Restoration Of Sinus Rhythm In Patients Research Articles

Cavutilide (Refralon) for pharmacological cardioversion of early recurrence atrial fibrillation and flutter in blanking period after pulmonary veins isolation

Objective. Evaluate efficacy and safety of cavutilide (Refralon) for pharmacological cardioversion in patients with recurrent atrial fibrillation and flutter (AF/AFL), in 90days blanking period of catheter ablation.Materials and methods. included 56 patients: 46 patients with recurrent paroxysmal AF/AFL and 10 patients with recurrent persistent AF/AFL. In 45 patients (80.3%), sinus rhythm (SR) restoration was performed within 7 days from the moment of catheter ablation. Intraoperative confirmation of pulmonary vein (PV) isolation was noted in 85.7% cases (n=48). After excluding contraindications, cavutilide was administrated in the intensive care unit according to a 4-stage protocol (5 µg/kg – 5 µg/kg-10 µg/ kg – 10 µg/kg). Effectiveness of pharmacological cardioversion was assessed as the fact of restoring SR and the fact of preservation of SR 24 hours after cavutilide administration. Safety points – QT prolongation, ventricular arrhythmogenic effects, pauses and bradyarrhythmias.Results. The overall effectiveness of cavutilide among all included patients reached 98.2% (n=55), and preservation of SR 24 hours after cavutilide administration was observed in 94.5% (n=53) patients. All the patients with recurrent persistent AF/AFL successfully restored and maintained SR 24 hours after cavutilide administration 100% (n=10). In patients with recurrent paroxysmal AF/AFL restoration of SR observed in 97.8% (n=45) and preservation of SR after 24 hours – in 93.4% (n=43), respectively. The effectiveness of cavutilide did not depend on the results of the catheter ablation. Recurrences of AF/AFL after SR restoration were more common in patients without successful PV isolation. QT prolongation >500ms observed in 8.9% (n=5) of cases, including 1 case of self-terminating torsade de pointes, managed by MgSO4 infusion. Bradyarrhythmias that did not require urgent therapy were noted in 10.7% (n=6) of cases.Conclusion. Pharmacological cardioversion with Cavutilide (Refralon) is highly effective and safe method of SR restoration in patients with recurrent AF/AFL in 90days blanking period after catheter ablation.

Improvement in atrial functional and ventricular functional tricuspid regurgitation following catheter ablation or cardioversion of atrial fibrillation

Abstract Background The majority of cases of significant tricuspid regurgitation (TR) are secondary to tricuspid annular dilation and leaflet tethering in the context of RV remodeling due to pressure or volume overload, as seen in patients with pulmonary hypertension (primary or secondary to left-sided heart disease) or dilated cardiomyopathies. Secondary TR induced by tricuspid valve annular dilatation secondary to right atrial dilatation is referred to as atrial functional TR, while secondary TR caused by RV remodeling is referred to as ventricular functional TR. In current guidelines, GDMT (Guideline-Directed Medical Therapy) is effective for secondary TR attributable to HF with reduced LVEF. Normal sinus rhythm should be restored for secondary TR caused by AF-related annular dilatation. In patients with ventricular functional TR, however, AF may also accompany the clinical condition. It is unknown whether restoring sinus rhythm will reduce tricuspid regurgitation in these patients. Purpose The objective of this study was to investigate the degree of tricuspid regurgitation change in patients with atrial and ventricular functional tricuspid regurgitation after sinus rhythm restoration. Methods A retrospective cohort study of patients undergoing AF ablation and cardioversion at a single center between 2019 and 2023 was performed. Patients with at least grade 1 TR on echocardiography and a baseline echocardiogram and a follow-up echocardiogram after ablation were included. A-FTR and V-FTR were defined according to the latest ACC/AHA guidelines. According to the latest guidelines, patients with mild to severe FTR were classified as A-FTR if they had atrial fibrillation, left ventricular ejection fraction >60%, pulmonary artery systolic pressure (PASP) <50 mm Hg, no left-sided valve disease, and normal-appearing tricuspid leaflets. FTR patients who did not meet at least one of these three criteria were defined as ventricular FTR (V-FTR). Results A total of 88 patients were enrolled. The prevalence of A-FTR in our cohort was 62% (53 patients), and 38% of the patients were in the V-FTR group. There was no significant difference between the A-FTR and V-FTR groups regarding age, gender, and NYHA class. 21 of the patients underwent DCCV, and 67 underwent catheter ablation. The prevalence of severe FTR was similar (%17 in A-FTR vs. %8,6 in V-FTR, p= 0.205). There was no difference in preintervention TR grade between the two groups. TR severity improved significantly from baseline to follow-up in both V-FTR and A-FTR patients. These outcomes were observed in patients who underwent both DCCV and catheter ablation. Conclusion The degree of tricuspid regurgitation is reduced with sinus rhythm restoration in patients with both ventricular functional and atrial functional TR.Changes in TR severity with interventionGraph of changes in severity of TR

Left Atrial Reduction Plasty and Sinus Rhythm Restoration in patients undergoing Mitral Valve Surgery with Chronic Atrial Fibrillation

Objective: To assess outcome of Left Atrial reduction plasty and sinus rhythm restoration in patients undergoing Mitral valve surgery with chronic Atrial Fibrillation. Study Design: Longitudinal study. Place and Duration of Study: Adult Cardiac Surgery Unit, Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi Pakistan, from Jan 2017-Jun 2022. Methodology: Thirty three (n=33) patients with mitral valve disease were recruited via convenience sampling, all of whom exhibited an enlarged left atrium and pre-operative Atrial Fibrillation (AF). Pre-operative cardiac evaluations were performed using Transthoracic Echocardiography (TTE). Pre- and post-surgery trans-esophageal echocardiography studies were conducted as a routine procedure. Follow-up echocardiographic assessments were carried out at intervals of 1 month, 3 months, and 6 months, alongside Electrocardiograms (ECGs). During surgery, median sternotomy was done. Cardiopulmonary Bypass (CPB) time was established followed by cardiac arrest. After Mitral valve Repair/Replacement (MVR), Left Atrial (LA) plication was done by a double needle. Results: Out of thirty three (n=33) patients, 25(75.7%) females and 8(24.2%) male patients, with mean age of 44.3±15.5 years, underwent mitral valve surgery(repair/replacement) followed by LA reduction & sinus rhythm restoration procedure. Complete restoration of sinus rhythm with re-appearance of “a” wave on echocardiography, signifying LA transport function through mitral valve was observed in 31(93.9%) patients on 3rd month and only 1(3.0%) individual continued to have persistent AF after 6 months. (83.70±2.50 mm vs. 47.50±1.08 mm) (p<0.001).................. Conclusion: Left atrial reduction by “Plication technique” followed by “Diathermy Fulguration” as a part of mitral valve surgery has yielded ...............

Intravenous Cavutilide for Pharmacological Conversion of Paroxysmal and Persistent Atrial Fibrillation in Patients with Heart Failure.

In this retrospective cohort study, 58 patients with stable HF (aged 69 [61;73] years, 30 males, 78% with persistent AF) and 274 patients without HF (aged 63 [57;70] years, 196 males, 56% with persistent AF) were included. The median AF duration in the group with HF was 35.5 [10.6;124] days, and that in the group without HF was 14.5 [3.6;90] days. All patients received 5-30 µg/kg cavutilide intravenously in one to four (if needed) boluses of 5-5-10-10 µg/kg at 15 min intervals. Subsequent boluses were not administered if the patient's sinus rhythm (SR) was restored or if bradycardia, QT prolongation > 500 ms or evidence of proarrhythmia was observed. Holter electrocardiogram monitoring was started before infusion and was continued for 24 h. The main criterion for an antiarrhythmic effect was sinus rhythm restoration within 24 h of the initial bolus. Cavutilide converted AF to SR in 37.9% of patients with HF after bolus 1 (5 µg/kg), in 58.6% after bolus 2 (cumulative dose = 10 µg/kg), in 74% of cases after bolus 3 (cumulative dose = 20 µg/kg) and in 92.8% of cases after bolus 4 (cumulative dose = 30 µg/kg). Cavutilide was effective in 89% of cases with persistent AF with a median duration of 70.5 [30;159] days and in 92% of cases with paroxysmal AF with a median duration of 36 [24;102] h. In the group of patients without HF, the effectiveness of bolus 1 was 36.9%, that of the bolus 2 was 58%, that of the bolus 3 was 77% and that of the bolus 4 was 90.1%. Cavutilide restored SR in 90% of patients with persistent AF with a median duration of 82.5 [28;180] days and in 90% of cases with paroxysmal AF with a median duration of 50 [24;120] h. No statistically significant difference in the probability of SR restoration or the effectiveness of each bolus of cavutilide was found between patients with and without HF. The median time to restoration of SR in patients with HF was 23 [11;55] min, and that in patients without HF was 22 [10;45] min (p = 0.424). No cases of symptomatic/severe bradycardia were observed in either group. QT prolongation over 500 ms after cavutilide injection was registered in 19% of patients without HF and in 15.5% of those with HF (p = 0.58). Short runs of Torsade de pointes tachycardia occurred in one patient (0.4%) without HF after 10 µg cavutilide administration and were successfully treated with MgSO4. Cavutilide demonstrated a high likelihood of AF conversion to SR in paroxysmal (92%) and persistent (89%) arrhythmia and HF. Concomitant HF and its severity do not affect the efficacy and safety of cavutilide.

Spontaneous Sinus Rhythm Restoration in Patients With Refractory, Permanent Atrial Fibrillation Who Underwent Conduction System Pacing and Atrioventricular Junction Ablation

Ablate and pace (A&P) with conduction system pacing (CSP) improves outcomes in patients with symptomatic permanent atrial fibrillation (AF). Data on spontaneous sinus rhythm restoration (SSRR) in this setting are lacking. This study aimed to assess the incidence and the predictors of SSRR in a population of patients with permanent AF who underwent A&P with CSP. Prospective, observational study, enrolling consecutive patients with symptomatic permanent AF (of documented duration >6months) and uncontrolled, drug-refractory high ventricular rate, who underwent A&P with CSP. The incidence and predictors of SSRR were prospectively assessed. A total of 107 patients (79.0 ± 9.1years, 33.6% male, 74.8% with New York Heart Association class ≥III, 56.1% with ejection fraction <40%) were enrolled: 40 received His' bundle pacing, 67 left bundle branch area pacing. During a median follow-up of 12months SSRR was observed in 14 patients (13.1%), occurring a median of 3months after A&P (interquartile range 1 to 6; range 0 to 17). Multivariable analysis identified a duration of permanent AF <12months (hazard ratio 7.7, p=0.040) and a left atrial volume index <49ml/m2 (hazard ratio 14.8, p=0.008) as independent predictors of SSRR. In patients with coexistence of both predictors the incidence of SSRR was of 41.4%. In a population of patients with symptomatic, permanent AF, treated with A&P with CSP, SSRR was observed in 13% of patients during follow-up. A duration of permanent AF <12months and a left atrial volume index <49 ml/m2 were independent predictors of this phenomenon.

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

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 &lt; 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.

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.

Impact of heart rate reduction on recurrence after catheter ablation of persistent atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Johnson &amp; Johnson KK OnBehalf OCVC Arrhythmia Investigators Background Predicting heart rate (HR) after restoration of sinus rhythm (SR) remains one of the challenges when performing catheter ablation (CA) of persistent atrial fibrillation (AF). Purpose To evaluate the association between pre-ablation HR during AF and post-ablation HR during SR, and whether the HR reduction is associated with AF recurrence. Methods The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. After excluding patients with beta-blocker prescription, a total of 216 patients (median age, 67 years; 20% female; 23% long-standing persistent AF) with AF rhythm at baseline and SR at discharge were enrolled in this study. Baseline HR during AF and post-ablation HR during SR was measured on admission and at discharge using the 12-lead electrocardiograms, respectively. Results There was a mild correlation between baseline HR (median 82 [interquartile range 72-95] bpm) and post-ablation HR (78 [48-117] bpm) (r = 0.27, p &amp;lt;0.001). Reduction in HR was positively associated with baseline HR (r = 0.79, p &amp;lt;0.001) and was negatively associated with post-ablation HR (r = - 0.37, p &amp;lt;0.001). During the follow-up of 1 year, 56 patients (25.9%) experienced AF recurrence. HR reduction had the higher diagnostic accuracy in predicting AF recurrence than HR at baseline and HR after CA (area under the curve, 0.625; 95% confidence interval, 0.557–0.690; p = 0.003). AF recurrence rate was significantly higher in 141 patients with smaller HR reduction (cut-off, &amp;lt;14bpm) than those with larger HR reduction (31.9% vs. 14.7%, p = 0.009). After adjustment of age, gender, long-standing persistent AF, and CA strategy, HR reduction of &amp;lt;14 bpm was a significant predictor of AF recurrence (hazard ratio, 2.32; 95% confidence interval, 1.20–4.51; p = 0.013). Conclusions There was a mild correlation between HR during AF and HR after restoration of SR in patients underwent CA of persistent AF. HR reduction after restoration of SR predicted AF recurrence.

Stroke risk assessment in patients with persistent atrial fibrillation to consider performing pre-cardioversion transesophageal echocardiography

Aim. To study the potential of stroke risk assessment to evaluate the probability of detecting left atrial appendage (LAA) thrombus in patients with persistent atrial fibrillation (AF) to consider performing transesophageal echocardiography (TEE) before cardioversion.Material and methods. TEE before elective cardioversion was performed in 590 patients with persistent AF, of whom 316 (53,6%) had a high stroke risk (valvular AF, hypertrophic cardiomyopathy, CHA2DS2-VASc score &gt;1 in men and &gt;2 in women), and 274 (46,4%) — not high. Adequate anticoagulation at least 3 weeks prior to elective cardioversion was received by 164 (51,9%) patients with a high stroke risk and 151 (55,1%) patients with a low risk. The rest of patients either did not receive adequate anticoagulation or received it for less than 3 weeks.Results. In the group of patients who received anticoagulation at least 3 weeks, LAA thrombus was detected in 23 (14,0%) patients with a high stroke risk and in 8 (5,3%) patients with a low risk (p&lt;0,05). In patients who did not receive adequate anticoagulation or received it for less than 3 weeks, LAA thrombus was identified in 60 (39,5%) patients with a high stroke risk and in 22 (17,9%) patients with a low risk (p&lt;0,005). Thus, a high stroke risk almost 3 times increases the likelihood of LAA thrombus detection in patients who did not receive adequate anticoagulation (odds ratio, 2,99; 95% confidence interval: 1,70-5,26;p&lt;0,001) and in patients receiving adequate anticoagulation (odds ratio, 2,92; 95% confidence interval: 1,26-6,74; p=0,012).Conclusion. In patients with persistent AF with a low stroke risk according to CHA2DS2-VASc score, TEE before sinus rhythm restoration in patients without 3-week anticoagulation should be considered. In patients with a high stroke risk, performing pre-cardioversion TEE is advisable even after adequate anticoagulation.

Abstract 11138: Impact of Heart Rate Reduction on Recurrence After Catheter Ablation of Persistent Atrial Fibrillation

Introduction: Predicting heart rate (HR) after restoration of sinus rhythm (SR) remains one of the challenges when performing catheter ablation (CA) of persistent atrial fibrillation (AF). Objectives: To evaluate the association between pre-ablation HR during AF and post-ablation HR during SR, and whether the HR reduction is associated with AF recurrence. Methods: The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. After excluding patients with beta-blocker prescription, a total of 216 patients (median age, 67 years; 20% female; 23% long-standing persistent AF) with AF rhythm at baseline and SR at discharge were enrolled in this study. Baseline HR during AF and post-ablation HR during SR was measured on admission and at discharge using the 12-lead electrocardiograms, respectively. Results: There was a mild correlation between baseline HR (median 82 [interquartile range 72-95] bpm) and post-ablation HR (78 [48-117] bpm) (r = 0.27, p &lt;0.001). Reduction in HR was positively associated with baseline HR (r = 0.79, p &lt;0.001) and was negatively associated with post-ablation HR (r = - 0.37, p &lt;0.001). During the follow-up of 1 year, 56 patients (25.9%) experienced AF recurrence. HR reduction had the higher diagnostic accuracy in predicting AF recurrence than HR at baseline and HR after CA (area under the curve, 0.625; 95% confidence interval, 0.557-0.690; p = 0.003). AF recurrence rate was significantly higher in 141 patients with smaller HR reduction (cut-off, &lt;14bpm) than those with larger HR reduction (31.9% vs. 14.7%, p = 0.009). After adjustment of age, gender, long-standing persistent AF, and CA strategy, HR reduction of &amp;lt;14 bpm was a significant predictor of AF recurrence (hazard ratio, 2.32; 95% confidence interval, 1.20-4.51; p = 0.013). Conclusions: There was a mild correlation between HR during AF and HR after restoration of SR in patients underwent CA of persistent AF. HR reduction after restoration of SR predicted AF recurrence.

Mechanism of improvement in atrial functional mitral regurgitation after catheter ablation for atrial fibrillation: Three-dimensional analysis using multislice computed tomography.

Several factors associated with atrial functional mitral regurgitation development have been reported; however, geometric changes in the mitral apparatus after catheter ablation for atrial fibrillation have not been sufficiently investigated. This study aimed to clarify what determines improvements in atrial functional mitral regurgitation after sinus rhythm restoration in patients who underwent catheter ablation for atrial fibrillation by using multislice computed tomography. We analysed volumetric multislice computed tomography images of 44 atrial fibrillation patients with significant atrial functional mitral regurgitation (moderate or worse) before and after catheter ablation. We measured the three-dimensional geometry of the mitral apparatus including the mitral annular area and interpapillary muscle distance. We calculated the differences before and after catheter ablation (Δmitral annular area, Δinterpapillary muscle distance) and assessed mitral regurgitation severity based on the mitral regurgitant jet area and its changes before and after catheter ablation (Δjet area) using transthoracic echocardiography. After catheter ablation, the jet area was significantly decreased. The left ventricular ejection fraction was significantly increased and the left ventricular volume had a decreasing trend. The Δjet area was significantly correlated with the Δinterpapillary muscle distance (r = .43; p = .004). The Δinterpapillary muscle distance was the strongest determinant of improvements in atrial functional mitral regurgitation severity (p = .026). Decreased interpapillary muscle distance was strongly associated with improvements in atrial functional mitral regurgitation. Amelioration of left ventricular dysfunction by sinus rhythm restoration might be related to improvements in atrial functional mitral regurgitation after catheter ablation.

Restoration of normal sinus rhythm in atrial fibrillation: impact of reverse remodelling of right chambers on tricuspid regurgitation severity

Abstract Background The severity of tricuspid regurgitation (TR) in patients with restored normal sinus rhythm (SR) after atrial fibrillation (AF) has been poorly assessed. Purpose Our study aimed to assess (1) right chamber remodelling and (2) TR severity in patients with AF who have had their rhythms restored to normal sinus. Methods We prospectively evaluated 94 consecutive patients hospitalized for AF who received either ablation, direct current cardioversion, or pharmacological therapy. Patients were divided into two groups according to their cardiac rhythm at 6 months follow up (6M): restoration to SR (SR group, n=54), persistence of AF (AF group, n=40). TR vena contracta (VC), TR grade severity was divided into 4 grades using an integrated approach (0: none or trace; 1: mild; 2: moderate; 3: severe TR). Two dimensional (2D) end diastolic (ED) tricuspid annulus (TA) diameter in the apical 4 chambers view, three-dimensional (3D) indexed volumes (3D Vi) of the right atrium (RA) and right ventricle (RV) in end systole (ES) and ED were acquired using transthoracic echocardiography at admission and at 6M. Results At 6M, in the SR group a significant improvement in TR VC (Figure A) and TR grade (Figure B) were noted, whereas there was no differences in the AF group (0.41 vs. 0.42cm, p=0.24 for TR VC; 1.70 vs. 1.76, p=0.16 for mean TR grade). In the SR group a significant reduction in 3D ES RV Vi, 2D ED TA diameter, 3D ES and ED Vi of the RA (Table) were observed. Regression of TR VC was correlated with regression of right cavities parameters (ρ=0.47, p&amp;lt;0.001 for 2D ED TA diameter; ρ=0.34, p&amp;lt;0.005 for 3D ES RA Vi; ρ=0.33, p&amp;lt;0.005 for 3D ED RV Vi; ρ=0.29, p&amp;lt;0.005 for 3D ES RV Vi). Conclusion Restoration of normal SR in patients with AF results in beneficial remodelling of right cavities at 6M of follow-up which were associated with a significant decrease in TR severity. Strategies for normal SR restoration in patients with AF and TR should be vigorously attempted. TR Evolution Funding Acknowledgement Type of funding source: None

Rapid improvement in left ventricular function after sinus rhythm restoration in patients with idiopathic cardiomyopathy and atrial fibrillation.

Sinus rhythm restoration (SRR) in patients with atrial fibrillation (AF) and heart failure may improve systolic function and impact on consecutive clinical management, but time course and potential predictors of response to SRR are uncertain. We prospectively studied 50 consecutive patients who presented in heart failure with reduced ejection fraction (EF) and concomitant AF. After exclusion of valvular and coronary artery disease patients underwent electrical cardioversion. Serial echocardiography, cardiac magnetic resonance imaging (cMRI), and 24-h electrocardiograms were performed at baseline, and on Days 3 and 40 following SRR. Baseline left ventricular EF of the study population (76% male, age 69 ± 11 years) was 30 ± 7%. Sustained SRR (≥3 days) significantly improved EF (Day 3: 43 ± 7%, n = 46; Day 40: 53 ± 9%, n = 34; P < 0.001) as quantified by echocardiography. Comparable results were obtained using cMRI (baseline: 29 ± 8%; Day 3: 42 ± 9%). Three patients showed no response to SRR (EF improvement <15%). The percentage of patients meeting current criteria for implantable cardioverter-defibrillator (ICD) implantation for primary prevention dropped from 76% (n = 38) to 11% (n = 3) on Day 40 following SRR. No specific clinical or echocardiographic factor predicting improved EF after SRR could be identified. The majority of patients presenting with non-ischaemic, non-valvular heart failure with reduced EF and concomitant AF show a significant and rapid improvement in EF following SRR. An attempt at SRR and reassessment of the need for ICD implantation after 40 days may be warranted in all such patients.

Restoration of Sinus Rhythm in Patients With Persistent Atrial Fibrillation and Obesity: New Possibilities of Pharmacological Cardioversion

We present in this article 2 cases of successful pharmacological restoration of sinus rhythm by a new class III antiarrhythmic drug refralon in patients with obesity and persistent atrial fibrillation. In both cases, the effective use of refralon was preceded by repeated ineffective attempts of electrical cardioversion. In the article we discuss the role of obesity as the factor leading to a substantial increase of transthoracic electrical resistance, and thus significantly reducing the probability of sinus rhythm restoration by means of electrical cardioversion. The clinical examples described in this article clearly show that the use of refralon may represent a unique clinical alternative to electrical cardioversion for sinus rhythm restoration in patients with persistent atrial fibrillation, and in some cases where the success of electrical cardioversion is obviously questionable, like in patients with severe obesity, the use of refralon seems preferable.

Strategy of sinus rhythm restoration after single stage correction of mitral valve defect and maze procedure for improvement of efficacy and safety of anticoagulant therapy

We analyzed clinical efficacy of a strategy of sinus rhythm (SR) restoration after single stage correction of mitral valve defect and failed radiofrequency maze procedure elaborated and realized in the Research Institute for Complex Issues of Cardiovascular Diseases, and assessed its value for increase of efficacy and safety of anticoagulant therapy. First stage of this strategy--cardiosurgical treatment with maze procedure--resulted in restoration of SR in 61.8% of cases. In case of persistence of tachyarrhythmia external elelectro-impulse therapy was used in 1-1.5 months after cardiac surgery as a second stage of our strategy. Third stage--catheter radiofrequency ablation--was applied to patients with implanted biological cardiac valves. Second and third stages facilitated restoration of SR in 84.8 and 93.2% of patients, respectively, and provided 100% SR restoration in patients with biological valve prostheses. The suggested strategy allowed to withdraw anticoagulant therapy in patients with biological valves and to reduce level of hypocoagulation to lower limit of target range in patients with mechanical prostheses.

Elevated brain natriuretic peptide level in patients undergoing atrial fibrillation ablation: is it a predictor of failed ablation or a mere function of atrial rhythm and rate at a point in time?

Pre- and postablation atrial fibrillation (AF) brain natriuretic peptide (BNP) levels were shown to predict increased recurrence of AF following ablation. Our objective was to assess whether elevated BNP levels merely represent the presence of AF at the time of measurement or indeed the true recurrence of AF. In a prospective study of 88 patients undergoing AF ablation, BNP levels were measured immediately before, after, 24 h, and 4-6 months postablation. BNP levels were stratified by presenting rhythm and ventricular rate at the time of measurement. Median BNP level preablation was higher in patients presenting in AF compared to sinus rhythm (SR) (54(44-79) pg/ml vs. 30(18-47) pg/ml, p < 0.001). Postablation restoration of SR in patients presenting in AF reduced median BNP levels from 54(44-79) pg/ml to 40(37-51) pg/ml, (p < 0.001). However, no change was noted in patients who presented in and maintained SR throughout the procedure (30(18-47) pg/ml to 27(16-40) pg/ml, p = 0.270). At 4-6 months, BNP measured in patients in SR was not significantly different from postablation BNP (35(22-53) pg/ml vs. 38(20-52) pg/ml, p = 0.656), although 35% of them had AF recurrence in 1-year follow-up. Median BNP level measured in five patients while in atrial arrhythmia was elevated compared to postablation BNP (464(421-464) pg/ml to 37(36-37) pg/ml, p = 0.043). BNP levels and ventricular rates are positively correlated at all times pre- and postablation. BNP level rises acutely during AF and with rapid ventricular rates. BNP level seems to be a function of atrial rhythm and ventricular rate rather than short- or long-term predictor of AF ablation success.

325 * TOTALLY ENDOSCOPIC SURGICAL EPIMYOCARDIAL ABLATION IN PATIENTS TURNED DOWN FOR CATHETER TREATMENT DUE TO PERSISTENT LONE ATRIAL FIBRILLATION AND SIGNIFICANT ATRIAL DILATATION

Objectives: To analyse the safety and efficacy of surgical endoscopic epimyocardial ablation in patients turned down for interventional catheter therapy due to long-standing persistent atrial fibrillation (AF) combined with significant atrial dilatation (>5 cm). Methods: Since December 2010, 15 patients with no reasonable interventional therapy option were referred by electrophysiology for surgical ablation (persistent AF + biatrial dilatation [left atrial diameter 5.8 ± 0.6 cm]). The mean patient age was 52 ± 6 years, 66.6% were male, body mass index 38 ± 6, AF duration 2.8 ± 1.2 years, left ventricular ejection fraction 46 ± 12%, and left ventricular end diastolic diameter 54 ± 6 mm. Ablation was performed via a bilateral endoscopic approach by bipolar radiofrequency. All patients received intra- and postoperative amiodarone for three months, and monitoring was achieved by an implanted event recorder. The primary endpoint was cardiac rhythm after 12 months. Results: All patients successfully received bilateral pulmonary vein isolation + box lesion + trigonum lesion + left atrial appendage resection. Successful isolation was confirmed by intraoperative mapping followed by conversion to sinus rhythm (SR). The mean procedure duration was 235 ± 70 min. There was no intraoperative complication; one patient shows persistent left phrenic nerve palsy. The mean hospital stay was 4 ± 2 days, and mean follow-up 18 ± 6 months. The incidence of SR was 67%, 73% and 80% at discharge, and at 3- and 12-month follow-up respectively. Two additional patients were free from AF, but developed paroxysmal right atrial tachycardia which was successfully treated by catheter intervention at three and four months postoperatively. All patients in SR (14/15, 93%) are off anticoagulation and anti-arrhythmic drugs. Conclusions: Totally endoscopic complete left atrial ablation, including left atrial appendage resection, can be safely performed even in this difficult patient population. It achieved excellent rates of SR restoration in patients with long-standing persistent AF combined with significant atrial dilatation, particularly if combined with additional interventional follow-up.

Atrial Fibrillation reduces the Functional REServe of the Heart by a fifth: A pilot FRESH-AF study

The advent of catheter ablation has reignited the controversy about whether rhythm or rate control should be the preferred mode of therapy for atrial fibrillation (AF) [1]. It is well known that compared to sinus rhythm (SR), AF is associated with increased mortality and morbidity including stroke, heart failure, and impaired quality of life. Furthermore, patients may experience adverse effects from drug treatment that may negate thebeneficial effects ofmaintaining SR [2].What is still unknown is inwhatways and by howmuch overall cardiac function is impairedwhen the atrial “kick” in SR is lost after the onset of AF. To fill this gap in knowledge, it is essential to assess cardiac functionnot onlyat rest but also during maximal stress, and not merely piecemeal aspects of cardiac function. This can be achieved by conducting full cardiopulmonary exercise testing (CPX) in combination with non-invasive evaluation of central haemodynamics [3]. Thiswouldprovide a quantitative assessment of aerobic physical exercise capacity represented by peak O2 consumption (VO2max), together with peak cardiac power output (CPOmax) which measures the overall cardiac dysfunction [4], and is by far the strongest predictor of prognosis in heart failure patients [5]. As metabolic and circulatory demands increase during severe exercise, patients with AF have lower cardiovascular reserve. Previous studies have shown that VO2max improved by 5–13% after restoration of SR in patients with AF [6], buthowmuchcardiac functional gain is achieved thereby is still unknown. We therefore measured changes in CPOmax after successful DC cardioversion (DCCv) in patients with optimally rate-controlled AF. In so doing, we tested the hypothesis that the cardiac pumping capability of patients in AF is diminished by about a fifth. Twelve unselected ambulatory patients (10 males, age: 57.5 ± 13.7 (mean ± SD) years) with symptomatic persistent AF recruited from outpatient clinics underwent full CPX with measurements of non-invasive haemodynamics before and after successful DCCv. The aetiologies (including overlaps) of their AF were ischaemic heart disease (17%), hypertension (25%), LV dysfunction (42%), valve disease (25%), lone AF (25%), and obesity (BMI N 35, 25%). None of the patients had previous catheter ablation, or any contraindication to undergomaximal exercise, such as significant outflow obstruction, haemodynamically serious structural heart disease, uncontrolled ventricular tachyarrhythmia, uncontrolled hypertension, limiting symptoms of ischaemic heart disease, inability or deemed unsafe to exercise on treadmill, contraindications to electrical cardioversion or full anticoagulation, or inability to provide full informed consent. Standardexerciseparametersweremeasuredaspartof an incremental cardiopulmonary exercise test performed on a Trackmaster TMX425 treadmill (Full Vision, Kansas, USA) using the Bruce or modified Bruce protocol, as previously described [3]. Rates of oxygen consumption (VO2) and other gaseous exchanges were recorded breath-by-breath using the Medgraphics Ultima CardiO2 analytic system (Medgraphics, Minnesota, USA). Using the CO2-rebreathing technique (indirect Fick), cardiac output were measured at rest and during peak exercise. Mean arterial pressure was calculated from the equation, MAP=DBP+ 0.412 ∗ (SBP− DBP) [7]. CPOmax in watts is the product of peak cardiac output (COmax in l.min−1)multiplied by theMAP inmm Hg at peak exercisemultiplied by a conversion factor (2.22 × 10−3) [8]. A paired sample t-test was used to assess the change in cardiac reserve variables pre and post DCCv. This study was approved by the National Research Ethics Service Committee for Yorkshire & Humber in Leeds East. After successful cardioversion, subjectively all patients claimed to feel better and more energetic and, as shown in Table 1, objectively their treadmill exercise duration increased by 19.3% (P b 0.05), coupled with an improvement in peak O2 consumption by 16.5% (P b 0.01). Their resting ventricular rate decreased from 83.1 ±20.3 to 66.9 ± 20.5 min− 1 (P b 0.05), while peak exercise HR decreased from 163 ± 42 to 128 ± 18 min−1 to (P b 0.05). Secondarily, these negative chronotropic effects led to heightened stroke volume at peak exercise by 46% (P b 0.0001), thereby raising the peak cardiac output by 16.5% (P b 0.0001). Due to a concomitantly greater

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