Permanent Atrial Fibrillation Research Articles

Left Atrium Reverse Remodeling in Fusion CRT Pacing: Implications in Cardiac Resynchronization Response and Atrial Fibrillation Incidence.

Background: When compared to biventricular pacing, fusion CRT pacing was linked to a decreased incidence of atrial fibrillation (AF). There is a gap in the knowledge regarding exclusive fusion CRT without interference with RV pacing, and all the current data are based on populations of patients with intermittent fusion pacing. Purpose: To assess left atrium remodeling and AF incidence in a real-life population of permanent fusion CRT-P. Methods: Retrospective data were analyzed from a cohort of patients with exclusive fusion CRT-P. Device interrogation, exercise testing, transthoracic echocardiography (TE), and customized medication optimization were all part of the six-monthly individual follow-up. Results: Study population: 73 patients (38 males) with non-ischemic dilated cardiomyopathy aged 63.7 ± 9.3 y.o. Baseline characteristic: QRS 159.8 ± 18.2 ms; EF 27.9 ± 5.1%; mitral regurgitation was severe in 38% of patients, moderate in 47% of patients, and mild in 15% of patients; 43% had type III diastolic dysfunction (DD), 49% had type II DD, 8% had type I DD. Average follow-up was 6.4 years ± 27 months: 93% of patients were responders (including 31% super-responders); EF increased to 40.4 ± 8.5%; mitral regurgitation decreased in 69% of patients; diastolic profile improved in 64% of patients. Paroxysmal and persistent AF incidence was 11%, with only 2% of patients developing permanent AF. Regarding LA volume, statistically significant LA reverse remodeling was observed. Conclusions: Exclusive fusion CRT-P was associated with important LA reverse remodeling and a low incidence of AF.

Reduced FNDC5-AMPK signaling in diabetic atrium increases the susceptibility of atrial fibrillation by impairing mitochondrial dynamics and activating NLRP3 inflammasome

Fibronectin type III domain-containing protein 5 (FNDC5) exerts potential anti-arrhythmic effects. However, the function and mechanism of FNDC5 in diabetes-associated atrial fibrillation (AF) remain unknown. In this study, bioinformatics analysis, in vivo and in vitro experiments were conducted to explore the alteration and role of FNDC5 in diabetes-related atrial remodeling and AF susceptibility. RNA sequencing data from atrial samples of permanent AF patients and diabetic mice exhibited significantly decreased FNDC5 at the transcriptional level, which was in line with the protein expression in diabetic mice as well as high glucose and palmitic acid (HG+PA) injured atrial myocytes. Diabetic mice exhibited adverse atrial remodeling and increased AF inducibility. Moreover, reduced atrial FNDC5 was accompanied with exacerbated NOD-like receptor pyrin domain containing 3 (NLRP3) activation and disturbed mitochondrial fission and fusion processes, as evidenced by decreased expressions of optic atrophy 1 (OPA-1), mitofusin (MFN-1, MFN-2) and increased phosphorylation of dynamin-related protein 1 (Ser616). These effects were validated in HG+PA-treated atrial myocytes. Critically, FNDC5 overexpression remarkably enhanced cellular antioxidant capacity by upregulating the expressions of superoxide dismutase (SOD1, SOD2) level. In addition, HG+PA-induced mitochondrial dysfunction was ameliorated by FNDC5 overexpression as evidenced by improved mitochondrial dynamics and membrane potential. Moreover, NLRP3 inflammasome-mediated inflammation was reduced by FNDC5 overexpression, and AMPK signaling might serve as the key down-stream effector. The present study demonstrated that reduced atrial FNDC5-AMPK signaling contributed to the pathogenesis of diabetes- associated AF by impairing mitochondrial dynamics and activating the NLRP3 inflammasome. These findings provide promising therapeutic avenues for diabetes-associated AF.

La fibrillation atriale à l'Hôpital Principal de Dakar au Sénégal : résultats et limites de la prise en charge

ObjectivesThe aim of the study was to determine the prevalence of AF in the cardiology department of the Hospital Principal of Dakar, then to evaluate the clinical, paraclinical, etiological and evolutionary profiles of AF and finally to identify the limits of its management in our context. Patients and methodsThis was a retrospective, descriptive, analytical, mono-centric study carried out at Hospital Principal of Dakar from January 2019 to August 2021. Were included, all patients admitted for atrial fibrillation, or patients who presented an atrial fibrillation during hospitalization, confirmed by electrocardiogram or long-term electrocardiographic recording during the study period. ResultsThe prevalence of atrial fibrillation during the period of our study compared to the hospital population was 7.71%, with a sex ratio of 1.03. The mean age was 67.88 ± 14.09 years. We noted that 83.64% of patients had at least one cardiovascular risk factor, with 56.36% suffering from hypertension, 50.91% of sedentary person and 23.64% of diabetics. Clinically, 92.72% of the patients were symptomatic, with dyspnea predominating (70.91%). Cardiac arrhythmia was present in 85.45% of patients, and congestive heart failure in 47.27%. Long-term electrocardiographic recording was performed in 10 patients, showing 50% of paroxysmal atrial fibrillation. Sixty-three patients (57.27%) had permanent AF, twenty-three patients (20.91%) had persistent AF, fourteen patients (12.73%) had long-term persistent AF and ten patients (9.09%) had paroxysmal AF. Transthoracic echocardiography showed 57.27% of left atrial dilatation and 72.3% of reduced left ventricular ejection fraction. Etiologies for cardiac causes were dominated by dilated cardiomyopathy (21.82%), followed by ischemic heart disease (17.27%). In terms of treatment, the most commonly used molecule was bisoprolol (38.18%), followed by digoxin (21.81%). Anticoagulants were used in 85.46% of cases. Acenocoumarol alone was used in 69.09% of patients. Drug-induced cardioversion was attempted in 2 patients without success, and 4 patients benefited from external electric shock with 3 successes. Most patients had a favorable outcome, but 34.54% suffered hemodynamic complications (18.18%) and thromboembolic ones as well (16.36%). In-hospital mortality in our series was 20%. It was significantly related to heart failure, with a left ventricular ejection fraction < 35% (p < 0.001). ConclusionAtrial fibrillation is serious because of its hemodynamic, thromboembolic and rhythmic complications. The high mortality is explained by the underlying condition, but also by the delay in management with late diagnosis and, above all, the unavailability of ablation procedures in our context.

Comparison of Conventionally Performed and Intracardiac Echocardiography Guided Catheter Ablation of Atrioventricular Node in Patients with Permanent Atrial Fibrillation-A Retrospective Single-Center Study.

Background: Atrioventricular node (AVN) ablation is an effective treatment for atrial fibrillation (AF) with uncontrolled ventricular rates despite maximal pharmacological treatment. Intracardiac echocardiography (ICE) can help with visualizing structures, positioning catheters, and guiding the ablation procedure. We compared only fluoroscopy-guided and ICE-guided AVN ablation regarding patients with permanent AF. Methods: Sixty-two consecutive patients underwent AVN ablation were enrolled in our retrospective single-center study (ICE group: 28 patients, Standard group: 34 patients). Procedural data, acute and long-term success rate, and complications were analyzed. Results: ICE guidance for AVN ablation significantly reduced fluoroscopy time (0.30 [0.06; 0.85] min vs. 7.95 [3.23; 6.59] min, p < 0.01), first-to-last ablation time (4 [2; 16.3] min vs. 26.5 [2.3; 72.5] min, p = 0.02), and in-procedure time (40 [34; 55] min vs. 60 [45; 110], p = 0.02). There was no difference in either the total ablation time (199 [91; 436] s vs. 294 [110; 659] s, p = 0.22) or in total ablation energy (8272 [4004; 14,651] J vs. 6065 [2708; 16,406] J, p = 0.28). The acute success rate was similar (ICE: 100% vs. Standard: 94%, p = 0.49) between the groups. Conclusions: In our retrospective trial, ICE-guided AVN ablation reduced fluoroscopy time, procedure time, and first-to-last ablation time. There was no difference in ablation time, total ablation energy, acute and long-term success, and complication rate.

Delayed diagnosis and missed opportunities in the early detection of atrial fibrillation: a cross-sectional study

IntroductionWe analysed the frequency of atrial fibrillation (AF) delayed diagnosis and the factors associated with it in newly diagnosed patients. MethodsThis was a descriptive, cross-sectional, multicentre study. Data were collected from newly diagnosed patients with AF through medical records review and interviews during cardiology, internal medicine, primary care and emergency department consultations in Spain. ResultsA total of 201 physicians participated in the study (64.2% cardiologists, 21.4% internists). 948 patients (58% men; mean age 72.8 years) were included. In 41.8% of patients, AF was classified as paroxysmal at diagnosis, 30.9% as persistent and 27.3% as permanent. The diagnosis was coincidental in 37%. It was considered that a delayed diagnosis occurred in 49.3% of patients. This delay was associated with the presence of permanent or persistent AF, older age or valvular disease. 74.8% of patients had some contact with the healthcare system in the preceding year. The diagnosis could have been established between 1 and 6 months earlier in 50.7% of cases and more than six months earlier in 20.1%. 54.4% of the patients had experienced AF compatible symptomatology previously. Of these, 32.6% had a consultation without a diagnosis. ConclusionsIn a significant proportion of AF cases, there is a diagnostic delay. Many people with compatible symptoms neither seek consultations nor contact the healthcare system facilities. Consequently, the opportunity for early diagnosis is lost.

Association of Atrial Fibrillation Burden and Mortality Among Patients With Cardiac Implantable Electronic Devices.

Current estimates of atrial fibrillation (AF)-associated mortality rely on claims- or clinical-derived diagnoses of AF, limit AF to a binary entity, or are confounded by comorbidities. The objective of the present study is to assess the association between device-recognized AF and mortality among patients with cardiac implantable electronic devices capable of sensitive and continuous atrial arrhythmia detection. Secondary outcomes include relative mortality among cohorts with no AF, paroxysmal AF, persistent AF, and permanent AF. Using the deidentified Optum Clinformatics US claims database (2015 to 2020) linked to the Medtronic CareLink database, we identified individuals with a cardiac implantable electronic device who transmitted data ≥6 months after implantation. AF burden was assessed during the first 6 months after implantation (baseline period). Subsequent mortality, assessed from claims data, was compared between patients with and without AF, with adjustment for age, geographic region, insurance type, Charlson Comorbidity Index, and implantation year. Of 21 391 patients (age, 72.9±10.9 years; 56.3% male) analyzed, 7798 (36.5%) had device-recognized AF. During a mean of 22.4±12.9 months (median, 20.1 [12.8-29.7] months) of follow-up, the overall incidence of mortality was 13.5%. Patients with AF had higher adjusted all-cause mortality than patients without AF (hazard ratio, 1.29 [95% CI, 1.20-1.39]; P<0.001). Among those with AF, patients with nonparoxysmal AF had the greatest risk of mortality (persistent AF versus paroxysmal AF: hazard ratio, 1.36 [95% CI, 1.18-1.58]; P<.001; permanent AF versus paroxysmal AF: hazard ratio, 1.23 [95% CI, 1.14-1.34]; P<.001). After adjustment for potential confounding factors, the presence of AF was associated with higher mortality in our cohort of patients with cardiac implantable electronic devices. Among those with AF, nonparoxysmal AF was associated with the greatest risk of mortality.

Echocardiographic parameters and Galectin-3 in patients with atrial fibrillation as a marker of left atrial fibrosis

Abstract Background Atrial fibrillation (AF) is the most common type of sustained arrhythmia in clinical practice. Many cardiovascular nursing studies incorporate markers into the design and conduct of the study. Biochemical markers and imaging tests have been used with the aim of stratifying the risk and detecting atrial fibrosis. Speckle-tracking echocardiography (STE) is used for the detection of atrial fibrosis and Gal-3 provides an important prognostic value. The objective of the study was to assess the association between atrial fibrosis markers and serum levels and genic expression of galectin-3. Methods Two hundred and six patients with permanent AF and 70 patients with paroxysmal AF were included in the study. Serum levels of Gal-3 were determined by ELISA and STE was performed to assess fibrosis. Results Mean age of individuals with permanent AF was 66.56±12 years. With regard to echocardiographic parameters, the alterations that occur mainly in the permanent AF group when compared to the paroxysmal AF group are noteworthy, namely LA diameter (46.49±7.68 vs. 41±5.85, p=0.007), LA volume (106.5±41.64 vs. 79; P25: 54.7, P75: 97, p=0.02), and LA volume indexed to body surface area (51.29; P25: 39.9, P75: 78.1 vs. 41.55; P25: 28; P75: 54.9, p=0.04), in addition to the peak atrial longitudinal strain values (PALS) (10; P25: 7.2, P75: 12.4 vs. 16.3; P25: 8.1, P75: 21.2, p=0.002). When we compared the Gal-3 mRNA expression with the types of AF, there was no association (p=0.95). Serum levels of Gal-3 were assessed and compared to the parameter LA strain (PALS). The Spearman and Pearson correlations were evaluated in both groups and the group with permanent AF was correlated with serum levels of Gal-3 (r=0.24; p=0.01). The lower is the Gal-3 serum levels, the lower is the LA strain. Other comparisons presented no statistically significant correlation. Conclusions The integration of markers in cardiovascular nursing studies unfolds as a complex journey from the initial study design to the reporting phase, researchers may be intricately involved in all of these steps. The present study assessed the association between echocardiographic parameters that are suggestive of atrial fibrosis and coding for galectin-3, as well as its genic expression and serum levels in patients with atrial fibrillation. In this way, the use biomarkers can be incorporated into care practice as a tool for assessment and care planning.

Gender related incidence of frailty syndrome occurrence in patients with atrial fibrillation

Abstract Introduction Atrial fibrillation (AF) is one of the biggest challenges associated with the treatment of cardiovascular diseases in modern countries. On the other hand frailty syndrome is one of the main problems of modern gerontology and is also an indicator of a poor prognosis. The exact relationship between frailty syndrome and AF is still the subject of research. The aim of the study was to evaluate the relationship between the gender of patients with AF and the presence of frailty syndrome. Methods 132 consecutive patients over 60 years (58 women; 72,71 ± 6,73) of age with diagnosed atrial fibrillation were included. In all patients occurrence of frailty syndrome using the Tilburg Frailty Indicator scale (TFI) was analyzed. Having 5 or more points indicates that a patient has frailty syndrome. AF was also divided into types according to modified ESC guidelines: paroxysmal (first diagnosed AF + paroxysmal AF); persistent AF and permanent AF (long-standing persistent AF + permanent AF). Results Frailty syndrome was diagnosed in 59,85% of patients with atrial fibrillation, including 47,95% of men and 81,49% of women, p = 0,0002. The mean point value of the frailty syndrome was 5,31 ± 2,69. Women had a greater severity of frailty syndrome in general and in the physical and social domain – exact results are presented in the table below. Regardless of the type of atrial fibrillation, frailty syndrome was more common syndrome in women: persistent AF: 7,64 ± 2,53 vs 5,28 ± 2,39; p = 0,0226 paroxysmal AF: 6,18 ± 2,63 vs 3,88 ± 2,47; p = 0,0465, permanent AF: 5,52 ± 2,58 vs 3,86 ± 1,77; p = 0,0324. Conclusions Frailty syndrome is more common among women what can suggest worst prognosis. Existing of frailty syndrome was independently from the type of AF.

Atrial fibrillation burden: a new outcome predictor and therapeutic target.

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is not a dichotomous disease trait. Technological innovations enable long-term rhythm monitoring in many patients and can estimate AF burden. These technologies are already used to detect and monitor AF. This review describes the relation between AF burden and outcomes and potential effects of AF burden reduction. A lower AF burden is associated with a lower risk of stroke and heart failure in patients with AF: stroke risk without anticoagulation is lower in patients with device-detected AF and a low AF burden (stroke rate 1%/year) than in patients with persistent and permanent AF (stroke rate 3%/year). Paroxysmal AF shows intermediate stroke rates (2%/year). Atrial fibrillation burden-reducing interventions can reduce cardiovascular outcomes in patients with AF: early rhythm control reduces cardiovascular events including stroke and heart failure in patients with recently diagnosed AF and cardiovascular conditions. In patients with heart failure and AF, early rhythm control and AF ablation, interventions that reduce AF burden, reduce mortality and heart failure events. Recent technological innovations allow to estimate AF burden in clinical care, creating opportunities and challenges. While evidence remains limited, the existing data already suggest that AF burden reduction could be a therapeutic goal. In addition to anticoagulation and treatment of cardiovascular conditions, AF burden reduction emerges as a therapeutic goal. Future research will define the AF burden that constitutes a relevant risk of stroke and heart failure. Technologies quantifying AF burden need careful validation to advance the field.

Consumer wearable devices for evaluation of heart rate control using digoxin versus beta-blockers: the RATE-AF randomized trial

Consumer-grade wearable technology has the potential to support clinical research and patient management. Here, we report results from the RATE-AF trial wearables study, which was designed to compare heart rate in older, multimorbid patients with permanent atrial fibrillation and heart failure who were randomized to treatment with either digoxin or beta-blockers. Heart rate (n = 143,379,796) and physical activity (n = 23,704,307) intervals were obtained from 53 participants (mean age 75.6 years (s.d. 8.4), 40% women) using a wrist-worn wearable linked to a smartphone for 20 weeks. Heart rates in participants treated with digoxin versus beta-blockers were not significantly different (regression coefficient 1.22 (95% confidence interval (CI) −2.82 to 5.27; P = 0.55); adjusted 0.66 (95% CI −3.45 to 4.77; P = 0.75)). No difference in heart rate was observed between the two groups of patients after accounting for physical activity (P = 0.74) or patients with high activity levels (≥30,000 steps per week; P = 0.97). Using a convolutional neural network designed to account for missing data, we found that wearable device data could predict New York Heart Association functional class 5 months after baseline assessment similarly to standard clinical measures of electrocardiographic heart rate and 6-minute walk test (F1 score 0.56 (95% CI 0.41 to 0.70) versus 0.55 (95% CI 0.41 to 0.68); P = 0.88 for comparison). The results of this study indicate that digoxin and beta-blockers have equivalent effects on heart rate in atrial fibrillation at rest and on exertion, and suggest that dynamic monitoring of individuals with arrhythmia using wearable technology could be an alternative to in-person assessment. ClinicalTrials.gov identifier: NCT02391337.

Sleep Apnea and Atrial Fibrillation: Clinical Features and Screening Diagnostic Options.

Obstructive sleep apnea (OSA) is associated with an increased risk of hypertension, coronary artery disease, heart failure (HF), and atrial fibrillation (AF). A total of 179 patients aged 34-81 years were included in the study. The median age was 63 years (interquartile range: 56-69 years). Of these patients, 105 (58.7%) were men, and 74 (41.3%) were women; there were cases of paroxysmal (n = 99), persistent (n = 64), and permanent AF (n = 16). All patients underwent investigations including respiratory sleep monitoring, echocardiography, and 24 h Holter electrocardiography monitoring. Statistical analyses were performed using IBM SPSS Statistics 26.0. OSA was detected in 131 (73.2%) patients. In patients with OSA, paroxysmal AF was commonest (n = 65), followed by persistent AF (n = 51) and permanent AF (n = 15). The patients with sleep apnea had increased body mass index (33.6 kg/m2; p = 0.02), waist circumference (114 cm; p < 0.001), and neck circumference (42 cm; p < 0.001) values. HF (OR 2.9; 95% CI: 1.4-5.9; p = 0.004) and type 2 diabetes (OR 3.6; 95% CI: 1.5-8.3; p = 0.001) were more common in patients with AF and OSA. The STOP-BANG scale (AUC = 0.706 ± 0.044; 95% CI: 0.619-0.792; p < 0.001) and the Berlin questionnaire (AUC = 0.699 ± 0.044; 95% CI: 0.614-0.785) had a higher predictive ability for identifying sleep apnea. Patients with AF demonstrate a high prevalence of OSA and an increased association with cardiovascular comorbidities. The STOP-BANG scale and the Berlin questionnaire can be used to screen for OSA in patients with AF.

Ten-year prognosis of acute atrial fibrillation in ST-elevation myocardial infarction: recurrence and risk stroke.

Atrial fibrillation (AF) often complicates ST elevation acute myocardial infarction (STEMI), with associated risks including stroke and mortality. Anticoagulation therapy for these patients and AF prognosis remains controversial. The aim was to evaluate long-term prognosis of STEMI patients complicated with AF in the acute phase. We performed a retrospective analysis on a prospective register involving 4,184 patients admitted for STEMI to the intensive cardiac care unit of 2 tertiary centres from 2007 to 2015. Patients with pre-existing permanent AF were excluded. Out of these, 269 (6.4%) patients developed AF within the first 48 hours after STEMI and were matched with a control group based on age and left ventricular ejection fraction (LVEF). After matching, a total of 470 patients were included (n=235, AF-STEMI; n=235, control group). Mean age 69.0 years, and 31.7% women. No differences were found in gender, cardiovascular risk factors or ischemic heart disease. AF-STEMI patients experienced more sustained ventricular tachycardia, advanced atrioventricular block, heart failure, and cardiogenic shock. In-hospital mortality was also higher in AF-STEMI patients (11.9% vs 7.2%, p=0.008). After 10-years follow-up, the AF-STEMI group had remained with higher mortality (50.5% vs. 36.2%; p=0.003) and a greater recurrence of AF (44.2% vs. 14.7%; p<0.001), without differences in stroke incidence (10.1% vs. 9.3%). As a conclusion, patients with AF complicating STEMI have higher rates of heart failure, cardiogenic shock, and in-hospital mortality. After a 10-year follow-up, they exhibit a high risk of AF recurrence and mortality, with no significant differences in stroke incidence.

Inflammation Burden and Atrial Fibrillation Burden: A Bidirectional Relationship.

Atrial fibrillation (AF) burden is defined as the proportion of time the patient remains in AF over a given period of time; thus, it is theoretically highest in permanent AF and lowest in paroxysmal AF. Inflammation is associated with the initiation and maintenance of AF. However, the relationship between systemic immune-inflammation index (SII) and AF burden is unknown. In the present study, we investigated the relationship between SII and AF burden. The present study is a cross-sectional analysis of 453 patients (252 females and 201 males, aged 44 to 94 years) with AF (138 with paroxysmal AF and 315 with permanent AF) who visited the cardiology outpatient clinic between October 2022 and June 2023. SII was calculated as (neutrophils × platelets/lymphocytes). The predictive role of SII and other inflammatory markers in the likelihood of AF pattern was evaluated by logistic regression analyses, and p value < 0.05 was considered statistically significant. Age, diastolic blood pressure, heart rate, diabetes mellitus, neutrophil, platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, SII, C-reactive protein, red blood cell distribution width, hemoglobin A1c, and left atrial diameter were significantly higher in the permanent AF group. According to the logistic regression analysis, age (p = 0.038), diabetes mellitus (p = 0.024), red blood cell distribution width (p = 0.023), C-reactive protein (p = 0.010), SII (p = 0.001), and left atrial diameter (p < 0.001) significantly contributed to the prediction of the likelihood of permanent AF. SII is independently associated with the AF burden. Prospective studies are needed to determine whether SII may be useful in identifying patients at high risk for AF progression.

Complementary use of conduction system pacing techniques for the “pace and ablate” strategy in permanent atrial fibrillation - a case report

Abstract Introduction The feasibility of the conduction system pacing combined with atrioventricular node ablation was demonstrated in patients with atrial fibrillation in whom rate control can’t be achieved with medication and heart failure. Clinical case We present a case of an 82-year-old man with a personal history of permanent atrial fibrillation, admitted with symptoms of heart failure. The resting electrocardiogram showed a very fast ventricular response, and the echocardiography showed a depressed left ventricular function, raising the suspicion of a tachycardia-mediated cardiomyopathy. Since the patient was on maximum doses of atrioventricular nodal-blocking drugs, we opted for a physiological pacing and atrioventricular node ablation strategy. First, the His bundle capture was achieved at low pacing thresholds, and ablation of the atrioventricular node was attempted. Unfortunately, after several failed attempts, an acute increase in the His bundle capture threshold was noted, suggesting inadvertent tissue ablation beneath the pacing lead. In this scenario, we removed the lead from the His bundle area and achieved optimal left bundle branch area pacing. With the lead in this position, atrioventricular node ablation was performed during the first attempt. At the six-month follow-up, there was no recovery of atrioventricular node conduction. Device interrogation revealed stable pacing and sensing parameters, and there was a significant improvement in clinical status and left ventricular function. Conclusions Mastering both His bundle pacing and left bundle branch area pacing offers the potential to overcome intraprocedural challenges, giving alternative strategies to achieve physiological pacing. These approaches can be used interchangeably based on the evolving dynamics of the procedure and the patient’s specific needs.

The effectiveness of cardiac contractility modulation: results of two-year follow-up

Aim. To evaluate the survival and dynamics of clinical and instrumental data in patients with chronic heart failure (CHF), atrial fibrillation (AF) and cardiac contractility modulation (CCM).Methods. There were included 54 patients (40 men, median age 59.7 [56.6; 63.9] years) with signs of CHF II (n=27, 50%) functional class and III (n=27, 50%) NYHA functional class, significantly decreased left ventricular ejection fraction (LVEF=30 [24,7; 35,5]%), LV dilatation and paroxysmal (n=27, 50%) or permanent (n=27, 50%) AF. In all patients, devices for CCM were implanted. The dynamics of clinical and instrumental parameters were assessed in 2, 6, 12 and 24 months after implantation. The actual survival patients with CCM was compared with the predicted survival calculated using the Seattle model of heart failure and MAGGIC risk score.Results. In 14 (28%) of patients CCM resulted in significantly increased clinical, echocardiographic parameters (increase in LVEF by 15 [11; 20]%, decrease in end-systolic volume by 68,5[37.5;104.5] ml and end-diastolic volume by 44 [30,100] мл), increase in walking distance during 6-minute walking test and decrease of NT-proBNP. The only factor significant for maximal response was non-ischemic etiology of CHF (χ2=4.54, p=0.034). During 2 years 21 (42%) patients died. The all-cause mortality in patients with CCM to the first year of observation was 16%, two-year all-cause mortality - 40%. These figures turned out to be significantly higher than predicted according to the Seattle model (χ2=10.93, p=0.001). The predicted and actual risk of death at 12-month follow-up turned out to be comparable when assessing survival parameters according to the MAGGIC scale. (χ2=2.24, p=0.134).Conclusion. CCM therapy in some patients with CHF of non-ischemic etiology can lead to an improvement of all clinical and instrumental characteristics. At the same time, there is no effect of CCM on the prognosis of patients with CHF. This fact may suggest the need of additional studies with increased number of cases.

Permanent and Persistent Atrial Fibrillations Are Independent Risk Factors of Mortality after Severe COVID-19.

Background: The new coronavirus disease (COVID-19), a pandemic infection caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2), had a deep global influence on morbidity and mortality profiles. Comorbidities, especially cardiovascular diseases, were identified to strongly modify the clinical course of COVID-19. However, the prognostic role of incident or prevalent atrial fibrillation has not been fully explained. The aim of this study was to evaluate the association between atrial fibrillation and outcomes following hospitalization in patients with severe COVID-19. Methods: We analyzed 199 patients (72 female, median age 70 years) with severe COVID-19 hospitalized between November 2020 and February 2021, due to SARS-CoV-2 infection. The study cohort included 68 patients with a history of AF (34 patients with paroxysmal AF, 19 with permanent AF, 15 patients with persistent AF), and 51 patients presented with AF during hospitalization. Results: Overall mortality during 90 days from the admission to hospital was 41% (n = 82). Non-survivors were older, had significantly elevated inflammation markers (CRP, WBC, procalcitonin, IL-6), NT-proBNP and D-dimer on the first day of hospitalization, lower left ventricular ejection fraction and worse kidney function, as compared to those who stayed alive during the follow-up. Among the hospitalized patients with COVID-19, a history of AF and the presence of AF during hospitalization contributed to higher mortality. Patients with permanent and persistent AF were at the highest risk of death. Different presentations of AF (any history of AF, the subtypes of AF-paroxysmal, permanent, persistent-and the presence of AF during hospitalization) were included in multivariate analysis, aiming to identify independent risk factors of death in the study period. We found that AF was related to worse prognosis, and persistent or permanent forms represented an independent predictor of mortality. Conclusions: Different clinical presentations of AF have varying impacts on survival in severe COVID-19. Mortality in hospitalized patients with severe COVID-19 was higher among patients with a history of AF, especially with persistent and permanent types of AF, and with AF present during hospitalization.

Stroke risk assessment in different atrial fibrillation subtypes: CHA2DS2-VASc score and beyond

Abstract Background Patients with atrial fibrillation (AF) have been known to have an inhomogeneous risk of stroke, with several well-documented risk factors including hypertension, history of stroke, and diabetes mellitus that have been incorporated into the CHA2DS2–VASc score to stratify risk levels. Accumulating evidence has suggested that AF subtype, namely persistent AF and paroxysmal AF, also have an impact on stroke development. Purpose This study focused on the impact of AF subtype on stroke risk in a large, long-term follow-up cohort as to provide insight of the impact on ischemic stroke risks. Such findings may play a role in future ischemic stroke risk stratification in selected patients. Methods A total of 7346 AF patients were followed up for 10 years from January 2010 to December 2020 (mean follow-up time 2.74 years). Among these patients, 2460 (33.5%) had persistent or permanent AF (PerAF) and 4886 (66.5%) had paroxysmal AF (PAF). The study evaluated the risk of ischemic stroke between the two groups using Cox models adjusting for all components of the CHA2DS2–VASc score. Analyses were further stratified into the usage of oral anticoagulation (OAC) or no OAC. Results Comparing AF patients based on subtype, it was found that PerAF patients were older, had a higher prevalence of previous stroke, congestive heart failure, PAD, DM, and were more often prescribed anticoagulants. Univariate analysis found patients with PerAF at a higher risk for ischemic stroke (HR 1.262, p&amp;lt;0.001). The results remained significant after multivariate analysis with factors of the CHA2DS2–VASc score (HR 1.234, p&amp;lt;0.001). After stratifying patients according to anticoagulation prescription, PerAF and PAF patients were found to have similar rates of developing ischemic stroke in patients under DOAC. Conclusions Patients with PerAF have a higher risk of stroke during follow-up independent of components of the CHA2DS2VASc score. In patients with OAC use, there was no difference in stroke risk between AF subtypes.Stroke Risk in OAC-naive patientsStroke Risk in OAC-experienced patients

Single-chamber versus dual-chamber pacing: real world data from the German national VIDEO project

Abstract Background Dual-chamber (DC) cardiac pacing is thought to offer a clinical benefit as compared to single-chamber (SC) cardiac pacing. With the introduction of leadless pacers and the recommendation for DC-pacing in sinus node dysfunction, the implantation rates of SC-pacemaker have markedly decreased. However, little is known from real word national healthcare data. The purpose of this VIDEO substudy is to analyze the German national healthcare situation with regards to SC- vs. DC-pacing. Methods German hospitals are obliged to provide a dataset including case data, diagnosis, operational and procedural codes to the Institute for hospital remuneration system (InEK) every year. The VIDEO project aims at analyzing these data to report real world data on patients undergoing Cardiac implantable electronic device (CIED) surgery in Germany. As of now, 22 German centers were contacted by the Institute for Myocardial Infarction Research (IHF). Ten centers provided their data from 2018 to 2023. Datasets from the remaining centers are pending. The project is supported by the German Heart Foundation. Results A total of 12,474 patients (35.6% females, mean age 71.2 ± 14.5 years) underwent CIED surgery at 10 centers in Germany. A SC-pacemaker was implanted in 1071 patients (group A), a DC-pacemaker in 6343 patients (group B) and other CIEDs including defibrillators in the remaining 5060 patients. Only a minority of the surgeries in both groups were revisions. The median patient age in group A was 81 years (IQR 77;85) compared to 78 years (IQR 70;83) in group B. Of the patients receiving a SC-pacemaker only 4.2% were adults between 40-64 years old compared to 13.4% in the DC-pacemaker group. Diabetes mellitus, chronic obstructive pulmonary disease and a heart failure were more common in group A (30.5% vs. 25.1%, 9.0 vs. 6.0%, 53.2% vs. 35.9%, p &amp;lt;0.01). Atrial fibrillation was known in 942/1050 (89.7%) in patients receiving as SC-pacemaker and in 2589/6197 (42.4%) in those with a DC-pacemaker (p &amp;lt; 0.01). The main indication for pacemaker implantation in both groups was atrioventricular block (41.5% vs. 69.5%, p &amp;lt;0.01) followed by sinus node dysfunction (19.7% vs 27.6%, p &amp;lt; 0.01). All patients were treated as inpatients. The median hospital stay in group A was significantly longer than in group B (8.0 (IQR 3.0; 16.0) vs. 6.0 (IQR 2.0; 13.0), p &amp;lt; 0.01). Half of the patients in both groups were treated on an intensive care unit (ICU) (51.7% and 56.6%) with a median ICU stay of 2.8 (IQR 1.1;5.8) in group A and 2.3 (IQR 1.0;10.0) in Group B. The in-hospital mortality was higher in patients receiving a SC-pacemaker (2.6%) as compared to the DC-pacemaker group (1.6%). Conclusion In Germany, single-chamber pacemakers are implanted six times less common than dual-chamber pacemakers. Patients receiving SC-pacemakers are older, more likely to suffer from permanent atrial fibrillation and have a prolonged in-hospital stay.

Acute haemodynamic changes during left atrial appendage closure

Abstract Purpose Left atrial appendage closure (LAAC) presents an alternative treatment for stroke prevention in atrial fibrillation (AF) in patients with contraindication for long-term anticoagulation. However, even in patients in AF, left atrial appendage plays an important role in reservoir function of left atrium. The purpose of this study was to assess acute hemodynamic effects during LAAC. Methods Consecutive patients indicated for LAAC from January 2022 to October 2023 were enrolled. The invasive hemodynamic measurements were done at the beginning of the procedure after transseptal puncture, and at the end from the procedure after device deployment. Following parameters were measured: systolic, and diastolic blood pressure, and pressure in left atrium (LA), all measurements were done at rest and after 3 minute isometric exercise (handgrip). Results Thirty-two patients were included (age 76,2+7,1 yrs, 22 (69%) males, 23 (72%) permanent AF, left ventricular ejection fraction 52+11,8%). No patients experienced moderate/severe mitral insufficiency, the saline intake during procedure was 738 ml. Isometric exercise significantly increased the LA pressure: the LA pressures (rest/exercise) were 13.7+6.7 mmHg/16.7+8.8 mmHg (p=0.003) at the beginning of the procedure, and 17.0+7.3mmHg/20.0+7.3 mmHg (p=0.005) after device deployment. The LA pressure obtained after device deployment (both rest/exercise) were significantly higher compared to values obtained at the beginning of the procedure. (p=0.003). Conclusions LAAC is associated acute increase of both rest and exercise LA pressure. Whether its acute negative effect remains over time needs further investigation.

The use of left bundle branch pacing as a bail-out in case of CRT pacing failure: a case series

Abstract Introduction LBBB pacing has emerged as a novel alternative to CS pacing for cardiac resynchronization therapy in patients with heart failure. Purpose We hereby present a series of four cases wherein the use of LBB pacing, although not initially planned as first choice, was able to overcome a variety of different limitations of traditional CRT pacing. Presentation Patient #1 was an 81-year old man with a history of ischemic HF and AF who was admitted with recurring episodes of sustained ventricular tachycardia (VT) below the detection zone of the CRT-D that had been implanted 11 years ago. Interrogation of the device revealed fracture in the RV lead, intact values of the RV defibrillation coil and inability to capture from an LV lead in an anterior vein. Following initial stabilization the patient underwent successful LBB lead implantation combined with a new RV pace-sense lead as backup due to acceptable but non-optimal LBB lead values attributed to ischemic septal scarring. We were able to retain the previous CRT-D device by relegating the LBB lead to the atrial port and with the use of DDDR programming with custom AV delay values in order to achieve LBB pacing with RV pacing as backup. Patient #2 was a 51-year old man with a history of ischemic HF and permanent AF with a previously implanted CRT-D who was also admitted due to episodes of VT. Device interrogation revealed high threshold of an LV lead located in an anterior vein. The patient underwent supplementary LBB lead implantation which was then connected to the atrial port of the pre-existing CRT-D device, providing primarily LBB pacing with RV pacing backup through the use of custom DDDR programming same as in the previous case. Patient #3 was a 71–year old man with newly-diagnosed ischemic cardiomyopathy and multiple episodes of hemodynamically unstable VT that persisted even after successful reperfusion, necessitating VT ablation. The patient had narrow QRS at baseline and was not eligible for CRT-D, however after medical therapy to suppress ventricular arrhythmias the patient seemed prone to developing LBBB-like QRS widening. The decision was made to proceed with standard ICD implantation and combine a standard defibrillation lead with an LBB lead through the use of a DF1 port, so as to be able to provide LBB pacing as needed in the future. Patient #4 was a 62-year old man with a history of hypertrophic cardiomyopathy and HF with extensive apical scar scheduled for CRT-D implantation. CS venography during implantation revealed a single lateral vein draining the apical LV, lead was implanted but with no capture. An LBB pacing lead was successfully implanted and used instead of the LV lead in the conventional CRT-D set up. Conclusion In this case series we demonstrate that LBB pacing is a viable option as a bail-out in various cases of CRT pacing failure, including both septal scar and hypertrophy, as well as different anatomical substrates and CRT status.LBB pacing characteristics summary