Persistent AFib Research Articles

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.

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.

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.

Recurrence of Arrhythmias after Thoracoscopic MAZE procedure

BACKGROUND: Thoracoscopic version of the MAZE operation alone or in combination with catheter ablation (hybrid approach) has become widespread in the treatment of atrial fibrillation (AFib). However, recurrences of arrhythmias after such operations, in particular recurrence of AFib, remain unresolved problem.
 AIM: The aim of this study was to establish the structure of arrhythmia recurrence in patients with long-standing persistent AFib after primary epicardial ablation using the Dallas lesion set technique, as well as determining the optimal RFA strategy for recurrence.
 METHODS: 138 catheter ablation procedures for 100 patients, who applied with recurrence of various atrial arrhythmias after thoracoscopic MAZE. 34 patients had 2 or more RFA (31 pts 2, 2 pts 3, 1 pts 4).
 RESULTS: After Dallas lesion set thoracoscopic ablation in the structure of recurrences dominated: 1 AFib recurence; 2 incisional left atrial flutter. After the operation, a potential arrhythmogenic substrate remains, which must be fully eliminated by RFA (in addition to ablation the main cause of recurrence). This minimally necessary intervention implies: control and reisolation of the pulmonary veins; control and reisolation of the posterior wall; septal line from the mitral valve to the right superior pulmonary vein with Y-shaped branch to the left superior pulmonary vein; cava-tricuspid isthmus-blockade. This will eliminate and prevent in the future potentially possible incisional arrhythmias in fragmentary scars after thoracoscopic MAZE procedure. The return of AFib represents the most difficult group of patients. Restoration of sinus rhythm in recurrent AFib after epicardial ablation is possible, but may require extensive ablations in both atriums, as a result of repeated procedures, until all potential arrhythmia mechanisms, present in a particular patient, are eliminated.
 CONCLUSIONS: Catheter ablation remains the only method of effective treatment of recurrences after thoracoscopic MAZE procedure. The complexity and multicomponent nature of long-standing AFib causes the frequent need for repeated procedures, especially in cases of recurrence of atrial fibrillation.

Abstract #1402013: Relapse of Graves Disease 15 Years After Hypothyroid Phase with Radioactive Iodine

Permanent Hypothyroidism is the known consequence of Radioactive iodine (RAI) therapy and is one of the widely used therapy for Graves’ disease (GD). Relapse of Graves disease, within a few months is a well-known treatment failure either due to inadequate RAI dosage, rarely Marine-Lenhart syndrome. We present a case of GD which reappeared 15 years after successful RAI therapy, with a hypothyroid phase in the meantime. To the best of our knowledge, this is one of four cases reported with GD relapse after more than ten years, following RAI-induced hypothyroidism. Patient is a 58-year-old Hispanic female with a remote history of GD status post RAI treatment 15 years ago in Mexico. No further details were available at this time. During the interval, patient was treated with levothyroxine, for post-ablative hypothyroidism to date. Patient did well until recently when she presented to ER in Mexico with palpitations and unintentional weight loss of 30 pounds over 3 months. She was diagnosed with new onset Afib and hyperthyroidism. Patient was started on Eliquis and Amiodarone while levothyroxine was discontinued. After one month, Patient presented to the ED, in the USA with persistent Afib. Biochemical assessment of thyroid showed TSH < 0.005 (0.4-4.1 mIU/ml), free T4 > 7.70 (0.93-1.7 ng/dl), Total T3 321 (80-200ng/dl), TSI 20.10 (< 0.54 IU/L). Ultrasound thyroid showed enlarged heterogeneous hyper vascular thyroid gland consistent with Graves' disease. Amiodarone was discontinued since there was a concern for Amiodarone induced Type I thyrotoxicosis. Hence, treatment with beta-blocker and methimazole was initiated. While on Methimazole 30mg/day for 8 weeks, repeat labs showed TSH < 0.005 (0.4-4.1 mIU/ml), free T4 0.97 (0.93-1.7 ng/dl), Total T3 174 (80-200 ng/dl), TSI 10.30 (< 0.54 IU/L). There has been clinical and biochemical improvement. GD recurrence is extremely rare after successful treatment with therapeutic doses of RAI treatment. Once RAI treatment induces hypothyroidism, it is usually irreversible and requires thyroid replacement for life. Our Patient had a true recurrence that relapsed after a prolonged period following the achievement of hypothyroidism. Speculations may refer to the autoimmune nature of GD, in subjects with high elevations of antibody titer, inappropriate dose or non-adherence with levothyroxine, which may also contribute to an enlarged thyroid gland with increased production of endogenous thyroid hormones. As a result, complete ablation fails, and the disease may reoccur. This case illustrates the need for on-going monitoring of GD even after an effective RAI treatment.

PO-03-221 BURDEN OF ARRHYTHMIAS AND CLINICAL OUTCOMES IN PATIENTS WITH DILATED CARDIOMYOPATHY ACCORDING TO LARGE DATASET

Dilated cardiomyopathy (DCM) is characterized by dilation & impaired systolic function of one or both ventricles. Although heart rhythm disorders are associated with DCM, description of their prevalence & clinical outcomes is limited in the literature. Aim of this study was to investigate the burden, basic characteristics, & clinical outcomes of arrhythmias in DCM. We queried the National Inpatient Sample between 2017-2020 for adult patients who were hospitalized with DCM. The primary outcome was inpatient mortality. The secondary outcomes were cardiogenic shock, cardiac arrest, invasive mechanical ventilation, length of stay (LOS) & total hospital cost. Multivariable logistic, linear & Poisson regression analyses were used to estimate clinical outcomes. p-value < 0.05 was significant. There were 875,625 hospitalizations with DCM, of which 402,947 (46.1%) had arrhythmia of any type. Mean age was 64.2 yrs, 57.7% were Caucasian, 66.2% were male. The most prevalent arrhythmia was ventricular tachycardia (VT) 105,810 (12.08%), followed by paroxysmal atrial fibrillation (AFib) 104,330 (11.9%), permanent AFib 77824 (8.8%), persistent AFib 30,810 (3.5%), different degree of atrioventricular block (AVB) 26,644 (3.04%) with complete AVB being the most frequent (1.5%), & sick sinus syndrome 20220 (2.3%). Subgroup with arrhythmia vs without arrhythmia had HTN 6.3% vs 8.2%; PH 19.8% vs 15.5%; HF 89.0% vs 85.9%; HLD 53.3% vs 47.2%; CKD 45.5% vs 39.7%; COPD 28.3% vs 26.9%, respectively. During hospitalization, these subgroups had following complication rates: ACS 12.5% vs 14.1%; AKI 37.6% vs 31.8%; stroke 2.8% vs 3.1%, respectively. Subgroup with arrhythmia was associated with higher ICD (6.1% vs 2.0%), PPM (2.4% vs 0.2%), and LVAD (1.4% vs 0.6%) insertion rate. Subgroup with VT showed worse primary and secondary outcomes, while populations with AFib and AVB showed significant secondary outcomes (Table 1). Significant proportion of DCM patients is affected by arrhythmia (46%), where VT, AFib, AVB, & sick sinus syndrome being the most prevalent. Subgroup with arrhythmia is associated with HF, PH, HLD, CKD, COPD & with increased insertion rates of PPM, ICD, LVAD devices. Moreover, DCM population with different types of arrhythmias showed worse clinical outcomes & had higher resource utilization. This signifies the importance of early detection & treatment of rhythm disorders in DCM population. More research aimed at pathogenesis & long-term outcomes is needed.

ПОШУКОВЕ ДОСЛІДЖЕННЯ ПРЕДИКТОРІВ ПІЗНІХ РЕЦИДИВІВ АРИТМІЇ У ПАЦІЄНТІВ З ПЕРСИСТУЮЧОЮ ФІБРИЛЯЦІЄЮ ПЕРЕДСЕРДЬ ПІСЛЯ КАРДІОВЕРСІЇ

Introduction. The existing guidelines do not contain a clear algorithm for predicting the late recurrences of atrial fibrillation (AFib). Objectives. We have studied the predictors of late recurrence of arrhythmia in patients with persistent AFib after the restoration of sinus rhythm (SR). Research methods. A prospective single-center study included 120 hospitalized patients with persistent AFib who underwent successful cardioversion. The recurrence of AFib was assessed in the early period after cardioversion by recording 12-channel ECG, Holter ECG monitoring and event ECG monitoring. After a nine-month period follow-up visit was performed. Baseline demographic, clinical-functional features and comorbidities were compared in group with (n = 87) and without (n = 33) late recurrences of Afib. Results. There were no differences in demographic, anthropometric data and comorbidities. Patients with late recurrence of AFib had a lower heart rate (HR) after SR recovery (p &lt;0.001). Early recurrences of AFib were found in 43 (49.4%) patients with late recurrences of arrhythmia and only in two (6.0%) without late recurrences (p &lt;0.001). Patients with late recurrences of arrhythmia had a lower average daily HR (p &lt;0.001), a higher number of single atrial extrasystoles (p = 0.001), atrial pairs and runs (p = 0.01) recorded by Holter ECG monitoring. Conclusions. Late recurrences of arrhythmia during the nine-month follow-up period were reported in 72.5% of patients. Groups of patients with and without late recurrence of arrhythmia had significant differences in the incidence of early recurrences, mean HR on SR, and the presence of atrial extrasystoles after rhythm recovery.

Abstract 12646: Cryoablation vs. Radiofrequency Ablation in Persistent AFib: An Updated Meta-Analysis

Introduction: Catheter ablation is recommended for drug-refractory atrial fibrillation (AF). Cryoablation (CBA) has shown to be equivalent to radiofrequency ablation (RFA) in paroxysmal AF. However, there is a paucity of evidence regarding the efficacy and safety of CBA compared to RFA in persistent AF. An updated meta-analysis was conducted comparing CBA to RFA in persistent AF. Methods: A systematic literature review was performed in Embase, PubMed and SCOPUS for all the related articles until May 2021 yielding 112 publications. Eight studies fulfilled inclusion criteria including 1 randomized clinical trial and 7 observational studies. The Mantel- Haenszel random-effects model was used to calculate odds ratio (OR) and 95% confidence intervals (CI). Outcomes analyzed were rate of freedom from atrial arrhythmias, conversion to sinus rhythm during ablation, need for repeat ablation, total complications, vascular injury, phrenic nerve palsy, and cardiac tamponade. Results: CBA was performed in 500 patients and RFA was performed in 533 patients. There was no difference in the rate of freedom from atrial arrhythmias (OR = 1.12, 95% CI [0.87-1.46], P=0.38), need for repeat ablation (OR = 0.73, 95% CI [0.44-1.23], P=0.24), total complications (OR = 1.00, 95% CI [0.56-1.76], P=0.99), vascular injury (OR = 1.06, 95% CI [0.45-2.50], P=0.89), phrenic nerve palsy (OR = 3.09, 95% CI [0.86-11.11], P=0.08) and cardiac tamponade (OR = 0.43, 95% CI [0.11-1.77], P=0.24). The rate of conversion to sinus rhythm during ablation was higher in the CBA arm (OR = 2.33, 95% CI [1.41-3.87], P=0.001). Conclusions: Cryoablation is a safe and effective alternative to RFA in patients with persistent AF.

Molecular Signatures of Human Chronic Atrial Fibrillation in Primary Mitral Regurgitation.

Objectives Transcriptomics of atrial fibrillation (AFib) in the setting of chronic primary mitral regurgitation (MR) remains to be characterized. We aimed to compare the gene expression profiles of patients with degenerative MR in AFib and sinus rhythm (SR) for a clearer picture of AFib pathophysiology. Methods After transcriptomic analysis and bioinformatics (n = 59), differentially expressed genes were defined using 1.5-fold change as the threshold. Additionally, independent datasets from GEO were included as meta-analyses. Results QRT-PCR analysis confirmed that AFib persistence was associated with increased expression molecular changes underlying a transition to heart failure (NPPB, P = 0.002; ANGPTL2, P = 0.002; IGFBP2, P = 0.010), structural remodeling including changes in the extracellular matrix and cellular stress response (COLQ, P = 0.003; COMP, P = 0.028; DHRS9, P = 0.038; CHGB, P = 0.038), and cellular stress response (DNAJA4, P = 0.038). Furthermore, AFib persistence was associated with decreased expression of the targets of structural remodeling (BMP7, P = 0.021) and electrical remodeling (CACNB2, P = 0.035; MCOLN3, P = 0.035) in both left and right atrial samples. The transmission electron microscopic analysis confirmed ultrastructural atrial remodeling and autophagy in human AFib atrial samples. Conclusions Atrial cardiomyocyte remodeling in persistent AFib is closely linked to alterations in gene expression profiles compared to SR in patients with primary MR. Study findings may lead to novel therapeutic targets. This trial is registered with ClinicalTrials.gov identifier: NCT00970034.

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.

Obesity paradox in catheter ablation of atrial fibrillation: analysis of national inpatient sample 2016-2018

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Obesity is a common cardiovascular risk factor and have been associated with favorable outcomes in congestive heart failure, coronary artery disease and atrial fibrillation (Afib), the so-called obesity paradox. Purpose To study the phenomenon of obesity paradox for in-hospital and procedural outcomes in catheter ablation of Afib hospitalizations. Methods We queried January 2016 to December 2018 National Inpatient Sample (NIS) to identify adult (≥18 yrs) hospitalizations with a primary diagnosis of Afib. Patients with appropriate ICD-10 PCS codes for catheter ablation were identified. Obese patients were compared with non-obese patients. We used the Chi-square tests to evaluate the differences between binary or categorical variables, and Student’s t-tests for continuous variables. Multivariate logistic regression was used in outcomes analysis to adjust for potential hospital and patient-level confounders. Results We identified 53,524 weighted catheter ablation of Afib procedural hospitalizations across three years. Of which, 13,335 (25%) of them were associated with obesity. The obese hospitalizations were associated with younger age (mean age 64.0 vs 69.3 yrs; P &amp;lt; 0.01), higher persistent Afib (46.6% vs 37.5%; P &amp;lt; 0.01), higher comorbidity burden (% of &amp;gt;3 Elixhauser comorbidity score 96.8% vs 72.6%; P &amp;lt; 0.01) and had more OSA (43.6% vs 14.7%; P &amp;lt; 0.01). After adjusting for patient and hospital-level characteristics, we observed statistically significant decrease in odds of in-hospital mortality in obese Afib patients undergoing catheter ablation compared to non-obese [Odds Ratio (OR): 0.000004; P &amp;lt; 0.01]. We also observed the obese group had statistically significant association with longer LOS [4.1 vs 3.8 days; P &amp;lt; 0.01], lower total hospitalization charges [US$ 144,882 vs 157,412; P &amp;lt; 0.01] and increased odds of post-operative respiratory failure [OR: 1.97 (1.03 – 3.7); P = 0.04] compared to non-obese group. Conclusion In this large retrospective study of catheter ablation of Afib hospitalizations, higher BMI and obesity was associated with decreased in-hospital mortality consistent with the obesity paradox phenomenon. However, it was associated with longer LOS. The vascular complications and other procedural outcomes except respiratory failure were comparable between both groups. Further prospective studies are necessary to verify our study findings.

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.

S2020 Development of Esophageal Injury Following Radiofrequency Ablation for Atrial Fibrillation

INTRODUCTION: We present a case of esophageal injury following radiofrequency ablation (RFA) for Atrial Fibrillation (Afib) management. Despite being a relatively rare occurrence, this complication can have dire consequences if there is perforation of the esophagus with subsequent fistula formation to the left atrium, also known as Atrioesophageal fistula. Following a recent RFA, our patient’s main complaint was dysphagia with epigastric pain. Due to a high degree of suspicion, we were able to work closely with the Gastroenterology (GI) department in order to determine the most likely etiology of our patient’s symptoms with appropriate management in a timely manner. CASE DESCRIPTION/METHODS: A 77-year-old male with a past medical history of hypertension, ischemic cardiomyopathy and longstanding persistent Afib presented to our hospital for his scheduled inpatient RFA to manage his persistent Afib. The procedure was performed 2 days after admission without any acute complications but the patient began to complain of epigastric pain and odynophagia shortly thereafter. Workup of the patient’s symptoms yielded no significant laboratory values on CBC or CMP. GI was consulted as there was suspicion for esophageal involvement following the patient’s recent ablation procedure. Per GI recommendations, CT- chest with oral contrast was performed and showed no signs of GI tract abnormality. GI eventually performed EGD that showed near-circumferential ulcerations in the esophagus at 30-33cm and this was attributed to the patient’s recent RFA procedure. The patient was started on a clear liquid diet and all of his medications were switched to liquid or Intravenous (IV) route to promote healing. Oral (PO) Carafate and IV Protonix were also started. Repeat EGD performed 8 days later showed near-complete resolution of the patient’s esophageal ulcers. Patient’s diet was steadily advanced until he could tolerate solids and he was eventually discharged with close follow-up with GI as an outpatient. He is currently scheduled to undergo repeat surveillance EGD 4 months after discharge. DISCUSSION: This case is relevant to the fields of both Gastroenterology and Cardiology because it discusses a rare cause of esophageal injury following a routine intracardiac procedure. Atrio-esophageal fistua should be kept on the differential in individuals with a recent RFA, experiencing symptoms of epigastric pain and odynophagia.Figure 1.: Initial EGD showing circumferential ulcers in patient's esophagus.Figure 2.: Repeat EGD performed 8 days later showed near-complete resolution of the patient’s esophageal ulcers (Black arrows). White spots suspected to be secondary to Carafate therapy.

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.

Role of NT-pro BNP Levels as a Marker of Early and Late Recurrence in Patients Submitted to Atrial Fibrillation Ablation with Normal Ventricular Function

BACKGROUND: Levels of NT-pro BNP has diagnostic and prognostic correlation in patients with heart failure. It is also described as a possible marker of atrial myocardial disease in patients with normal ventricular function associated with atrial fibrillation (AFib). Retrospective and prospective studies have shown that their high dosage prior and few months after AF ablation may be a risk factor for recurrence. OBJECTIVE: Determine if in patients submitted to first AFib ablation the previous levels of NT-pro BNP and at 6 and 12 months after the procedure the modification in these levels by the restoring and maintenance of sinus rhythm can identify patients at higher risk of recurrence of atrial tachyarrhythmias. METHODS AND RESULTS: From June 2015 and June 2017 we sequentially began the NT-pro BNP serial dosing in patients with paroxysmal and persistent AFib with preserved ventricular function. Levels were in the previous week, 6 and 12 months after the procedure. We prospectively analyzed 73 patients submitted to first time ablation of atrial fibrillation. In pre-procedure set 33 patients had elevated concentrations. Of these 15 (45.5%) remained elevated with a 40% recurrence rate at 12-months compared to 5.5% for those which normalized the levels. On the other hand, we had 40 patients that we considered normal NT-pro BNP levels before ablation. Of these 15 (37.5%) do not had a descent of more than 50% from baseline levels had recurrence rates of 33.3% at 12 months. The remaining 25 (62.5%) who show drops > 50% of NT-pro BNP recurrence was of only 8%. Patients who had high concentrations of NT-pro BNP or who did not present a significant decrease in these levels were, respectively, 2.25 and 2.28 times more likely to present atrial arrhythmias recurrences after catheter ablation. CONCLUSION: Our data showed that serial levels of NT-pro BNP in patients with atrial fibrillation and normal ejection fraction might identify those at higher risk of recurrence after successful catheter ablation.

SARCOMA METASTASIS CAUSING ATRIAL FIBRILLATION AND REFRACTORY PLEURAL EFFUSION

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Lungs are a primary site for metastasis of sarcomas, however malignant pleural effusion, which indicates a more widespread disease, are much rarer representing only 1-6% of all malignant effusions. We describe a case of a young man with a low-grade pelvic sarcoma that had progressive metastatic lung disease who went on to develop a refractory pleural effusion and new-onset atrial fibrillation CASE PRESENTATION: A 43-year-old male diagnosed with low-grade sarcoma in the pelvis had undergone a left hemipelvectomy. Nine months later he developed metastatic disease and underwent radiation/chemotherapy and eventually Nivolumab trial with no improvement of the disease. The patient then presented three months later with respiratory distress and atrial fibrillation (Afib). A Computed Tomography Scan(CT) of the chest showed increased muscular, bone, lung, and now pleural/ possible pericardial metastases. The CT also showed a large right-sided pleural effusion. The patient underwent thoracentesis with pleural fluid analysis demonstrating an exudative effusion, with cytology showing rare atypical large cells with high nuclear/cytoplasmic ratio consistent with malignant pleural effusion. Echocardiogram showed a new pericardial space mass likely a metastatic deposit. It was felt that mass contributes to persistent Afib. Due to recurrent pleural effusions, the patient received a PleurX catheter. This PleurX catheter initially drained well but later failed to continue to drain fluid and was removed. He later required admission to ICU due to acute hypoxic and hypercapnic respiratory failure. The patient failed to improve with non-invasive ventilation. The family declined intubation and the patient passed away on comfort measures. DISCUSSION: Metastatic pulmonary metastases arise most commonly in patients with malignant fibrous histiocytoma, synovial sarcoma, liposarcoma, & leiomyosarcoma, especially if histology is high grade. Lower grade sarcomas are considered more indolent and lung metastatic rate is lower. In our case, the patient had low-grade sarcoma which makes it more unusual. Complete resection of metastasis, when feasible, is the most important factor in determining post-metastasis survival, with the median survival of 33 months vs median survival of 11 months if resection is not done. This was not able to be done in our patient. When metastasis to the pericardium occurs it is common to see arrhythmias on ECG; the most common being PAC’s, PVC’s, and SVT's such as Afib as in our patient CONCLUSIONS: Metastatic progression of sarcoma to the lung can be managed surgically and with chemotherapy in select patients but prognosis remains poor. Pleural involvement, especially with malignant effusion, portends a very poor prognosis Reference #1: Cates CU, Virmani R, Vaughn WK, et al. Electrocardiographic markers of cardiac metastasis. Am Heart J 1986;112:1297–303. Reference #2: Marulli G, Mammana M, Comacchio G, Rea F. Survival and prognostic factors following pulmonary metastasectomy for sarcoma. J Thorac Dis. 2017;9(Suppl 12):S1305-S1315. Reference #3: Yildirim H1, Metintaş M, Ak G, Dündar E, Erginel S. Soft tissue sarcoma metastatic to pleura. Tuberk Toraks. 2008;56(2):197-200 DISCLOSURES: No relevant relationships by Edward Conuel, source=Web Response No relevant relationships by Lezah McCarthy, source=Web Response No relevant relationships by Kristoffer Neu, source=Web Response No relevant relationships by Raina Patel, source=Web Response No relevant relationships by Muhammad Salick, source=Web Response No relevant relationships by Ali Wazir, source=Web Response No relevant relationships by Robert Wilcott, source=Web Response

1374 Pancreatic Cancer: Leading to Failure of Rivaroxaban as an Anticoagulant

INTRODUCTION: Vascular Thromboembolism (VTE) is seen with hypercoagulable state and it can be a reason of significant morbidity and mortality. Cancer is considered as one of the most common causes of hypercoagulability and developing VTE. Since novel oral anticoagulants (NOAC) have been introduced in market for VTE prophylaxis and treatment, their use have been increased significantly as they are easy to use without episodic monitoring. Rivaroxaban is one of the commonly used NOACs and some of studies have shown its good efficacy for VTE. CASE DESCRIPTION/METHODS: 71 year old female with PMH of persistent A-fib on Rivaroxaban, pulmonary hypertension, HTN, DM-2 who presented to ED with severe pain in both feet. On physical examination, they seemed ischemic with splotchy cyanotic/pallor discoloration on multiple toes of both feet. Patient was already on 20 mg PO daily dose of Rivaroxaban for A-fib which is also prophylactic dose for VTE. Her fibrinogen and D-dimer were elevated at 185 and &gt;5000 respectively. Vascular surgery was consulted and they put patient on heparin drip. CTA Aorta with run off was ordered to find out source of VTE. Unfortunately, CT report showed pancreatic head cancer with metastasis to liver, adrenals and lumber vertebrae which was definitively diagnosed as “Primary Pancreatic Adenocarcinoma” on biopsy. Oncology was consulted and they recommended higher dose of Rivaroxaban 15 mg PO BID on discharge. Still patient came back to ED with worsening of symptoms and pain in both feet due to VTE exacerbation. Patient was then switched to fondaparinux and it helped her from keep getting recurrent VTE exacerbation. DISCUSSION: Traditionally, warfarin and enoxaparin have been used as first-line agents for VTE treatment. Their efficacy have been proven with acceptable risks of bleeding. As enoxaparin needs to be injected and warfarin requires regular monitoring of INR, patients were not complaint with using them. Conversely, NOACs were invented to provide innocuous and more compliant alternative to warfarin and enoxaparin. Rivaroxaban has been most commonly used NOAC for this purpose and some of the studies bolsters its efficacy for VTE. Nonetheless, few case reports are out that don't support Rivaroxaban's effectiveness as a prophylactic agents for preventing VTE. We propose that it still requires more post-marketing research in assessing Rivaroxaban's real efficacy/effectiveness as prophylactic agent for VTE in Pancreatic as well as other cancers.

Comparison of high‐power short‐duration (HPSD) ablation of atrial fibrillation using a contact force‐sensing catheter and conventional technique: Initial results

Atrial fibrillation (AFib) ablation is alternative treatment to drugs. Literature suggests that use of contact force (CF) catheter with higher power for short periods is effective and safe. Retrospectively analyzed 76 patients undergoing the first ablation. Third five patients-group A: 27 (77%) paroxysmal AFib (PAFib) and 8 (23%) persistent AFib (PersAFib) who underwent ablation at the power of 30 W-17 mL/minute flow with a CF of 10-30 g for 30 seconds. Fourty one patients-group B: 28 (68.3%) PAFib and 13 (31.70%) PersAFib underwent ablation using 45 W on posterior wall with CF of 8/15 g, as well as 50-W anterior wall with CF of 10/20 g-35 mL/minute flow for 6 seconds. Pulmonary vein isolation in both groups and ablated. For patients not in the sinus, we performed cardioversion before ablation. No complications. Group A: Left atrial time 110 ± 29 minutes, total 148 ± 33.6 minutes, radiofrequency time (RF) 4558 ± 1998 seconds, X-ray 8.5 ± 3.5 minutes, and elevation of esophageal temperature (ET) in 26 (74.3%). group B: Left atrial time 70.7 ± 18.5 minutes ( P < .00001), total 106 ± 23 minutes ( P < .00001), RF 1909 ± 675.8 seconds ( P < .00001), X-ray 8.8 ± 6.6 minutes ( P = .221) and elevation of ET in 21 (51.20% - P = .0578). In 6 and 12 months follow-up, we had 9 (25.71%) and 11 (31.42%) recurrences in group A and 5 (12.19%) and 7 (17.07%) in group B ( P = .231 at 6 and P = .14 at 12 months), respectively. HPSD was safe, useful, and efficient compared with CT, and reduced procedural time and total RF time. HPSD may reduce esophageal injury because of lower heating rate and it may reduce the recurrence of atrial tachyarrythmias.

Restoration of sinus rhythm does not improve peripheral blood flow in hemodynamically stable patients with atrial fibrillation

Background. Atrial fibrillation (AFib) is the most common atrial tachyarrhythmia with multiple negative hemodynamic consequences. Although there have been many studies on the effects of AFib on cardiac function, very few have focused on changes in peripheral circulation during arrhythmia. Therefore, the aim of the present study was to determine the effect of the reversal of AFib to sinus rhythm (SR) on peripheral blood flow. Material and methods. The forearm blood flow was determined by strain gauge plethysmography (EC 5R, Hokanson, Bellevue, USA) in hemodynamically stable 41 patients aged 63 ± 12 years with paroxysmal or persistent AFib. Venous capacity (VC), venous outflow (VO) and V 0.5–2.0 index, arterial inflow (AI) and fast blood flow (FBF) were measured. 24 patients underwent successful cardioversion. The assessment of peripheral blood flow, BP and HR was performed during arrhythmia and then replicated within 7 day period after restoring of SR. Results. At baseline, plethysmographic parameters, heart rate, systolic and diastolic BP did not differ significantly for patients who underwent successful cardioversion vs. in those who failed to restore SR. Conversion of AFib to SR did not change values of indices characterizing both venous and arterial vessels, values of systolic and diastolic blood pressure, whereas heart rate was significantly reduced. Conclusions. Restoration of sinus rhythm does not improve peripheral blood flow in hemodynamically stable patients with AFib in short term observation.