. The primary end point was efficacy of TTE during the transcatheter PFO closure defined as the successful implantation of the device without malposition, without need of TOE, and absence of significant residual shunt at 3-month TTE control. Safety was defined as the absence of any periprocedural complications. Results 280 patients were enrolled from January 2018 to October 2020 ( male sex : 59.5%; Average age 57 years old ). Average ROPE score was 7; Cumulative immediate procedural success with the TTE-guided method was 99%, without any device embolization. However, in 2 patients, TOE was needed to guide device deployment. There was no severe vascular complication, or any ischaemic event during or after the procedure. 6 post-procedure groin hematomas occurred but none needed anyblood transfusion .One patient experienced a transient periprocedural atrial fibrillation. At 3 months there were only 8 (2,8%) residual right to left shunts (3 large, 5 moderate). Conclusion A simplified procedure for percutaneous PFO closure based on TTE and local anesthesia is safe and effective. Randomized controlled trials should be performed to confirm these results.

Patent foramen ovale closure in non-elderly and elderly patients with cryptogenic stroke: a hospital-based cohort study.

The efficacy of patent foramen ovale (PFO) closure in the elderly population is unclear. We aimed to investigate the efficacy and safety of PFO closure in non-elderly and elderly patients. Patients over 18 years of age with cryptogenic stroke (CS) or transient ischemic attack and PFO were prospectively enrolled and classified into two groups according to treatment: (1) closure of PFO (the PFOC group) and (2) medical treatment alone (the non-PFOC group). The primary outcome was a composite of recurrent cerebral ischemic events and all-cause mortality during the follow-up period. A modified Ranking Scale [mRS] at 180 days was recorded. The safety outcomes were procedure-related adverse events and periprocedural atrial fibrillation. The results between the PFOC and non-PFOC groups in non-elderly (<60 years) and elderly (≥60 years) patients were compared. We enrolled 173 patients, 78 (45%) of whom were elderly. During a mean follow-up of 2.5 years, the incidence of primary outcome was significantly lower in the PFOC group (6.2% vs. 17.1%, hazard ratio[HR] = 0.35, 95% CI 0.13-0.97, p = 0.043) in adjusted Cox regression analysis. Compared with the non-PFOC group, the PFOC group had a numerically lower risk of the primary outcome in both the elderly (HR 0.26, 95% CI 0.07-1.01, p = 0.051) and the non-elderly (HR 0.61, 95% CI 0.11-3.27, p = 0.574) groups. In addition, patients with PFO closure in the elderly group had a lower median mRS at 180 days (p = 0.002). The rate of safety outcome was similar between the non-elderly and elderly groups. PFO closure was associated with a reduced risk of the primary outcome in patients with PFO and CS in our total cohort, which included non-elderly and elderly patients. Compared to those without PFO closure, elderly patients with PFO closure had a better functional outcome at 180 days. PFO closure might be considered in selected elderly patients with PFO.

Abstract TMP103: Acute Ischemic Stroke Readmission In Patients With Periprocedural Atrial Fibrillation

Introduction: Anticoagulation therapy are commonly interrupted in patients with atrial fibrillation (AF) for elective procedures. However, risk factors of subsequent stroke during the periprocedural period is uncertain. We performed a nationwide analysis to evaluate risk factors for acute ischemic stroke (AIS) readmission in patients with AF admitted for elective procedure. Methods: Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmission Database, we included electively admitted adult patients, who had AF diagnosis and procedural Diagnosis-related group code from 2016 to 2019. AF, AIS and other diagnosis were identified based on standard ICD-10 CM codes. Patients who had history of stroke or stroke during the index admission were excluded. We constructed a Cox regression model to determine hazard ratios (HR) of demographic, clinical factors and procedural type associated with AIS readmission. Results: Of the 1,048,422 patients with AF admitted for elective procedure, the mean age was 71.5 and 39.1% were female, and 1625 (0.15%) had AIS readmission within 30 days of discharge. In the adjusted Cox regression model, age (adjusted HR 1.05, 95% CI 1.04-1.06, P &lt; 0.001), female sex (aHR 1.22, 95% CI 1.05-1.41, P = 0.009), cancer (aHR 1.45, 95% CI 1.89-1.76, P &lt; 0.001), congestive heart failure (aHR 1.22, 95% CI 1.03-1.44, P = 0.021), diabetes (aHR 1.33, 95% CI 1.14-1.55, P &lt; 0.001), neurological surgery (aHR 2.27, 95% CI 1.69-3.06, P &lt; 0.001), cardiovascular surgery (aHR 1.59, 95% CI 1.32-1.91, P &lt; 0.001). Furthermore, higher CHADS 2 VASC 2 score (aHR 1.29 by one point, 95% CI 1.22-1.37, P &lt; 0.001) were associated with AIS readmission. Conclusion: AF patients with higher CHADS 2 VASC 2 score and those undergoing cardiac or neurological surgeries are at higher risk of perioperative stroke. Studies are needed to tailor anticoagulation management during the perioperative time to reduce perioperative AIS risk in such patients.

Teaching NeuroImage: Acute Onset Gait Instability and Lateropulsion Secondary to Cerebellar Vermis Stroke.

A 65-year-old woman with hypertension, hyperlipidemia, ascending aortic aneurysm repair and valve replacement, and periprocedural atrial fibrillation (not on anticoagulation) presented with sudden-onset imbalance. The patient was on a treadmill when she experienced acute gait instability without vertigo. She held onto the bars to stay midline; otherwise, she leaned rightward. Examination revealed past-pointing and ataxic gait without dysarthria or nystagmus. Brain MRI demonstrated small superior vermis infarct. MRA revealed no significant stenosis. CTA of the chest showed an increase in known aortic pseudoaneurysm (Figure). Such pseudoaneurysms are not known to form thrombi or become embolic sources; she continued aspirin without anticoagulation. Gait instability and vertigo are common presenting signs of cerebellar infarction1; isolated lateropulsion may be seen in lesions involving the vermis.2

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

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

Thirty-day clinical outcomes after rhythmology procedures in patients with non-valvular atrial fibrillation on apixaban: Results of the AMPER AF study

To evaluate the factors associated with bleeding complications in patients taking apixaban and undergoing a rhythmology procedure in everyday clinical practice. AMPER AF is a multicenter, observational, prospective study of patients with non-valvular atrial fibrillation (AF) undergoing a rhythmology procedure (ablation, pacemaker or implantable cardioverter defibrillator [ICD], or cardioversion). Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥ 3 weeks before the procedure, and were followed for 30 days afterwards. A total of 1013 patients (69 [60,76] years,71% male, mean CHA2DS2-VASc score 1.9 ± 1.4) were enrolled at 25 academic/non-academic centres in France; 842 patients (84.8%) were receiving apixaban 10 mg/day and 171 (15.2%) 5 mg/day.56 patients (5.5%) had a history of stroke. Median weight was 82.7 ± 17.9 kg and mean creatinine clearance (Cockroft − Gault) was 81.8 ± 34 mL/min. 126 (12.43%) patients underwent a pacemaker or ICD implantation, 323 (31.9%) AF ablation, 272 (26.8%) flutter ablation and 278 (27.4%) electric cardioversion. Complication rates at 30 days are shown in Table 1 . Comparing patients with a bleeding event to patients without a bleeding complication revealed a higher rate of heparin or LMWH switching (3.7% vs. 2.2%; P = 0.02) in patients having a bleeding complication in patients undergoing an AF or atrial flutter ablation. This difference remains significant in patients undergoing AF and atrial flutter ablation (60% vs. 35%; P = 0.02). A switch to heparin or LMWH was the only factor associated with an increase rate of bleeding (odds ratio 2.5; [CI 95%; 1.1], 7.1; P = 0.01). These observational data of patients on apixaban undergoing rhythmology procedures in everyday practice show thatheparin or LMWH switch in the periprocedural AF or flutter ablation period is associated with an increased rate of bleeding complications at 30 days.

Heparin and Low-Molecular-Weight Heparin switch associated with an increase in bleeding complications in patients on apixaban undergoing catheter ablation:The AMPER ABLATION Study

The aim of this study was to identify the factors associated with bleeding complications in patients taking apixaban and undergoing a catheter ablation in everyday clinical practice. AMPER ABLATION is a multicenter, observational, prospective study of patients with non-valvular atrial fibrillation (AF) undergoing a catheter ablation. Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥ 3 weeks before the procedure and were followed for 30 days afterwards. A total of 595 patients (65[interquartile range 59, 72] years, 67% male, mean CHA2DS2-VASc score 1.85 ± 1.37) were enrolled at 25 academic/nonacademic centers in France; 524 patients (88%) were receiving apixaban 10 mg/day and 71(12%) 5 mg/day. 323 patients (54%) underwent an AF ablation, and 272 (46%) an atrial flutter (AFL) ablation. Mean creatinine clearance (Cockcroft-Gault) was 82 ± 34 mL/min. Overall, 264 patients were switched to unfractionated heparin or enoxaparin (238 for AF ablations and 26 for AFL ablations). The median duration of switch was 29 hours Complications were reported at 30 days, and included 12 bleeding events (1 tamponade needing drainage,1 pericardial effusion without drainage, 7 International Society on Thrombosis and Haemostasis [ISTH] non major bleedings for AF ablations and 1 pericardial effusion without drainage, and 2 ISTH non-major bleedings for AFL ablations) and 1 embolic event (non disabling stroke for an AF ablation). Comparing patients with and without a bleeding event revealed a higher rate of heparin or low-molecular-weight heparin (LMWH) switching in patients with a bleeding event (60% vs. 35%; P = 0.02). A switch to heparin or LMWH was the only factor associated with an increase rate of bleeding (odds ratio 2.5; [CI 95%; 1.1], 7.1; P = 0.01). Heparin or LMWH switch in the periprocedural AF and AFL-ablation period is associated with an increased rate of bleeding complications at 30 days.

Is ablation to atrial fibrillation termination of persistent atrial fibrillation the end point?: A systematic review and meta-analysis.

Background:The ideal ablation strategy and end point for persistent atrial fibrillation (AF) have not been well founded. Defining periprocedural AF termination as the end point of catheter ablation is still controversial. This meta-analysis aimed to analyze the differences between periprocedural AF termination and non-termination in the long-term AF recurrence rate and postoperative complications.Methods:Randomized controlled trials (RCTs) were identified by a systematic search of electronic databases including PubMed, EMBASE, and Cochrane library from January 2008 to August 2019. The primary outcome was freedom from AF or any atrial arrhythmia without antiarrhythmic drugs at the long-term (≥12 months) follow-up. The secondary outcome was overall postoperative complication rates. The risk ratio (RR) with 95% confidence interval (CI) was pooled for these outcomes. A forest plot, fixed-effects model or random-effect model, Q test, I2 statistic, and Egger funnel plot were used in the statistical analysis.Results:Fourteen RCTs were included in this meta-analysis. Overall, no significant difference was found in freedom from AF at the long-term follow-up between patients in whom AF termination was achieved and not achieved (RR = 0.93, 95% CI = 0.78-1.09, P = .36, I2 = 69%). Patients with AF non-termination had a lower complication occurrence rate than those with AF termination (RR = 1.74, 95% CI = 1.11-2.73, P = .02, I2 = 0%).Conclusion:Our meta-analysis suggests that AF termination is not a reliable procedural end point during ablation of persistent AF.

P1899Heparin and low-molecular-weight heparin switch associated with an increase in bleeding complications in patients on apixaban undergoing catheter ablation: The AMPER ABLATION study

Abstract Background The aim of this study was to identify the factors associated with bleeding complications in patients taking apixaban and undergoing a catheter ablation in everyday clinical practice. Methods AMPER ABLATION is a multicenter, observational, prospective study of patients with non valvular atrial fibrillation (AF) undergoing a catheter ablation. Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥3 weeks before the procedure, and were followed for 30 days afterwards. Results A total of 595 patients (65 [interquartile range 59, 72] years, 67% male, mean CHA2DS2-VASc score 1.85±1.37) were enrolled at 25 academic/nonacademic centers in France; 524 patients (88%) were receiving apixaban 10 mg/day and 71 (12%) 5 mg/day. 323 patients (54%) underwent an AF ablation, and 272 (46%) an atrial flutter (AFL) ablation. The most prevalent concomitant disorders were hypertension (51% of patients), diabetes (15%) and vascular disease (10%). Mean creatinine concentration was 1.06±0.28 mg/dL, median weight was 83±18 kg and mean creatinine clearance (Cockcroft-Gault) was 82±34 mL/min. The management of apixaban in the periprocedural period was left to the investigator's preference. Overall, 264 patients were switched to unfractionated heparin or enoxaparin (238 for AF ablations and 26 for AFL ablations). The median duration of switch was 29 hours. Complications were reported at 30 days, and included 12 bleeding events (1 tamponade needing drainage, 1 pericardial effusion without drainage, 7 International Society on Thrombosis and Haemostasis [ISTH] non major bleedings for AF ablations and 1 pericardial effusion without drainage, and 2 ISTH non major bleedings for AFL ablations) and 1 embolic event (non disabling stroke for an AF ablation). Comparing patients with and without a bleeding event revealed a higher rate of heparin or low-molecular-weight heparin (LMWH) switching in patients with a bleeding event (60% vs 35%; p=0.02). A switch to heparin or LMWH was the only factor associated with an increase rate of bleeding (odds ratio 2.5; [CI 95%; 1.1, 7.1]; p=0.01). Conclusion Heparin or LMWH switch in the periprocedural AF and AFL-ablation period is associated with an increased rate of bleeding complications at 30 days. Acknowledgement/Funding Financial support from BMS

New-onset of postoperative atrial fibrillation is likely to recur in the absence of other triggers.

BackgroundIncident atrial fibrillation (AF) is reported in 10%–65% of patients without previous AF diagnosis after open heart surgery. The risk of late AF recurrence after a postoperative AF onset is unclear, and it is controversial whether AF limited to the postoperative period should elicit oral anticoagulation (OAC) therapy. The primary objective of this study was to evaluate the long-term recurrence of AF in patients developing new-onset peri-procedural AF.Patients and methodsPatients (n=189) with available baseline and follow-up data included in Left Atrial Appendage Closure with Surgery trial were coded for known AF at baseline and for postoperative first-time AF diagnosis. AF occurrence was classified as follows: peri-procedural ≤7 days postoperatively, early >7 days but ≤3 months and late >3 months. Patients with no AF recurrence registered during follow-up were invited to undergo Holter monitoring.ResultsA total of 163 (86.2%) patients had no history of AF. Among these, 80 (49.1%) developed new-onset peri-procedural AF. After a mean follow-up of 3.7±1.6 years, late AF occurred in 35 of the 80 (43.8%) patients who developed peri-procedural AF and in 6 additional patients (7.2%) who remained in sinus rhythm until discharge (hazard ratio [HR] 9.3, 95% CI 3.8–22.4, p<0.001). Patients with peri-procedural AF and early AF had 12.24 times higher risk of late AF (95% CI 4.76–31.45, p<0.001) as compared to the group with no postoperative AF.ConclusionNew-onset of AF after open heart surgery has a high rate of recurrence and should not be regarded as a self-limiting phenomenon secondary to surgery.

Outcomes of patients with periprocedural atrial fibrillation undergoing percutaneous coronary intervention for chronic total occlusion

Successful CTO recanalization has been associated with clinical benefit. Outcomes of patients with atrial fibrillation undergoing CTO PCI have not been investigated, yet. This study sought to evaluate the association between atrial fibrillation and outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Consecutive patients undergoing CTO PCI between January 2005 and December 2013 were divided into patients with and without atrial fibrillation, and propensity-matched models used to adjust for baseline differences between groups. The primary outcome was all-cause mortality at a median follow-up of 3.2 (interquartile range 3.1-4.5) years. Of 2002 patients undergoing CTO PCI, atrial fibrillation was present in 169 (8.4%) patients. Patients with atrial fibrillation were older, and more frequently had hypertension, left ventricular systolic dysfunction, and chronic kidney disease. Before matching, all-cause mortality was 39.6 and 14.5% in the atrial fibrillation and the sinus rhythm groups (HR 2.92, 95% CI 2.23-3.82, p<0.001). In the propensity-matched model, atrial fibrillation remained associated with an increased risk of mortality (HR 1.62, 95% CI 1.06-2.47, p=0.03). In the unmatched patient cohort, all-cause mortality was significantly reduced in patients with procedural success, both in the atrial fibrillation (34.9 versus 55.0%, adjusted HR 0.99, 95% CI 0.97-1.00, p=0.02) and the sinus rhythm groups (12.8 versus 23.0%, adjusted HR 0.70, 95% CI 0.53-0.92, p=0.01). Although atrial fibrillation is independently associated with mortality after CTO PCI, substantial survival benefit of successful CTO recanalization is observed in both patients with and without atrial fibrillation.

Colchicine in cardiac disease: a systematic review and meta-analysis of randomized controlled trials.

BackgroundColchicine has unique anti-inflammatory properties that may be beneficial in various cardiovascular conditions. This systematic review and meta-analysis of randomized controlled trials (RCTs) examines this issue.MethodsWe searched MEDLINE, EMBASE, and the Cochrane Database from inception to June 2014 for RCTs using colchicine in adult patients with cardiac diseases. Results were pooled using random effects.Results15 RCTs (n = 3431 patients, median treatment 3 and follow-up 15 months) were included. All but 2 used colchicine 1 mg/day. In 5 trials, n = 1301) at risk for cardiovascular disease (coronary artery disease, acute coronary syndrome or stroke, post-angioplasty [2 RCTs], or congestive heart failure), colchicine reduced composite cardiovascular outcomes by ~60 % (risk ratio [RR] 0.44, 95 % confidence interval [CI] 0.28-0.69, p = 0.0004; I2 = 0 %) and showed a trend towards lower all-cause mortality (RR 0.50, 95 % CI 0.23-1.08, p = 0.08; I2 = 0 %). In pericarditis or post-cardiotomy, colchicine decreased recurrent pericarditis or post-pericardiotomy syndrome (RR 0.50, 95 % CI 0.41-0.60, p < 0.0001; I2 = 0 %; 8 RCTs, n = 1635), and post-pericardiotomy or ablation induced atrial fibrillation (RR 0.65, 95 % CI 0.51-0.82, p = 0.0003; I2 = 31 %; 4 RCTs, n = 1118). The most common adverse event was diarrhea. Treatment discontinuation overall and due to adverse events (RR 4.34, 95 % CI 1.70-11.07, p = 0.002; I2 = 29 %; 7 RCTs, 83/790 [10.5 %] vs. 11/697 [1.6 %]) was higher in colchicine-assigned patients.ConclusionsCurrent RCT data suggests that colchicine may reduce the composite rate of cardiovascular adverse outcomes in a range of patients with established cardiovascular disease. Furthermore, colchicine reduces rates of recurrent pericarditis, post-pericardiotomy syndrome, and peri-procedural atrial fibrillation following cardiac surgery. Further RCTs evaluating the potential of colchicine for secondary prevention of cardiovascular events would be of interest.

Oral anticoagulant use around the time of atrial fibrillation ablation: a review of the current evidence of individual oral anticoagulant use for periprocedural atrial fibrillation ablation thromboembolic prophylaxis.

Atrial fibrillation is the most common arrhythmia and ablation is becoming more prevalent as a treatment option. Appropriate treatment of atrial fibrillation mandates thromboembolic prophylaxis, and atrial fibrillation ablation periprocedural management of oral anticoagulation is paramount because of the unique susceptibility for thromboembolism that exists for a patient undergoing ablation. Uninterrupted warfarin therapy is the current standard approach for periprocedural atrial fibrillation anticoagulation. Novel oral anticoagulants, including direct thrombin and factor Xa inhibitors, are being used more frequently for thromboembolic prophylaxis in atrial fibrillation patients, but the best strategy for using novel oral anticoagulants in periprocedural anticoagulation is unknown. Optimal periprocedural anticoagulation management strategies with oral anticoagulants, limitations of using novel oral anticoagulants, and future directions in this field are discussed.

Peri-ablation warfarin vs. dabigatran: different but the same

Warfarin has been the traditional oral anticoagulant used to prevent thrombo-embolic events in high-risk patients with atrial fibrillation (AF). The introduction of novel oral anticoagulants (NOACs) for stroke prevention in patients with non-valvular AF represents a major advance in the treatment of these arrhythmias. The NOACs provide an efficacy and safety profile equal to or better than warfarin. 1‐3 For the patient, they provide many advantages, including a rapid onset and offset of action and freedom from frequent blood testing to monitor the anticoagulant effect. Once these NOACs were approved by regulatory agencies, electrophysiologists beganusingthem forthrombo-embolic prophylaxis in patients with non-valvular AF. This promptedthe dilemma of how to manage oral anticoagulation in the peri-procedural AF ablation period, during which patients have an increased risk for thromboembolic events beyond each patient’s intrinsic risk because of prolonged left heart catheterization, the risk of sheath thrombi, and the potential for thrombo-embolic events related to energyapplicationduringtissueablation.Ourgroupwasanearlyadopterofutilizing dabigatran in the peri-ablation period and reported a small observational study suggesting that briefly interrupted dabigatran appeared safe and efficacious. 4 We chose to interrupt dabigatran 36 h preablation in patients with normal renal function because of the lack of an antidote should major bleeding occur during the procedure. Patients were given one dose of enoxaparin 0.5 mg/kg immediately at the end of the procedure, again 12 h later and the dabigatran was resumed the morning after the procedure. We chose to cover patients with enoxaparin in the early hours following the procedure because of reports in the orthopaedic literature that dabigatran was notwellabsorbedfollowingsurgery. 5 Shortlyafterthepublicationof our article, Lakkireddy et al. 6 reported a comparison of dabigatran with uninterrupted warfarin. The dabigatran was held the morning oftheprocedureandresumedshortlypost-procedure.Thispublicationcametotheoppositeconclusionofourstudyandsuggestedthat dabigatran resulted in significantly more thrombo-embolic events and more bleeding than uninterrupted warfarin. In that study, the increased risk of bleeding seemed largely attributable to the near lack of interruption of dabigatran; however, the increased rate of thrombo-embolic events is more difficult to explain. The disparate conclusions of these two early reports on the use of dabigatran in the peri-ablation period sparked the publication of a number of otherstudiescomparingwarfarinwithdabigatranintheperi-ablation period,severalofwhichdirectlycommenteduponthedifferentconclusionsoftheseearlystudiesasjustificationforpublishingmoredata on this subject. ThisissueoftheJournalcontainstwoexcellentmeta-analysesofall currently available studies in the literature comparing warfarin with dabigatranintheperi-ablationperiod. 7,8 Theincludedstudiesutilized bothuninterruptedandinterruptedwarfarintherapyandallthedabigatran studies used a brief period of dabigatran interruption ranging from holding the dabigatran the morning of the procedure to 24‐ 30 h pre-procedure. In general, dabigatran was resumed shortly after the procedure once haemostasis had been achieved. Both meta-analyses found that compared with warfarin, dabigatran had a similar rate of thrombo-embolic events and bleeding complications. These meta-analyses add clarity to the use of dabigatran in the periablation period. It would appear that a very brief period of interrup

Invited Commentary

Although not a surprise for a number of reasons, Motloch and colleagues' [1] finding of an abated risk of periprocedural atrial fibrillation (AF) after transarterial aortic valve implantation (TAVI) is an interesting confirmation. In fact, even though the risk that new AF episodes will develop is much higher after conventional open aortic valve replacement (AVR), recently published evidence shows that central nervous system embolic complications appear to occur much more frequently after endovascular procedures.

Impact of Periprocedural Atrial Fibrillation on Short-Term Clinical Outcomes Following Percutaneous Coronary Intervention

There are few data on the incidence and clinical outcomes of patients with atrial fibrillation (AF) treated in the era of percutaneous coronary intervention (PCI). We analyzed 30-day clinical outcomes in 3,307 consecutive patients with and without AF (sinus rhythm) undergoing PCI from January 2007 through December 2008 enrolled in a multicenter Australian registry. Periprocedural AF was present in 162 patients (4.9%). AF was associated with older age (74.1 ± 8.9 vs 63.9 ± 11.9 years, p <0.001), higher baseline serum creatinine (0.13 ± 0.14 vs 0.10 ± 0.13 mmol/L, p = 0.01), and lower left ventricular ejection fraction (49.5 ± 13.2% vs 53.4% ± 11.6%, p <0.001). Significantly more patients with AF had a history of heart failure and cerebrovascular and peripheral arterial diseases (p ≤0.01 for all comparisons). Periprocedural glycoprotein IIb/IIIa inhibitor (31.5% vs 31.4%, p = 0.98) and antithrombin use were not different between groups, but in-hospital bleeding complications were higher in patients with AF (5.0% vs 2.1%, p = 0.015). Fewer patients with AF received drug-eluting stents (p = 0.004). AF was associated with a greater than fourfold increase in 30-day mortality (9.9% vs 2.2%, p <0.0001) and readmission rates at 30 days (p = 0.01). Fewer patients with AF were on dual antiplatelet therapy at 30 days (86.3% vs 94.3%, p <0.0001), although 28.1% of patients with AF were on triple therapy (dual antiplatelet therapy plus oral anticoagulation). In conclusion, patients with periprocedural AF represent a very high-risk group. Excess 30-day morbidity and mortality after PCI may be due to the higher incidence of co-morbidities, bleeding complications, and suboptimal antiplatelet therapy.

Postprocedural Atrial Fibrillation After Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement

Transcatheter aortic valve implantation (TAVI) represents an alternative option for elderly patients with severe aortic valve stenosis who are denied surgical aortic valve replacement (SAVR) because of high perioperative risk. The impact of TAVI on postprocedural atrial fibrillation is undefined. In a single-center analysis, we assessed clinical data, preoperative risk scores (Society for Thoracic Surgeons score, logistic European System for Cardiac Operative Risk Evaluation), preprocedural electrocardiograms, and 72-hour postprocedural rhythm monitoring of 170 patients undergoing TAVI (n=84) or SAVR (n=86). In a subanalysis, transapical (n=43) and transfemoral TAVI (n=41) were compared. Expectedly, TAVI patients were significantly older, presented with more severe symptoms, had higher Society for Thoracic Surgeons score, higher logistic European System for Cardiac Operative Risk Evaluation score, and revealed more frequently intermittent atrial fibrillation compared with SAVR patients. Despite this more compromised health state, prevalence of postprocedural atrial fibrillation was significantly lower in the TAVI group (6.0%, versus 33.7% after SAVR, p<0.05). More than two thirds of TAVI patients but no SAVR patient with atrial fibrillation in preprocedural electrocardiograms had stable sinus rhythm during 72-hour postprocedural monitoring. Notably, no atrial fibrillation was observed after transfemoral TAVI. Whereas atrial fibrillation onset in the SAVR group predominantly occurred on postoperative day 3, atrial fibrillation onset after transapical TAVI was obtained within the first 24 hours after the intervention. Our results indicate that TAVI, compared with SAVR, reduces the risk of periprocedural atrial fibrillation. Furthermore, preprocedural atrial fibrillation may be converted into sinus rhythm particularly after transfemoral TAVI, suggesting an impact of decreased intracardiac pressures in the absence of adverse periprocedural factors that might promote atrial fibrillation.

Impact of peri-procedural atrial fibrillation (AF) on short-term clinical outcomes following percutaneous coronary intervention (PCI)

Background: Peri-procedural AF may adversely impact on short- and long-term clinical outcomes in patients undergoing PCI owing to the need for dual antiplatelet therapy along with warfarin.