Persistent Non-valvular Atrial Fibrillation Research Articles

Clinical and instrumental factors associated with sinus rhythm maintenance following direct current cardioversion of late persistent non-valvular atrial fibrillation at 6-months follow-up

Abstract Purpose To study the clinical and instrumental factors, associated with sinus rhythm (SR) maintenance following direct current cardioversion (DCCV) in patients with late persistent non-valvular atrial fibrillation (AF) at 6-months follow-up. Methods The cohort single-center study analyzed clinical and instrumental data from 59 late persistent AF patients (with duration of its episode ≥90 days [up to 12 months]), who underwent an elective DCCV. At 6-months follow-up, 32 (54 %%) patients succeeded to maintain SR, in contrast to 27 (46 %) patients with a failure to its maintenance. Results The univariate logistic regression analysis revealed, that the absence of heart failure (HF) stage C (i.e., the presence of its stage B), the higher left ventricular ejection fraction (LVEF) (by transthoracic echocardiography [TTE]), left atrial appendage flow velocity (LAAFV) >40 cm/s and the freedom from left atrial spontaneous echo contrast (LASEC) (by transesophageal echocardiography), ‒ all were associated with the higher chance to maintain SR at 6-months follow-up (Figure). At the same time, the higher baseline left atrial dimension (LAD) and more advanced pulmonary hypertension (PH) (by TTE) were associated with the failure of its maintenance to be more probable (Figure). At multivariate analysis, the following predictors of SR maintenance after DCCV at 6-months follow-up were identified: higher LVEF (OR 1,07 (95 % CI 1,01-1,13); р=0,021); LAAFV >40 cm/s (OR 4,33 (95 % CI 1,06-17,78); р=0,042), and less advanced PH (OR 0,24 (95% CI 0,06-0,93); р=0,038). Conclusion Better LV systolic function, LAAFV >40 cm/s and less advanced PH were the predictors of SR maintenance following DCCV in patients with late persistent (with duration of its episode ≥90 days) non-valvular AF at 6-months follow-up.

Associations of the left atrial epicardial fat thickness with the thrombosis prevalence and left atrial appendage flow velocity in patients with persistent non-valvular atrial fibrillation

Aim. To study the associations of the left atrial epicardial fat (LAEF) thickness with the thrombosis prevalence and left atrial appendage (LAA) flow velocity in patients with persistent non-valvular atrial fibrillation (AF).Material and methods. Transesophageal echocardiography in 475 patients with persistent non-valvular AF (men 58,9%, age 64,0 (58,3-70,0) years) assessed LAA flow velocity, interatrial septum and left lateral ridge thickness. Their average thickness was used to estimate the LAEF volume.Results. LAA thrombus was detected in 42 (8,8%) patients. LAA flow velocity without thrombus was 32,0 (26,0-39,0) cm/s, with thrombus — 20,0 (14,0-25,8) cm/s (p<0,0001). Depending on the LAEF thickness, patients were divided into 3 tertile groups: group 1 (n=168) — 5,6-7,4 mm, group 2 (n=154) — 7,45-8,2 mm, group 3 (n=153) — 8,25-10,9 mm. In group 1, no thrombus was detected, in group 2, thrombus was detected in 2 (1,3%) patients, in group 3 — in 40 (26,0%) patients (p<0,0001). In the absence of LAA thrombus, flow velocity in the selected groups did not differ (32,0 (26,0-39,0) cm/s, 31,0 (26,0-7,8) cm/s and 31,5 (25,0-40,0) cm/s, (p=0,9514)).Conclusion. EFL thickness, calculated as the average of interatrial septum and left lateral ridge thickness, can be used to study the relationship between epicardial obesity and LAA thrombosis in patients with AF. In patients with persistent non-valvular AF with a LAEF thickness >8,2 mm, LAA thrombosis occurs more than 40 times more often than in patients with a lower LAEF thickness. The influence of LAEF thickness on LAA flow velocity was not revealed in the pre­sent study.

Predictors of atrial thrombosis of persistent nonvalvular atrial fibrillation

Introduction. The clinical significance of atrial fibrillation (AF) is associated with the development of thromboembolic complications that occur when thrombus from the left atrial appendage enter the systemic circulation. Transesophageal echocardiography can detect the left atrial appendage thrombus, but due to lack of availability, high cost and complexity of performing such a routine examination is unlikely. Therefore, the search for predictors of the left atrial appendage thrombosis is relevant, the presence of which may become the basis for a more in-depth instrumental examination of patients with AF.Aim. To identify predictors of atrial thrombosis in patients with persistent nonvalvular atrial fibrillation.Materials and methods. The 551 patients with persistent nonvalvular atrial fibrillation underwent transesophageal echocardiography before cardioversion, thrombus in the left atrial appendage was detected in 74 (13.4%) patients. All patients were selected into training (400 people) and validation (151 people) cohorts randomly. Multivariate logistic regression analysis was performed to identify predictors of atrial thrombosis in the derivation cohort.Results. Five factors influenced the atrial thrombosis independently. They are the ratio of the transmitral velocity to the mitral annulus early Diastolic velocity (E/e’) ≥ 12 (D), the absence or inadequate Anticoagulant therapy (A), atrial Fibrillation, not flutter (F), left atrial volume Index (I), and age ≥ 75 years (DAFI75 scale). The number of predictors corresponds the risk of detecting atrial thrombosis: the area under the characteristic curve was 0.818 (0.768–0.868) in the derivation cohort and 0.847 (0.761–0.934) in the validation cohort. The sensitivity of the DAFI75 criterion ≥ 3 in the derivation and validation cohorts is 91.7 and 92.9%, the specificity is 58.8 and 65.7%, the predictive value of a positive result is 28.2 and 21.7%, and the predictive value of a negative result is 97.6 and 98.9%.Conclusion. The presence of three or more predictors score DAFI75 allows predicting the absence of atrial thrombosis more than in 97% of case.

Pulmonary vein perforation into the respiratory tract with systemic air embolism: a rare complication of left atrial appendage closure

BackgroundPulmonary vein perforation is an uncommon complication during cardiac intervention. We present a rare case of pulmonary vein perforation into the respiratory tract with systemic air embolism during left atrial appendage closure (LAAC).Case presentationA 77-year-old man with persistent nonvalvular atrial fibrillation was referred for percutaneous LAAC under local anaesthesia (CHA2DS2-VASc score of 4, HAS-BLED score of 3, and prior ischaemic stroke). During the procedure, after delivering a super-stiff guidewire into the left superior pulmonary vein (LSPV), the patient suddenly developed a severe cough with haemoptysis upon advancement of a delivery sheath along the guidewire. Fluoroscopy showed signs of blood entering the left main bronchus, and fast transthoracic echocardiography revealed bubbles in the left heart without pericardial effusion. The procedure was terminated because of a major complication indicated by the repeated haemoptysis and headache, and haemostatic drugs were immediately administered. Subsequent chest computed tomography angiography (CTA) revealed a filling defect in the LSPV branches and bubbles in the aorta. The patient was transferred to the critical care unit for haemostasis and antibacterial treatment. Transthoracic echocardiography later that day showed no bubbles in the heart. The headache and haemoptysis significantly abated the following day. The bubbles in the aorta disappeared on chest CTA 7 days later.ConclusionsInterventional cardiologists should pay attention to anatomical variations of the pulmonary vein, which are associated with a high risk of complications of pulmonary vein perforation during LAAC. Preoperative CTA examination and intraoperative transoesophageal echocardiography might be helpful to avoid this complication.

Prediction of low left atrial appendage velocity from echocardiographic left atrial function parameters in patients with atrial fibrillation undergoing catheter ablation

Abstract Funding Acknowledgements Type of funding sources: None. Background Decreased left atrial appendage velocity (LAAV) measured by transesophageal echocardiography is considered a significant risk factor for the presence of thrombus in both the left atrium (LA) and left atrial appendage (LAA). Purpose The aim of the study was to assess the role of echocardiographic LA function parameters in predicting low left atrial appendage velocity (LAAV) in patients with persistent atrial fibrillation (AF) undergoing catheter ablation. Methods We prospectively enrolled consecutive patients with persistent AF undergoing transesophageal echocardiography (TEE) directly before first AF ablation in 2019–2022. All patients underwent conventional two-dimensional (2D) echocardiography and 2D speckle tracking echocardiography on the day of ablation. Patients were divided into two groups according to the presence or absence of decreased LAAV≤25cm/s at TEE. Results Out of total 150 patients enrolled in the study, 29.3% (n=44) had a reduced LAAV ≤25cm/s. Patients with decreased LAAV value exhibited significantly lower left atrial reservoir and conduit strain (LASr and LAScd) (p<0.001 for both); LA emptying fraction (p<0.001) and average e’ value (p<0.001). At the same time, this group presented higher LA stiffness index (LASI) (defined as E/e' ratio/LASr) (p<0.001); LA and right atrial area (p = 0.002 and 0.004 respectively); LA volume index (p<0.001) and E/e’ ratio (p<0.001). In multivariable logistic regression analysis only LASI and LAVI remained significant predictors of the lower LAAV (odds ratio (OR) for LASI 3.065, 95% confidence interval(CI) 1.415–6.639, p<0.001; for LAVI OR 1.05 (1.011–1.091). The diagnostic accuracy of these two parameters in predicting low LAAV value calculated as the area under receiver operating characteristic curves (ROC) were 0.809 (95% CI 0.726–0.892) for LASI and 0.755 (CI 0.676–0.835) for LAVI. A ROC analysis found a LASI threshold of 1.6 with 64% sensitivity and 90% specificity and LAVI threshold of 44.47ml/m2 with 91% sensitivity and 53% specificity in predicting reduced LAAV defined as ≤ 25cm/s. Conclusions Among all noninvasive parameters assessed by conventional 2D and 2D speckle tracking echocardiography, LASI and LAVI were found to be the best predictors of reduced LAAV in patients with persistent non-valvular AF undergoing TEE before catheter ablation, with good sensitivity and specificity.

PO-02-124 MITOCHONDRIAL GLYCEROL-3-PHOSPHATE DEHYDROGENASE ACTS AT THE CROSSROAD OF METABOLISM REPROGRAMMING IN NON-VALVULAR ATRIAL FIBRILLATION: INDICATION FROM MULTI-OMICS ANALYSIS OF HUMAN AF MYOCARDIAL TISSUE

Metabolic remodeling has been known to play an important role in the development of atrial fibrillation(AF). Recent studies have shown prominent mitochondrial metabolic changes of atrium, which have significant impact on the electrical signaling and structural remodeling of atrium. However, there is limited data on AF metabolic remodeling from multi-omics analysis of human myocardial tissue. In addition, the metabolism-related hub gene and pathways are not completely known. We aimed to explore the mitochondrial metabolism reprogrammed in AF, and describe the key dysregulated molecules of AF patients, as well as related metabolic pathways. In-hospital patients diagnosed with AF from 2019 to 2022 were enrolled. Left atrial appendages were harvested from AF patients undergoing cardiovascular surgery and matched ones from healthy donors with sinus rhythm(SR). Metabolomics and proteomics were then performed and analyzed. Moreover, biostatistical analysis was done for further identification. Heart tissue samples were harvested from 10 persistent non-valvular AF patients (Table1) and 10 matched SR samples from healthy donors. In metabolomics analysis, 113 metabolites were up-regulated and 10 were down-regulated (Panel A), where multiple pathways related to amino acid and glycolipid metabolism were enriched (Panel B). After correlation analysis between the differentially expressed proteins and metabolites, mitochondrial glycerol-3-phosphate dehydrogenase (mGPDH) was found crucial in AF patients in both positive- and negative-ionized mode (MCC score=16 and MCC score=6 respectively)(Panel C-D), which locates in the inner membrane of mitochondria and participates in cardiac mitochondrial function and glucolipid homeostasis. Proteomics revealed that the mitochondrial metabolism demonstrated marked difference in AF hearts than SR, especially the oxidative phosphorylation (NES=-1.73)(Panel E), ATP biosynthetic process (NES:-2.29), NADH dehydrogenase (NES:-2.36) etc., which were closely related to the function of mGPDH. The expression level of mGPDH was associated with multiple pathways related to cardiac structural remodeling using gene set variation analysis, which was further validated by external database (Panel F). Mitochondrial metabolism underwent prominent reprogramming in AF. mGPDH may participate in the development of AF via regulating mitochondrial metabolism and contribute to atrial remodeling, which could be considered as a a novel target for AF treatment.

Features of Left Atrial Appendage Thrombosis in Patients With Persistent Nonvalvular Atrial Fibrillation After COVID-19.

Aim To evaluate the incidence and characteristic features of left atrial appendage (LAA) thrombosis in patients with persistent nonvalvular atrial fibrillation (AF) after COVID-19.Material and methods Transesophageal echocardiography (TEE) was performed for 469 patients (57.4 % males; mean age, 64.0 [58.0; 70.0] years) with persistent nonvalvular AF before scheduled sinus rhythm restoration. In 131 of these patients (27.9 %), the most recent episode of arrhythmia developed during the coronavirus infection. The time from the onset of COVID-19 to TEE was 145 [62; 303] days. All patients received an adequate anticoagulant therapy, in most cases, with direct oral anticoagulants for at least 3 weeks preceding the study.Results A LAA thrombus was detected in 20 (5.9 %) patients who have had no coronavirus infection and in 19 (14.5 %) patients after COVID-19 (р=0.0045). 18 of 19 (94.7 %) thrombi found in patients who have had COVID-19 were mural whereas only 5 (25.0 %) of such thrombi were found in patients who have had no COVID-19 (p<0.0001). In the absence of LAA thrombus, the LAA emptying velocity was 32.0 [25.0; 40.0] cm/sec whereas in the presence of a mural thrombus, it was 25.0 [20.0; 32.3] cm/sec, and in the presence of a typical thrombus, it was 17.0 [13.5; 20.0] cm/sec (р<0.0001). A Kaplan-Meier analysis showed that the median time of mural thrombus dissolution was 35.0 (95 % confidence interval (CI), 24.0-55.0) days and for a typical thrombus, this time was 69.0 (95 % CI, 41.0-180.0) days (р=0.0018).Conclusion Patients with persistent AF who have had COVID-19 had LAA thrombosis 2,5 times more frequently and, in most cases, the thrombus was mural. Mural thrombi, in contrast to typical, are not associated with a pronounced decrease in LAA emptying velocity and dissolve twice as fast as typical thrombi with an adequate anticoagulant treatment.

Healthcare Effect and Safety of Patients with Persistent Non-Valvular Atrial Fibrillation Using NOAC and Warfarin

Healthcare Effect and Safety of Patients with Persistent Non-Valvular Atrial Fibrillation Using NOAC and Warfarin

Predictors of dementia amongst newly diagnosed non-valvular atrial fibrillation patients

Atrial fibrillation (AF) confers a 2-to-3-fold increased risk of developing cognitive dysfunction and dementia, independent of age and past stroke. The purpose of study was to identify risk factors for developing dementia amongst AF patients in India. This was a single-centre, prospective, observational study wherein recently diagnosed, treatment naïve, persistent non-valvular AF patients were enrolled. All patients were screened for dementia using the Mini-Mental state exam. Amongst a total of 108 patients enrolled, 40 (37%) had dementia. The most common cognitive deficits were in attention and calculation followed by memory deficits. Factors independently contributing to dementia were advanced age, female sex, presence of diabetes, elevated pulmonary artery pressures and a lower serum albumin.

F Wave Amplitude as a Predictor of Thromboembolism and Success of Electrical Cardioversion in Patients with Persistent Atrial Fibrillation.

Atrial fibrillation (AF) is classified according to the amplitude of fibrillatory waves (f) into fine waves (fAF) and coarse waves (cAF). To correlate the amplitude of f waves with clinical, laboratory, electrocardiographic, and echocardiographic variables that indicate a high risk of thromboembolism and to assess their impact on the success of electrical cardioversion (ECV). Retrospective, observational study that included 57 patients with persistent non-valvular AF who underwent ECV. The maximum amplitude of f waves was measured in lead V1. cAF was defined when f ≥ 1.0mm and fAF when f < 1.0mm. The findings were correlated with the indicated variables. Values of p < 0.05 were considered statistically significant. cAF (n = 35) was associated with greater success in ECV (94.3% vs. 72.7%, p = 0.036) even after adjusting for variables such as age and BMI (p = 0.026, OR = 11.8). Patients with fAF (n = 22) required more shocks and more energy to revert to sinus rhythm (p = 0.019 and p = 0.027, respectively). There was no significant association between f-wave amplitude and clinical, echocardiographic, and laboratory parameters. The amplitude of f wave was not associated with echocardiographic, clinical and laboratory parameters that indicate a high risk of thromboembolism. cAF was associated with a higher chance of success reverting to sinus rhythm employing ECV. A greater number of shocks and energy were required for reversion to sinus rhythm in patients with fAF.

The effect of different preoperative left atrial appendage emptying speeds on left atrial function in patients with persistent atrial fibrillation after left atrial appendage closure combined with catheter ablation

ObjectiveThe present study aimed to investigate whether different preoperative left atrial appendage emptying speeds (LAAEVs) have an effect on left atrial function in patients with sinus arrhythmia after left atrial appendage closure (LAAC) combined with catheter ablation (CA).MethodsA total of 163 patients with persistent non-valvular atrial fibrillation who received combined LAAC+CA surgery were included in the present study. Regular follow-up was conducted for 12 months, and patients with complete data and successful sinus rhythm recovery were selected as the study subjects (n = 82). The patients were divided into two groups: the LAAEV < 25 cm/s group and the LAAEV ≥ 25 cm/s group (n = 41 each). The propensity score was used for matching according to gender, age, CHA2DS2-VASc score, and HAS-BLED score. The changes in the two groups in LA structure, storage function, conduit function, and pump function were compared.ResultsBefore surgery, the maximum LA volume (LAVmax) and minimum LA volume (LAVmin) were greater in the LAAEV < 25 cm/s group than in the LAAEV ≥ 25 cm/s group. The LA storage function (eg. Ƹ and SRs), conduit function (eg. SRe), and pump function (eg. SRa) were all worse in the LAAEV < 25 cm/s group than in the LAAEV ≥ 25 cm/s group. After the combined LAAC+CA surgery, the LA storage, conduit, and pump functions improved in both groups. At 12 months after surgery, there were no statistically significant differences between the two groups.ConclusionBefore combined LAAC+CA surgery, the LA structure and function of the LAAEV < 25 cm/s group were worse than those of the LAAEV ≥ 25 cm/s group. However, after LAAC+CA surgery, the LA structure and function of the patients were improved, and there were no significant differences between the two groups. Inferred improvement in LA structure and function in the LAAEV < 25 cm/s group was superior to that in the LAAEV ≥ 25 cm/s group.

A Differential Profile of Biomarkers between Patients with Atrial Fibrillation and Healthy Controls.

Atrial fibrillation (AF) is explained by anatomical and electrophysiological changes in the atria determined by high pressure, dilatation, infiltration and inflammation in the myocardium. There are some biomarkers implicated in these processes, namely, NT-proBNP, high sensitivity troponin (Hs-Tn), urate, galectin-3, ST2, C reactive protein and fibrinogen. The aim of this study was to assess differences in these biomarkers between patients with AF and healthy controls. We designed a cross-sectional study consecutively including all patients undergoing electrical cardioversion in our hospital for persistent AF and matched healthy controls. We included 115 patients with persistent non-valvular AF and 33 healthy subjects. The biomarkers NT-proBNP, ST2 and Hs-Tn T were significantly related to the presence of AF (1054 ± 833.30 vs. 58.31 ± 59.40, p < 0.001; 35.43 ± 15.89 vs. 27.43 ± 10.95, p < 0.001 and 10.25 ± 6.11 vs. 8.42 ± 6.85, p < 0.001, respectively). NT-proBNP was the best biomarker differentiating AF patients (area under the curve 0.995). The best NT-proBNP cut-off point to differentiate AF was 102 pg/mL; for Hs-Tn T it was 11.5 ng/L and for ST2 it was 37.7 ng/mL. It is possible that these biomarkers intervene at the onset of AF and have no role in AF maintenance.

Stroke risk evaluation for patients with atrial fibrillation: Insights from left atrial appendage with fluid-structure interaction analysis

The majority of cardioembolic strokes in patients with non-valvular atrial fibrillation (NVAF) are resulted from clot formation in the left atrial appendage (LAA). Current stroke risk stratification is based on the overall risks estimated from demographic and clinical profiles but not on individual anatomy or physiology. We aim to explore the differences in LAA morphological and hemodynamic parameters by comparing patients with and without a stroke history. Thirty-nine patients with persistent NVAF were included. Of these, 17 patients without a stroke history (non-stroke group) were compared with 22 patients with a history of stroke (stroke group). Their LAA geometric models were first reconstructed, and the morphological parameters were then measured. Furthermore, their LAA hemodynamic parameters were calculated by fluid-structure interaction analysis. Moreover, particle residual rates (PRR) and blood renewal rates (BRR) analyses were also employed to characterize the thrombogenesis dynamics. The results showed that compared to the non-stroke group, the stroke group had significant smaller LAA tortuosity and LAA orifice area, and significantly lower LAA orifice velocities (0.16 ± 0.10 vs 0.15 ± 0.06 cm/s; p = 0.044), but higher PRR (14.58 ± 9.43 vs 9.25 ± 4.67; p = 0.040) and BRR (52.41 ± 18.11 vs 38.36 ± 24.07; p = 0.044). These LAA morphological and hemodynamic parameters may be used to assess stroke risk in patients with NVAF.

Patients with Atrial Fibrillation Benefit from SAVR with Surgical Ablation Compared to TAVR Alone.

IntroductionIn patients with preoperative atrial fibrillation (AF) undergoing aortic valve replacement, the addition of surgical ablation to surgical aortic valve replacement (SAVR-SA) is efficacious and a Class I guideline. We hypothesized that this subgroup may benefit from SAVR-SA compared to transcatheter aortic valve replacement (TAVR) alone.MethodsMedicare beneficiaries with persistent non-valvular AF who underwent SAVR-SA or TAVR alone between 2012 and 2018 were included. Patients with high-risk surgical comorbidities were excluded. Groups were matched using inverse probability weighting. The primary outcome was all-cause mortality. Secondary outcomes were stroke, transient ischemic attack, permanent pacemaker implantation, bleeding, rehospitalization for atrial arrhythmias, and rehospitalization for heart failure. Kaplan–Meier estimates and Cox proportional-hazards regression were used to compare outcomes. Outcomes were adjusted for variables with a standardized mean difference greater than 0.1.ResultsOf 439,492 patients who underwent aortic valve replacement, 2591 underwent SAVR-SA and 1494 underwent TAVR alone. Weighting resulted in adequately matched groups. Compared to TAVR alone, SAVR-SA was associated with a significant reduction in all-cause mortality (HR 0.65, 95% CI 0.53–0.79), permanent pacemaker implantation (HR 0.62, 95% CI 0.44–0.87), bleeding (HR 0.63, 95% CI 0.39–1.00), and rehospitalization for heart failure (HR 0.49 (0.36–0.65). There was no difference in the incidence of stroke (HR 1.07, 95% CI 0.74–1.54), transient ischemic attack (HR 1.05, 95% CI 0.75–1.47), or rehospitalization for atrial arrhythmia.ConclusionSelect patients with persistent non-valvular AF may benefit from SAVR-SA compared to TAVR alone.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40119-022-00262-w.

Predictors of Thrombus Dissolution in the Left Atrial Appendage in Patients with Persistent Nonvalvular Atrial Fibrillation

The aim of this study is to identify factors influencing the likelihood of the thrombus dissolution in the left atrial appendage in patients with persistent nonvalvular atrial fibrillation. Material and methods. A repeated transesophageal echocardiography was performed in 88 patients with persistent nonvalvular atrial fibrillation and with the left atrial appendage thrombus at the first transesophageal echocardiography. Results. The second transesophageal echocardiography was performed on average 30.0 (22.0; 40.0) days after the first one, the thrombus dissolution in the left atrial appendage was revealed in 60 (68.2%) patients. The multivariate logistic regression analysis showed that the chances of the thrombus dissolution increased by 5.789 (1.907–17.568) times with the thrombus size not more 25 mm, by 5.318 (1.325–21.353) times with the left atrial appendage emptying flow velocity not less 20 cm/s and 3.687 (1.229–11.059) times when prescribing the direct oral anticoagulants, and not warfarin. Combination of two or more factors give the probability of the thrombus dissolution of more than 89.6%. Conclusion. The probability of the thrombus dissolution in left atrial appendage in patients with persistent nonvalvular atrial fibrillation increases with a small thrombus size, a high the left atrial appendage emptying flow velocity, and if direct oral anticoagulants were prescribed.

Features of sinus rhythm restoration in patients with paroxysmal and persistent non-valvular atrial fibrillation and previous COVID-19 infection in iron-deficiency anaemia

Background. Currently, there are conclusive data in the literature on the effect of reduced haemoglobin concentration on sinus rhythm restoration in patients with nonvalvular atrial fibrillation. It is relevant to study the features of rhythm restoration in patients with anaemia and atrial fibrillation in COVID-19 infection.&#x0D; Aim. To study the effects of iron-deficiency anaemia on sinus rhythm restoration rate and the dose of amiodarone required for this in patients with paroxysmal and persistent non-valvular atrial fibrillation and previous COVID-19 infection.&#x0D; Material and methods. The study included 63 patients aged between 53 and 94 years (mean age 60.810.9 years): 26 men (41.3%) and 37 women (58.7%). The patients were divided into groups according to the presence of anaemia and computed tomography staging (CT severity score) of lung damage. Criteria for inclusion: paroxysmal or persistent non-valvular atrial fibrillation; previous COVID-infection (according to the documents, medical records). We took into account medical histories, laboratory and instrumental findings, as well as treatment. The statistical analysis was performed by using the Statistica 13.3 software. The obtained data were presented as M or Me [Q1; Q3]. The differences between the indicators were assessed using Students t test, the MannWhitney U test and the KruskalWallis H test. Nominal variables were compared by using Pearsons 2 test with Yates correction or Fishers criterion. The relationship between the parameters was assessed using the Pearsons or Spearmans correlation coefficient. A p 0.05 was considered statistically significant.&#x0D; Results. The patients with normal haemoglobin concentration restored sinus rhythm for 10 [4; 13] hours and the patients with iron-deficiency anaemia for 5.5 [2; 10] hours (p=0.044). In patients with COVID-19 pneumonia, we found a direct correlation between the degree of lung damage and the dose of amiodarone (r=0.33, p 0.05), as well as the time of sinus rhythm restoration (r=0.48, p 0.05).&#x0D; Conclusion. The presence of iron-deficiency anaemia in patients with previous COVID-19 infection and paroxysmal and persistent non-valvular atrial fibrillation is associated with a shorter time and a lower dose of amiodarone required for successful sinus rhythm restoration in comparison to patients with normal haemoglobin concentration; in patients with more severe lung damage caused by COVID-19 pneumonia, it takes more time and a large dose of amiodarone for sinus rhythm restoration.

ASSOCIATION OF LEFT ATRIAL SPONTANEOUS ECHO CONTRAST WITH CLINICAL AND HEMODYNAMIC CHARACTERISTICS OF PATIENTS WITH LONG-TERM EPISODES OF PERSISTENT ATRIAL FIBRILLATION.

The aim: To identify clinical and hemodynamic factors, associated with left atrial spontaneous echo contrast (LASEC) (LASEC in general, and the dense LASEC), in non-valvular persistent atrial fibrillation (AF) patients with the duration of AF episode ≥90 days. Materials and methods: The cross-sectional study consecutively enrolled 115 persistent AF patients with the duration of its episode ≥90 days (82 (71,3 %) males; mean age 59 ± 11 years). Transthoracic (TEE) and transesophageal echocardiography (TEE) were performed. LASEC (by TEE) was observed in 79 (68,7 %) patients. The dense (moder¬ate-to-severe) LASEC was detected in 23 (20,0 %) cases. Results: Heart failure (HF) stage C (OR 2,09 (95 % CI 1,24-3,53); p=0,006), lower TEE-derived left atrial appendage (LAA) flow velocity (FV) (OR 0,94 (95 % CI 0,91-0,98); p=0,003), and the presence of TTE-derived pulmonary hypertension (PH), appeared to be strongly associated with LASEC (AUC for logistic regression model: 0,83 [95 % СI 0,75- 0,89]). The presence of diabetes mellitus type 2 (DM) (OR 2,34 (95 % CI 1,13-4,86); p=0,027), along with lower LAA FV (OR 0,83 (95 % CI 0,76-0,91); p<0,001), were strongly associated with dense LASEC (AUC: 0,89 [95 % CI 0,82-0,94]). Conclusions: The TEE-derived LASEC in patients with long term episodes (≥90 days) of persistent AF was strongly associated with HF stage C and TTE-derived PH, and with lower TEE-derived LAA FV. The presence of DM, in addition to lower LAA FV, was related to dense LASEC.

Angiographic profile and outcomes in persistent non-valvular atrial fibrillation: A study from tertiary care center in North India

BackgroundThe relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established, yet it is often missed. There is evidence of myocardial ischemia on stress imaging in AF patients in the absence of obstructive CAD. In this prospective cohort, we studied the angiographic profiles of non-valvular AF patients. MethodsThe study was a nonrandomized, prospective, single-center observational study of consecutive patients of persistent non-valvular AF. Patients symptomatic for AF despite optimal medical therapy for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with prior history of CAD were excluded. ResultsA total of 70 patients were followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49) years. Hypertension was the commonest comorbidity seen in 74% patients. Obstructive CAD was present in 32 (46%) patients, non-obstructive (<50% stenosis) CAD in 17 (24%) patients and normal coronaries in 21 (30%) patients. Overall 49 (70%) patients had evidence of CAD. Amongst patients without obstructive CAD, slow flow was seen in 16 (42%) patients. Lower baseline ejection fraction, lower haemoglobin & albumin levels and higher creatinine levels was associated with increased mortality. In patients without obstructive CAD, hospitalizations for fast ventricular rate were significantly increased in those having slow flow on CAG (p = 0.005). ConclusionsMajority (70%) of our patients had evidence of atherosclerotic CAD on CAG. A large proportion of patients without obstructive CAD had slow flow on CAG.

Metabolomic and Proteomic Analyses of Persistent Valvular Atrial Fibrillation and Non-Valvular Atrial Fibrillation.

Atrial fibrillation (AF) is an abnormal heart rhythm related to an increased risk of heart failure, dementia, and stroke. The distinction between valvular and non-valvular AF remains a debate. In this study, proteomics and metabolomics were integrated to describe the dysregulated metabolites and proteins of AF patients relative to sinus rhythm (SR) patients. Totally 47 up-regulated and 41 down-regulated proteins in valvular AF, and 59 up-regulated and 149 down-regulated proteins in non-valvular AF were recognized in comparison to SR patients. Moreover, 58 up-regulated and 49 significantly down-regulated metabolites in valvular AF, and 47 up-regulated and 122 down-regulated metabolites in persistent non-valvular AF patients were identified in comparison to SR patients. Based on analysis of differential levels of metabolites and proteins, 15 up-regulated and 22 down-regulated proteins, and 13 up-regulated and 122 down-regulated metabolites in persistent non-valvular AF were identified relative to valvular AF. KEGG pathway enrichment analysis showed the altered proteins and metabolites were significantly related to multiple metabolic pathways, such as Glycolysis/Gluconeogenesis. Interestingly, the enrichment pathways related to non-valvular AF were obviously different from those in valvular AF. For example, valvular AF was significantly related to Glycolysis/Gluconeogenesis, but non-valvular AF was more related to Citrate cycle (TCA cycle). Correlation analysis between the differentially expressed proteins and metabolites was also performed. Several hub proteins with metabolites were identified in valvular AF and non-valvular AF. For example, Taurine, D-Threitol, L-Rhamnose, and DL-lactate played crucial roles in valvular AF, while Glycerol-3-phosphate dehydrogenase, Inorganic pyrophosphatase 2, Hydroxymethylglutaryl-CoAlyase, and Deoxyuridine 5-triphosphate nucleotidohydrolase were crucial in non-valvular AF. Then two hub networks were recognized as potential biomarkers, which can effectively distinguish valvular AF and non-valvular persistent AF from SR samples, with areas under curve of 0.75 and 0.707, respectively. Hence, these metabolites and proteins can be used as potential clinical molecular markers to discriminate two types of AF from SR samples. In summary, this study provides novel insights to understanding the mechanisms of AF progression and identifying novel biomarkers for prognosis of non-valvular AF and valvular AF by using metabolomics and proteomics analyses.

Efficiency of the Left Atrial Appendage Thrombus Dissolution in Patients with Persistent Nonvalvular Atrial Fibrillation with Warfarin or Direct Oral Anticoagulants Therapy

Aim. Compare the incidence of the left atrial appendage (LAA) thrombus dissolution in patients with persistent nonvalvular atrial fibrillation receiving warfarin and direct oral anticoagulants (DOAC).Materials and methods. 68 patients with persistent nonvalvular atrial fibrillation were included in a retrospective study (age was 59.7±9.8 years, 60.3% men), in whom at least one repeated transesophageal echocardiographic examination was performed after detecting a thrombus. After detecting a thrombus in the LAA, 37 (54.4%) patients started or continued taking warfarin in doses that ensure the INR maintenance at the level of 2-3, 14 (20.6%) started or continued taking dabigatran at a dose of 150 mg 2 times/day, 14 (20.6%) started or continued taking rivaroxaban 20 mg 1 time/day and 3 (4.4%) started or continued taking apixaban 5 mg 2 times/day. Repeated transesophageal echocardiographic examination was performed on average 33.3±14.2 days after the first one.Results. Dissolution of a previously identified thrombus was found in 26 (83.9%) of 31 patients receiving DOAC and in 19 (51.4%) of 37 patients receiving warfarin (p=0.011). The logistic regression analysis showed that the chances of a thrombus dissolution in LAA while taking DOAC are 14.8 times (95% confidence interval [CI] was 2.469-88.72) higher than while taking warfarin. The size and the rate at which blood is expelled from the LAA also have an independent influence on the chances of thrombus dissolution. An increase in the size of a thrombus by 1 mm reduces the chances of a thrombus dissolution by 1.136 (95% CI was 1.040-1.244) times, and an increase in the rate of blood expulsion from the LAA by 1 cm/sec increases these chances by 1.105 (95% CI was 1.003-1.219) times.Conclusion. In the present study, the incidence of the LAA thrombus dissolution in patients with persistent nonvalvular atrial fibrillation while receiving DOAC was higher than while receiving warfarin.