Persistent Atrial Fibrillation Episodes Research Articles

The effectiveness of sinus rhythm restoration in patients with long-term episodes of persistent atrial fibrillation: The association with cardiovascular risk factors and structural heart disease

The effectiveness of sinus rhythm restoration in patients with long-term episodes of persistent atrial fibrillation: The association with cardiovascular risk factors and structural heart disease

Best Practice Guide for Cryoballoon Ablation in Atrial Fibrillation: The Compilation Experience of More than 1000 Procedures

Nowadays, the cryoballoon (CB) constitutes an established alternative to radio frequency (RF) ablation for pulmonary vein isolation (PVI), which offers the possibility to isolate the PVs with a single application. Since the introduction of the second-generation CB, we prospectively collected our data to optimize the procedure on >1000 consecutive patients who underwent CB PVI performed in our center. It is expected that subsequent guidelines will suggest first-line PVI through CB in patients with paroxysmal AF with a class I indication. Indeed, in the long-term follow-up (36 months) of the EARLY-AF trial, CB had a lower incidence of persistent atrial fibrillation episodes compared to the anti-arrhythmic drugs group. We now review the current best practices in an effort to drive consistent outcomes and minimize complications. PV isolation through CB is the most studied single-shot technique for atrial fibrillation ablation, having shown the potential to alter the natural history of the arrhythmia. Several procedural tips and tricks can improve procedural flow and effectiveness. In the present article we provided not only technical details but measurable biophysical parameters that can reliably guide the operator into achieving the best outcome for his patients.

Predictors of sinus rhythm restoration in patients with long-term episodes of persistent atrial fibrillation

The aim – to compare clinical, laboratory and instrumental characteristics of patients with persistent atrial fibrillation (AF) and duration of AF episode ≥ 90 days, undergoing direct current (DC) cardioversion, in groups with or without further sinus rhythm (SR) restoration, for the purpose of determining the predictors of SR restoration.Materials and methods. The cohort single-center study analyzed clinical, laboratory and instrumental data from 115 persistent AF patients with duration of its episode ≥ 90 days, who underwent an elective direct current cardioversion. Patients were subdivided into the groups depending on SR restoration effectiveness: 59 (51.3 %) and 56 (48.7 %) patients with restored and non-restored SR, respectively.Results and discussion. The group of patients with non-effective DC cardioversion was characterized more severe heart failure (HF) and more frequent percutaneous coronary intervention (PCI) cases, as opposed to the group with restored SR. The studied groups differed significantly by the certain echo parameters, characterizing the structure and function of left heart chambers. The transthoracic echocardiography (TTE) revealed a higher left ventricular (LV) dilatation and more frequent pulmonary hypertension (PH) cases in non-restored SR group. According to transesophageal echocardiography (TEE) data, both groups demonstrated the deterioration of left atrial (LA) function, namely the decrease of LA appendage flow velocity ≤ 40 cm/s in more than 60 % of patients. Additionally, the LA spontaneous echo contrast (SEC) was visualized in vast majority of non-restored SR patients (94.6 %). At the same time, only 2 (3.6 %) patients with non-effective DC cardioversion were free from SEC, as compared to 44 (74.6 %) restored SR patients (р < 0.001). The multivariable logistic regression analysis revealed SEC as an independent predictor of SR restoration.Conclusions. Persistent AF patients with duration of its episode ≤ 90 days and non-effective elective DC cardioversion demonstrated higher stage of HF, more frequent demand for PCI, the higher LV dilatation, and presence of PH (TTE) and LA SEC (TEE). Among other associated factors, the freedom from LA SEC appeared to be the only independent predictor of SR restoration in such patients.

Progression of Atrial Fibrillation after Cryoablation or Drug Therapy

BackgroundAtrial fibrillation is a chronic, progressive disorder, and persistent forms of atrial fibrillation are associated with increased risks of thromboembolism and heart failure. Catheter ablation as initial therapy may modify the pathogenic mechanism of atrial fibrillation and alter progression to persistent atrial fibrillation.MethodsWe report the 3-year follow-up of patients with paroxysmal, untreated atrial fibrillation who were enrolled in a trial in which they had been randomly assigned to undergo initial rhythm-control therapy with cryoballoon ablation or to receive antiarrhythmic drug therapy. All the patients had implantable loop recorders placed at the time of trial entry, and evaluation was conducted by means of downloaded daily recordings and in-person visits every 6 months. Data regarding the first episode of persistent atrial fibrillation (lasting ≥7 days or lasting 48 hours to 7 days but requiring cardioversion for termination), recurrent atrial tachyarrhythmia (defined as atrial fibrillation, flutter, or tachycardia lasting ≥30 seconds), the burden of atrial fibrillation (percentage of time in atrial fibrillation), quality-of-life metrics, health care utilization, and safety were collected.ResultsA total of 303 patients were enrolled, with 154 patients assigned to undergo initial rhythm-control therapy with cryoballoon ablation and 149 assigned to receive antiarrhythmic drug therapy. Over 36 months of follow-up, 3 patients (1.9%) in the ablation group had an episode of persistent atrial fibrillation, as compared with 11 patients (7.4%) in the antiarrhythmic drug group (hazard ratio, 0.25; 95% confidence interval [CI], 0.09 to 0.70). Recurrent atrial tachyarrhythmia occurred in 87 patients in the ablation group (56.5%) and in 115 in the antiarrhythmic drug group (77.2%) (hazard ratio, 0.51; 95% CI, 0.38 to 0.67). The median percentage of time in atrial fibrillation was 0.00% (interquartile range, 0.00 to 0.12) in the ablation group and 0.24% (interquartile range, 0.01 to 0.94) in the antiarrhythmic drug group. At 3 years, 8 patients (5.2%) in the ablation group and 25 (16.8%) in the antiarrhythmic drug group had been hospitalized (relative risk, 0.31; 95% CI, 0.14 to 0.66). Serious adverse events occurred in 7 patients (4.5%) in the ablation group and in 15 (10.1%) in the antiarrhythmic drug group.ConclusionsInitial treatment of paroxysmal atrial fibrillation with catheter cryoballoon ablation was associated with a lower incidence of persistent atrial fibrillation or recurrent atrial tachyarrhythmia over 3 years of follow-up than initial use of antiarrhythmic drugs. (Funded by the Cardiac Arrhythmia Network of Canada and others; EARLY-AF ClinicalTrials.gov number, NCT02825979.)

High epicardial fat volume is associated with atrial fibrillation recurrences after catheter ablation

Abstract Background Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation therapy for atrial fibrillation (AF). However, even with important technological improvements, AF recurrences are common in long-term follow-up. Recently, epicardial fat tissue (EFT) has been proposed as a potential AF modulator promoting and sustaining atrial arrhythmogenic milieu. Aim In this retrospective single-centre study, we sought to evaluate the association between CT-quantified EFT volume and long-term primary PVI outcome assed by means of continuous ECG monitoring with implantable loop recorders (ILR) in paroxysmal AF patients. Methods A cohort of 92 patients (median age 60.2 [IQR 51.9–64.0]; 74% male) with paroxysmal AF (a single persistent AF episode was accepted) undergoing catheter ablation targeted at PVI was analysed. Prior to CA all patients underwent cardiac CT imaging with subsequent implantation of implantable loop recorder (ILR). Radiofrequency CA ablation with electro-anatomical mapping for PVI was used in 79 patients, balloon cryoablation was used in 13 patients. Verified complete PVI was defined as procedural endpoint. EFT volume was semi-automatically segmented and quantified on contrast enhanced CT studies. AF recurrence, defined as AF burden >0.1% after the blanking period (90 days), was continuously assessed by ILR. Kaplan-Meier analysis of AF recurrence-free survival at 1-year, 2-year and 3-year follow-up periods compared patients stratified into EFT volume tertiles. Results During a median follow-up of 52.6 months [IQR 43–64], AF recurrence was detected in 58 (63%) patients, 29 (50%) of them underwent a repeat ablation. Patients in high, mid, and low total EFT volume tertiles had a median time to late AF recurrence of 154, 373, and 284 days (Fig. 1A). At a 1-year follow-up, patients in the high EFT volume tertile had the worst AF ablation outcome (p=0.023). However, this difference gradually faded-out and became non-significant at 2 and 3 years. ROC analysis revealed an EFT of 95 ml as an optimal cut-off (p=0.002) for expected arrhythmia recurrence post acutely successful PVI (Fig. 1B). Conclusion EFT volume quantification in a relatively homogenous, continuously monitored cohort of patients undergoing catheter ablation for paroxysmal AF revealed a significant association between AF recurrence at 1 year post ablation and volume of epicardial fat. These results suggest a possible role of epicardial adipose tissue as an adverse pro-fibrillatory factor. Identified EFT volume cut-offs have to be validated prospectively on a larger and balanced patient population. Funding Acknowledgement Type of funding sources: None.

Predictors of long-term atrial fibrillation recurrence after catheter ablation: non-linear analytical approach for individualized prognostic stratification

Abstract Background Recurrences are common in patients with atrial fibrillation (AF) during long-term follow-up after catheter ablation (CA) for pulmonary vein isolation (PVI). Recently, machine learning (ML) models identifying non-linear relationships among various patient parameters have been applied for prognostic stratification in different cardiac diseases. Aim This is a retrospective study aimed to determine whether ML-based models can identify non-linear relationships in individual clinical baseline characteristics and CT-quantified volumetric parameters of epicardial fat tissue (EFT) to aid in prognosing outcome of catheter ablation for PVI in patients with paroxysmal AF. Methods A cohort of 92 patients (median age 60.2 [51.9–64.0]; 74% male) with paroxysmal AF (a single persistent AF episode was accepted) undergoing catheter ablation targeting PVI was analysed. All patients underwent cardiac CT imaging and were fitted with implantable loop recorder (ILR) prior to CA. For PVI, radiofrequency CA with electro-anatomical mapping was used in 79 patients, cryoballoon ablation in 13 patients. AF recurrence, defined as AF burden >0.1% after the blanking period (90 days), was continuously assessed by ILR. Feature selection on 23 baseline parameters was performed using random forest models (XGBoostRegressor). Mean absolute Shapley values (|mSHAP| – Shapley Additive expLanations) were used to quantify the relative discriminative power of analysed parameters. Results During a follow-up of 3-years, AF recurrence was detected in 58 (63%) patients, 29 (50%) of them underwent a repeat ablation. Five most important predictors of AF recurrence during 3-year follow-up were upper epicardial fat volume, BMI, baseline AF burden, age and pericardial volume (lower segment) (Fig. 1). Upper EFT volume was twice as important for males than females (0.44 and 0.21 |mSHAP| respectively). For a patient with no AF recurrence, low age (41 years) and low upper EFT volume (13.2 ml) were the most important drivers predicting positive ablation outcome (Fig. 2A). In contrast, in a patient with AF recurrence post CA, an above-average EFT volume of 55.5 ml and a high BMI had the most significant net contribution for predicting his failed CA outcome (Fig. 2B). Conclusion Non-linear ML analysis applied to our limited cohort of patients with paroxysmal AF undergoing CA suggests: i) a significant association of high EFT volume with ILR determined AF recurrence during a 3-year follow-up; ii) potential role of such analyses for a more granular and highly individualized prediction of outcome of planned CA. However, these results need further testing, and validation in prospective trials. Funding Acknowledgement Type of funding sources: None.

The cardiovascular risk factors profile and structural heart disease in patients with long-term episodes of persistent atrial fibrillation

Background and Aims : To evaluate the cardiovascular risk factors (CVRF) profile and structural heart disease in patients with persistent atrial fibrillation (AF) and the duration of its episode <90 and ≥90 days.

EVALUATION OF ATRIAL FIBRILLATION BURDEN AFTER THE FIRST ECG-DOCUMENTED EPISODE VIA IMPLANTABLE LOOP RECORDERS

Objective: The natural history of paroxysmal atrial fibrillation (AF) after the first clinical AF episode is not well known. AF burden is of clinical significance as it may have clinical implications concerning the long-term management of the arrhythmia and the decision-making on AF patients. We studied the natural history of AF in patients after their first clinical AF episode. Design and method: Thirty consecutive patients (age 66.9 ± 10 years; 14 men) received an implantable loop recorder (ILR) (Reveal XT 9529; Medtronic, Minneapolis, Minnesota, USA) after their first symptomatic paroxysmal AF episode. We recorded the AF recurrences and burden (clinical and subclinical AF) during a follow-up period of three years. We excluded patients with persistent or permanent AF and patients with AF attributed to reversible or transient causes. Results: Eight patients (26.6%) did not present any AF recurrence during the first year of the follow-up period. Five patients (16.6%) did not also suffer any AF episode during the second year, while in three patients (10%) no AF episode was recorded during the three-year follow-up period. In 16 patients (53.3%) the AF burden was increased during the second year of follow-up period while in 9 patients (30%) the AF burden was decreased. During the third year of follow-up period the AF burden was increased in 19 patients (63.3%), decreased in 7 patients (23.3%) and remained almost the same in 4 patients (13.3%). Five patients (16.6%) presented at least one episode of persistent AF during the follow-up period. Seven patients (23.3%) suffered only from symptomatic AF episodes, while in nine patients (30%) only asymptomatic AF episodes were recorded. Eleven patients (36.7%) had both types of AF episodes (symptomatic and asymptomatic). Conclusions: The AF recurrences and burden increased in most AF patients during the three-year follow-up period. However, some patients did not suffer any AF recurrence or they presented a decrease in AF burden. Paroxysmal AF clinical profile differs among the AF patients significantly and this indicates that an individualized approach via long-term rhythm monitoring may be of clinical significance, at least in some newly diagnosed AF patients.

P188 MANAGEMENT OF ANTICOAGULANT AND ANTIPLATELET THERAPY IN THE GREAT ELDERLY: A REAL LIFE CLINICAL CASE

Abstract In daily clinical practice we have often to manage great elderly people with multiple comorbidities. In these cases it is not always easy to apply the guidelines, which must sometimes be adapted to the patient we are treating. We present the case of a 99–year–old hypertensive patient in therapy with oncocarbide and acetylsalicylic acid for polycythemia vera. No cardiological history. It came to our attention for NSTEMI during an episode of persistent atrial fibrillation (AF) with a high ventricular rate. Subsequent spontaneous restoration of sinus rhythm. Significant increase in troponin on blood tests. On the echocardiogram, normal biventricular kinetics and systolic function, no significant valvulopathies. Given the age and hemodynamic stability, a conservative approach was chosen. Therefore, antiplatelet therapy was started with acetylsalicylic acid (ASA) and anticoagulant therapy, initially with low molecular weight heparin and then with oral anticoagulant (NOAC); being the patient over 75 we chose Apixaban 2.5 mg bid, in accordance with weight and renal function (Consensus ESC 2016). At 1 month follow up the patient month was stable in good compensation, the 24h–Holter ECG showed stable sinus rhythm. At this point the question was how to proceed with the therapy: maintain the NOAC, as indicated in the NSTEMI guidelines, or continue with ASA alone, also considering that the risk scores usually used in patients with AF to determine the bleeding and cardioembolic risk (HASBLED and CHADS–VASC) are not validated in such elderly patients. We also hypothesized that the short AF paroxysm was related to ongoing myocardial ischemia (and not vice versa); in the literature, however, the indication for anticoagulant therapy does not take these extreme situations into account. Polycythemia vera also contributes to complicating the situation, exposing the patient to an increased risk of thrombotic events in the absence of antiplatelet therapy. After discussing the case with the haematologist, we decided to suspend the NOAC, also considering the absence of new arrhythmic episodes, and to continue with ASA alone. For now, with a follow–up of 6 months, we have not registered thrombotic / haemorrhagic problems or arrhythmic recurrences. The management of the elderly is always complex and will frequently lead us to adapt and customize the treatments on every single patient.

Atrial fibrillation progression and burden after the first clinical episode: a prospective observational study via implantable loop recorders

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Medtronic Inc Background The progression of atrial fibrillation (AF) after the first clinical AF episode is not well known. AF burden is of clinical significance as it may have clinical implications concerning the long-term management of the arrhythmia and the decision-making on AF patients. Continuous rhythm monitoring via implantable loop recorders (ILRs) can precisely evaluate the AF recurrence profile. Purpose To observe the AF progression and AF burden in patients after their first clinical AF episode. Methods Thirty consecutive patients (age 66.9 ± 10 years; 14 men) received an ILR after their first clinical AF episode. We recorded the AF recurrences and burden during a follow-up period of three years. We excluded patients with persistent or permanent AF and patients with an episode of AF attributed to reversible or transient causes. Results Three patients (10%) had no AF recurrence, whereas 4 patients (13.3%) presented only one episode. Almost half of the patients (46.7%) had a low recurrence rate (&amp;lt;5 episodes/year), whereas the majority of patients (19/30) suffered from episodes with maximum duration ≤24 hours. Eleven patients (36.7%) presented either no episode or a low recurrence rate with episodes lasting ≤24 hours. In 16 patients (53.3%) the AF burden was increased during the second year of follow-up period while in 9 patients (30%) the AF burden was decreased. During the third year of follow-up period the AF burden was increased in 19 patients (63.3%), decreased in 7 patients (23.3%) and remained almost the same in 4 patients (13.3%). Five patients (16.6%) presented at least one episode of persistent AF during the follow-up period. Seven patients (23.3%) suffered only from symptomatic AF episodes, while in nine patients (30%) only asymptomatic AF episodes were recorded. Eleven patients (36.7%) had both types of AF episodes (symptomatic and asymptomatic). Conclusions The AF recurrences and burden increased in most AF patients. However, a significant percentage of patients either suffer no AF recurrence after their first symptomatic episode or show a low recurrence rate. Most patients present episodes of short duration. Paroxysmal AF clinical profile differed significantly among the patients. If these findings are confirmed in larger studies, they could have clinical implications ensuring individualized management of the arrhythmia in the future in newly diagnosed AF patients.

Clinical characteristics of patients with long-term episodes of persistent atrial fibrillation

The aim – to compare clinical, instrumental and laboratory characteristics of persistent atrial fibrillation (AF) patients with the duration of AF episode &lt; 90 and ≥ 90 days.Materials and methods. The cross-sectional study consecutively enrolled and analyzed clinical, instrumental and laboratory data from 118 persistent AF patients with the duration of its episode more than 7 days, who underwent an electrical cardioversion. Patients were subdivided into groups with the duration of AF episode 8-89 days (n=58) and ≥ 90 days (n=60).Results and discussion. We observed a significant difference between the studied groups by the frequency of systolic dysfunction cases: 2 (3.5 %) vs. 12 (20.3 %) patients in AF episode duration &lt; 90 and ≥ 90 days groups, respectively (p=0.008). According to transesophageal echocardiography data, we revealed the difference between the groups of comparison by the value of left atrial appendage flow velocity (43.5 cm/s vs. 37.0 cm/s, respectively; p=0.020). The difference between the studied groups by left atrial volume index did not reach the statistical significance (98 (80–110) vs. 99 (86–114) ml/m2, respectively; p=0.088). Besides, both studied groups were characterized by the prevalence of patients with moderate decrease of estimated glomerular filtration rate (eGFR) (60–89 mL/(min·1.73 m2)): 36 (62.1 %) cases in AF episode duration &lt; 90 days, and 38 (63.3 %) – amongst patients with the duration ≥ 90 days. Furthermore, about one-third of patients in both studied groups presented with more pronounced eGFR decline (&lt; 60 mL/(min·1.73 m2)): 16 (27.6 %) and 18 (30.0 %) cases in the groups with AF episode duration &lt; 90 and ≥ 90 days, respectively.Conclusions. The groups of persistent AF patients with the AF episode duration &lt; 90 and ≥ 90 days were comparable by the majority of clinical, instrumental and laboratory characteristics, including the severity of kidney dysfunction. The AF episode duration ≥ 90 days was associated with the higher frequency of left ventricular systolic dysfunction cases, as well as with worse left atrial appendage function

The reinvented old player – an antazoline is effective in pharmacological cardioversion of atrial fibrillation

Abstract Introduction Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of atrial fibrillation (AF) to sinus rhythm (SR) and is widely used in Poland for this purpose in the last years. However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. Aim To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. Methods Our single center, retrospective, observational study included patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. Results A total of 176 pts (mean age 68.4±12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7–432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9±65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting &amp;lt;48h vs others: 75.3% vs 12.0%, p&amp;lt;0.001). In multivariable logistic regression model AF duration (for every 24h in AF – OR=0.97; 95% CI 0.96–0.98), the left atrium antero-posterior diameter (OR=0.92; 95% CI 0.86–0.99) and the serum creatinine level (OR=0.15; 95% CI 0.03–0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT's effectiveness was 48h (AUC=0.876; 95% CI 0.815–0.922) – Figure 1. There were only one episode of bradycardia &amp;lt;45 bpm related to ANT administration. Conclusions Antazoline is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (&amp;lt;48 hours) and in patients without the left atrium enlargement and significant renal disease. Funding Acknowledgement Type of funding sources: None. Figure 1. ROC curve analysis

Cinderella drug: an antazoline is effective in pharmacological cardioversion of atrial fibrillation - Single center experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of persistent atrial fibrillation (AF) to sinus rhythm (SR). However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. Aim To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. Methods We conducted a single center, retrospective, observational study including patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. Results A total of 176 pts (mean age 68.4 ± 12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7 – 432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9 ± 65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting &amp;lt;48h vs others: 75.3% vs 12.0%, p &amp;lt; 0.001). In multivariable logistic regression model AF duration (for every 24h in AF - OR = 0.97; 95% CI 0.96 – 0.98), the left atrium antero-posterior diameter (OR = 0.92; 95% CI 0.86 – 0.99) and the serum creatinine level (OR = 0.15; 95% CI 0.03 – 0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT’s effectiveness was 48h (AUC = 0.876; 95% CI 0.815 – 0.922). There were only one episode of bradycardia &amp;lt;45 bpm related to ANT administration. Conclusions Intravenous antazoline administration is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (&amp;lt;48 hours) and in patients without the left atrium enlargement and significant renal disease. Abstract Figure.

P1014The natural history of atrial fibrillation after the first clinical episode: a prospective observational study via implantable loop recorders

Abstract Funding Acknowledgements The study was supported by Medtronic Inc Background The natural history of paroxysmal atrial fibrillation (AF) after the first clinical AF episode is not well known. AF burden is of clinical significance as it may have clinical implications concerning the long-term management of the arrhythmia and the decision-making on AF patients. Purpose To observe the natural history of AF in patients after their first clinical paroxysmal AF episode. Methods Thirty consecutive patients (age 66.9 ± 10 years; 14 men) received an implantable loop recorder (ILR) after their first symptomatic paroxysmal AF episode. We recorded the AF recurrences and burden (clinical and subclinical AF) during a follow-up period of three years. We excluded patients with persistent or permanent AF and patients with an episode of AF attributed to reversible or transient causes. Results Eight patients (26.6%) did not present any AF recurrence during the first year of the follow-up period. Five patients (16.6%) did not also suffer any AF episode during the second year, while in three patients (10%) no AF episode was recorded during the three-year follow-up period. In 16 patients (53.3%) the AF burden was increased during the second year of follow-up period while in 9 patients (30%) the AF burden was decreased. During the third year of follow-up period the AF burden was increased in 19 patients (63.3%), decreased in 7 patients (23.3%) and remained almost the same in 4 patients (13.3%). Five patients (16.6%) presented at least one episode of persistent AF during the follow-up period. Seven patients (23.3%) suffered only from symptomatic AF episodes, while in nine patients (30%) only asymptomatic AF episodes were recorded. Eleven patients (36.7%) had both types of AF episodes (symptomatic and asymptomatic). Conclusions The AF recurrence and burden increased in most AF patients during the three-year follow-up period. However, some patients did not suffer any AF recurrence or they presented a decrease in AF burden. Paroxysmal AF clinical profile differs among the AF patients significantly and this indicates that an individualized approach via long-term rhythm monitoring may be of clinical significance, at least in some newly diagnosed AF patients.

A comparison of early versus delayed elective electrical cardioversion for recurrent episodes of persistent atrial fibrillation: A multi-center study

BackgroundDue to barriers to accessing timely elective electrical cardioversion (CV) for persistent AF (PeAF), we adopted a policy of instructing patients to present directly to the Emergency Department (ED) for CV. ObjectiveWe compare a strategy of Emergency CV (ED-CV) versus Elective CV (EL-CV) for treatment of symptomatic PeAF. MethodsBetween 2014 and 7, we evaluated 150 patients undergoing CV for PeAF. ED-CV patients were provided an AF action plan for recurrent symptoms and advised to present to ED within 36 h. EL-CV patients followed standard care, including cardiologist referral and placement on an elective hospital waiting list. Follow-up was 12 months. ResultsWe included 75 consecutive ED-CV patients and 75 consecutive EL-CV patients. ED-CV patients had a significantly shorter median AF duration prior to CV (1 day vs 3 months; p < 0.01) and less overall AF-related symptoms at 12 months (modified EHRA symptom score ≥ 2a in 44% vs 72%; p = 0.005). Time to next AF recurrence was longer in the ED-CV group (295 ± 15 vs 245 ± 15 days; logrank p = 0.001), as was time to AF ablation referral (314 ± 13 vs 276 ± 15 days; logrank p = 0.01). Baseline LA area was similar (ED-CV 27 ± 4 cm2 vs EL-CV 28 ± 11 cm2; p = 0.67), however EL-CV had larger atria at follow-up (31 ± 8 vs 26 ± 6 cm2; p = 0.01). There were no complications in either group. ConclusionED-CV is an acceptable strategy for symptomatic PeAF. In addition to reduced time spent in AF and improved symptom scores, this strategy may also slow progression of atrial substrate & delay onset of next AF episode.

P197Longer duration of persistent atrial fibrillation episodes prior to catheter ablation is associated with lower freedom of atrial arrhythmias after catheter ablation

P197Longer duration of persistent atrial fibrillation episodes prior to catheter ablation is associated with lower freedom of atrial arrhythmias after catheter ablation

Gabor frames for classification of paroxysmal and persistent atrial fibrillation episodes

In this study, we propose a new classification method for early differentiation of paroxysmal and persistent atrial fibrillation episodes, i.e. those which spontaneously or with external intervention will return to sinus rhythm within 7 days of onset from the ones where the arrhythmia is sustained for more than 7 days. Today, clinicians provide patients classification once the course of the arrhythmia has been disclosed. This classification problem is dealt with in this study. We study a sparse representation of surface electrocardiogram signals by means of Gabor frames and afterwards we apply a linear discriminant analysis. Thus, we provide an early discrimination, obtaining promising performances on a heterogeneous cohort of patients in terms of pharmacological treatment and state of progression of the arrhythmia: 95% sensitivity, 82% specificity, 89% accuracy. In this manner, the proposed method can help clinicians to choose the most appropriate treatment using the electrocardiogram, which is a widely available and non-invasive technique. This early differentiation is clinically highly significant in order to choose optimal patients who may undergo catheter ablation with higher success rates.

The clinical course of atrial fibrillation in patients with coronary heart disease

To elucidate evolution of the clinical course of AF in patients with CHD in a long-term prospective study. The study included. 112 patient aged 57-74 (mean 67.44±3.3) years with CHD and paroxysmal form of AF carried outfrom 2011 to 2015. Evolution of the clinical course of AF was evaluated based on the number of arrhythmic attacks during the last 3 months. The appearance of prolonged persistent AF episodes or permanent AF was regarded as progression of arrhythmia. During the 4 year study, 64 (57,2%) patients (group 1) did not experiencea rise in the frequency and duration of AF attacks. Progression of arrhythmia was documented in 48 (42,8%) of the 112 (100%) patients (group 2). These patients more frequently had the history of myocardial infarction and chronic heart failure than patients of group 1. The latter had the mean values of left ventricular (LV) ejection fraction 61,23±6,24%, i.e. significantly higher than 48,47±8,4% in group 2.47 and 28 % of the patients in group 2and 1 respectively suffered mitral regurgitation (p<0,05). Patients of group 2 had significantly more akineticzones. Intake of nitroglycerin in group 1 resulted in positive dynamics of local LV contractility that did not change in patients of group 2. 42,8% of the patients with CHD and paroxysmal form of AF experienced progression of arrhythmia into a persistent or permanent form. Predictors of AF progression in patients with CHD are the history of myocardial infarction, chronic heart failure, mitral regurgitation, and irreversible changes in local myocardial LV contraction.

Reduced progression of atrial fibrillation in hypertensive patients with long-term treatment of propafenone

In recent years, progress has been made in the study of the natural history of atrial fibrillation (AF) - that, from the stage of having no clinical manifestations, to the final stage, which is an irreversible arrhythmia, is associated with the development of serious cardiovascular complications. Most AF patients steadily progress in persistent or permanent form, but the risk factors and predictors of progression of the arrhythmia is not clearly defined. There is little research done on the effect of long-term antiarrhythmic therapy on the progression of AF. Objective. To evaluate the progression of arrhythmias in patients with arterial hypertension (AH) with paroxysmal AF in the treatment of propafenone (propanorm) compared to treatment with bisoprolol (Concor) in the long-term prospective study. Materials and methods. The study included 62 patients with essential hypertension aged 45 to 63 years. Patients were randomized into 2 groups: 32 patients in group 1 for storing heart rate propafenone took a daily dose of 450 mg, 30 patients in group 2 to control ventricular rate was appointed bisoprolol. Prospective monitoring of patients was carried out from 2011 to 2015, the progression of the arrhythmia was considered: increase in the frequency of paroxysms of arrhythmia in the last 3 months, the appearance of long-term persistent AF episodes or persistent AF. Results. In 14 (44%) patients in group 1 and 20 (67%) - group 2 5 years of observation, it was noted increase in the frequency and duration of AF episodes. The average value of arrhythmia progression into a more stable form of 9.3% per year in patients receiving propafenone, and 11.5% - bisoprolol (p=0.007). Keeping the treatment of sinus rhythm propafenone in a daily dose of 450 mg contributed to a significant reduction of the left atrium anteroposterior size from 43±3 to 36±3 mm (p=0.03). In the treatment with bisoprolol anteroposterior size of the left atrium was not significantly changed and amounted to 44±3 and 43±3 mm respectively. Portability of propafenone antiarrhythmic therapy was comparable with that of bisoprolol. No severe or serious side effects were observed in patients during the long-term prospective study. Conclusion. The five-year propafenone treatment of hypertensive patients with paroxysmal AF can reduce the progression of AF in a more stable form compared with bisoprolol therapy.

Patient Activity Decreases and Mortality Increases After the Onset of Persistent Atrial Fibrillation in Patients With Implantable Cardioverter-Defibrillators.

The study sought to determine the effect of persistent atrial fibrillation (AF) on device-measured activity and mortality. Patients with AF often complain of fatigue, which may be reflected in patient activity. Daily activity can be objectively measured by implanted devices. We retrospectively studied patients (n= 266, 88% male, 69 ± 10 years of age) from the deidentified Medtronic CareLink database with persistent AF (≥28 consecutive days with≥23 h of AF/day), dual-chamber implantable cardioverter-defibrillators (ICDs) capable of monitoring daily activity and AF burden, no AF between months 1 and 6 post-implant, and≥1 year of data. The first persistent AF episode occurred 980 ± 534 days after implant and lasted a median of 87 days (interquartile range: 49 to 161 days). Average daily activity over a week just prior (baseline) to the first persistent AF episode was compared to each of the 4 weeks during the AF episode and to each of the weeks following termination ofthe persistent AF episode. Daily activity decreased significantly from the baseline week (135 min/day) compared to each of the 4 consecutive weeks after AF onset (8%, 11%, 14%, and 17% decrease, p< 0.001). Mortality at 4 years was increased in patients with persistent AF compared to a matched group with no persistent AF (20.6% vs. 8.6%, p<0.01). Patients with ICDs have a significant reduction in activity following the onset of persistent AF andasignificant increase in mortality when compared to a matched group without persistent AF. Objective measuresofactivitymay more accurately reflect the impact of persistent AF on patients' functional status.