Restoration Of Sinus Rhythm Research Articles

Presence and predictors of atrial low voltage zones in patients with non cardiovertable atrial fibrillation

Abstract Background Interventional treatment of persistent atrial fibrillation (pAF) presents a challenge due to the lack of clear evidence on adjunctive strategies beyond pulmonary vein isolation (PVI). One promising approach is ablation of left atrial low voltage zones, which has been shown to improve outcomes in patients with pAF. However, reliable assessment of left atrial endocardial voltage requires sinus rhythm (SR). In a significant proportion of patients with persistent atrial fibrillation (pAF) however, restoration of sinus rhythm (SR) cannot be achieved. These may lead to extensive ablations such as defragmentation or empirical isolation of the posterior wall of the left atrium. This study aims to investigate the potential of unsuccessful cardioversion prior ablation as a predictor for the presence of low voltage zones (LVZ) in the left atrium. Methods This retrospective, single-centre study was conducted on 264 patients (31,8% female; age: 67±10 years; mean AF duration: 1-2 years) diagnosed with pAF who underwent catheter ablation for pAF between 01/2017 and 01/2020. All patients underwent electrical cardioversion (CV) before ablation. If restoration of SR was achieved, high-density contact mapping was performed in sinus rhythm before pulmonary vein isolation (PVI), in case of unsuccessful initial cardioversion, high-density contact mapping was performed after repeated CV followed the PVI, respectively. Results Initial cardioversion was unsuccessful in 53 out of 264 (19.7%) patients. Subsequent to pulmonary vein isolation, cardioversion was successful in 47 out of 53 (81%) patients initially considered non-cardiovertible. In 32 out of 53 (60.4%) patients who had an initial unsuccessful cardioversion, no left atrial low voltage was identified. Amongst patients who underwent a successful initial cardioversion, left atrial low voltage zones were apparent in 77 out of 211 patients (36.5%). There is no significant difference in the the presence of left atrial low voltage between patients who had initially successful and unsuccessful CV (χ²(1) = 0.178, p = 0.673, φ = 0.026). According to the ROC analysis, the success of CV does not have any predictive value for LVZ (AUC 0.511). Conclusion Cardioversion failure before pulmonary vein isolation does not predict left atrial low-voltage zones (LVZ). PVI alone may be adequate even in patient with clinically "end stage" non-cardiovertible atrial fibrillation. Ablation beyond pulmonary vein isolation have the potential to overtreat this specific patient group, resulting in an increase in secondary arrhythmias. These findings indicate that even single-shot devices such as balloon-based techniques may be a considerable ablation strategy in these patient cohort.

Injury to the sinus nodal artery during radiofrequency ablation of atrial fibrillation and atrial tachycardia: its prevalence and treatment with percutaneous coronary intervention

Abstract Background/Introduction Injury to the sinus node artery (SNA) leading to SN dysfunction during radiofrequency catheter ablation (RFCA) of atrial Fibrillation (AF) and atrial tachycardia (AT) has been reported. Purpose The purpose of this study was to elucidate the prevalence and clinical course of SNA injuries during RFCA of AF/AT and examine the efficacy of the percutaneous coronary intervention (PCI) to restore SN function. Methods We retrospectively analyzed data from 6,906 consecutive patients (pts) who underwent RFCA of AF/AT (6,379 pts with AF ablation and 527 pts with AT ablation) in two institutions between January 2013 and December 2022. Results Among 6,906 pts, 9 (0.13%) pts developed SN dysfunction due to SNA injury during RFCA (8 with AF, 1 with AT). Acute SNA injury (total occlusion or severe narrowing of the SNA) was confirmed by coronary angiography (CAG) during the RFCA session in 8/9 pts. In the remaining patient, SNA injury was suspected based on the CT angiography. The culprit sites of the SNA injury were located at the septal site of the superior vena cava-right atrium junction in 4 pts (44%), on the left atrial appendage ridge in 3 (33%), on the roof of the left atrium adjacent to the right superior pulmonary vein in 1 (11%), and in the persistent left superior vena cava in 1 (11%). PCI to the occluded SNA was performed in 8 of the 9 pts: 1) coronary blood flow of the SNA was restored by a 0.014" guidewire advancement into the occluded artery using a micro-catheter followed by direct nitroprusside injection in 4 pts; 2) the direct balloon angioplasty using 0.75-1.5 mm diameter balloons was required to maintain the blood flow of SNA in 3 pts; and 3) CAG revealed spontaneous recovery of the blood flow of SNA in one pt. The remaining patient did not receive the CAG/PCI. All 8 pts who underwent the PCI resulted in restoration of normal sinus rhythm. During a median of 44 months follow-up, all 8 pts who received the PCI maintained normal sinus rhythm, while one patient without PCI demonstrated persistent SN dysfunction. Conclusions SNA injury during RFCA is a rare but critical complication. Prompt recognition by CAG and subsequent PCI effectively restores SN function in pts with unexpected SN dysfunction during RFCA procedures.

Comparison of two DCCV algorithms - rational versus maximum fixed energy (PROTOCOLENERGY trial)

Abstract Introduction Direct current cardioversion (DCCV) is a common procedure used to restore sinus rhythm (SR) in patients with atrial fibrillation (AF). However, there is ongoing debate about the optimal discharge energy to use during DCCV, and there are no clear guidelines on the optimal protocol for selecting the discharge energy. Purpose The aim of this study was to compare the efficacy and safety of two different DCCV algorithms, Rational and Maximum Fixed Energy, in achieving sinus rhythm after DCCV. The energy of the first shock in the Rational Algorithm was based on our retrospective data. Methods We conducted a prospective single-blind, single-centre trial that enrolled 300 patients with AF undergoing DCCV. Patients were randomised to one of two algorithms: an initial discharge of biphasic 150 J with escalation to two times 360 J discharge if needed in a Rational Algorithm, or first discharge of 360 J and additional two 360 J discharges if needed in Maximum Fixed energy algorithm. The primary endpoint was SR in the first minute after DCCV and any neurological complications. Secondary endpoints were skin changes immediately after DCCV and chest pain on the day after. Results The trial included 300 patients, divided into two arms of 150 patients each. The mean age of the patients was 68 years and 66 % were male. The mean LA diameter was 47 mm and the mean LV EF was 54.2 %. Rivaroxaban was the most frequently used NOAC (62.8 %) and the most commonly used antiarrhythmic drug was amiodarone (39 %).All patient characteristics are shown in the Table 1 below. In the Rational Algorithm arm, 92.7 % of patients had SR one minute after DCCV compared to 94 % in the Maximum Fixed Energy Algorithm arm (p=0.643). Both arms had a similar rate of SR (91.3 %) at two hours post-DCCV. There were no neurological complications in either group. The incidence of skin redness was higher in the Maximum Fixed Energy Algorithm arm (36 %) than in the Rational Algorithm arm (19.3 %) (p=0.001), while the incidence of chest pain was similar between the two arms. We found the difference in cardioversion success rates of both algorithms after the initial shock, i.e. after 150 J vs. 360 J (109 [72.7%] vs. 125 [83.3%] patients). Univariate analysis revealed significant differences in weight (mean 104 kg in AF vs mean 91 kg in sinus rhythm, p<0.001) and BMI (mean 34.1 kg/m2 in AF vs mean 30.5 kg/m2 in SR p<0.001) between those who remained in AF and those who achieved SR after the initial 150 J discharge. The results are presented in Table 2 below. Conclusion The PROTOCOLENERGY trial suggests that both algorithms are safe and effective in achieving sinus rhythm after DCCV. Although the Maximum Fixed Energy Algorithm showed a slightly higher success rate, the difference was not statistically significant. The Rational Algorithm is associated with a lower incidence of skin redness compared to the Maximum Fixed Energy Algorithm.Table 1Table 2

Translational exploration of fully biological restoration of cardiac rhythm via ion channel gene therapy

Abstract Background Recently it was demonstrated how the heart itself could be enabled to quickly restore its rhythm by realizing a biologically-integrated cardiac defibrillator (BioICD) through modification and subsequent expression of ion channels in cardiomyocytes [1]. By incorporating these frequency-dependent depolarizing ion channels, abnormal cardiac rhythm could be rapidly detected and terminated to restore sinus rhythm in a fully biological and shock-free manner. However, from a translational point of view, it remains unclear how such rhythm restoration can be realized via ion channel gene therapy. Purpose To explore and understand the importance of the distribution and number of BioICD-expressing cardiomyocytes in realizing fully biological restoration of cardiac rhythm. Methods To this purpose, two different realistic gene therapy configurations, i.e. those corresponding to systemic and local transgene delivery, were tested in a digital twin of human ventricular cardiac monolayers. For the systemic delivery group, BioICD-expressing cells were homogeneously distributed over the tissue with fixed total expression percentage. For the local delivery group, circular areas were given BioICD-expressing cells, randomly patterned in a Gaussian distribution. In both groups spiral waves were initiated and subsequently studied for 10 seconds. For systemic delivery, an additional set of simulations was performed for an adapted BioICD ion channel with a slower opening and faster closing rate. Results Upon comparing both gene therapy methods, the systemic approach showed a gradually increasing arrhythmia termination chance with increasing BioICD-expression percentage, while local delivery did not result in termination. Instead, local delivery resulted in islands of ionic heterogeneity, causing attraction and anchoring of the spiral waves in a size and distance-dependent manner. Building on the results of the systemic approach, different ion channel parameters were tried, which resulted in normal rhythm being restored in all cases for >50% BioICD expressing cells. Time till termination was inversely related to the percentage, resulting in only 4.3s and 2.5s for 50% and 100%, respectively. Regarding termination, it was observed that conduction blocks appeared throughout the tissue and subsequently connected to force arrhythmic waves to terminate, while this process remained incomplete in the <50% groups. Conclusion This study reveals that wide-spread distribution of BioICD-expressing cardiomyocytes is required for the realization of fully biological self-restoration of cardiac rhythm, of which the efficiency is ion-channel-dynamics- and dosage-dependent. Local expression, however, results in stabilization of spiral wave activity. Further exploration of this emerging concept of biological cardioversion may not only expand our understanding of cardiac arrhythmias, but also pave the way to breakthrough advances in arrhythmia management.

Evaluation of the Effect of Conversion of Nonvalvular Atrial Fibrillation to Sinus Rhythm on Cardiac Remodeling.

Atrial fibrillation (AF)represents the most prevalent cardiac arrhythmia globally, with a significant burden on mortality and morbidity. While rhythm control strategies, particularly electrical cardioversion (EC), have gained traction in recent years, the precise impact of sinus rhythm (SR) restoration on cardiac reverse remodeling remains a subject of debate. In this study, 23 AF patients underwent elective EC. AF diagnosis was made via ECG by a cardiologist, and candidates for cardioversion were selected by an electrophysiologist. Transthoracic echocardiography (TTE) by utilizing two-dimensional, three-dimensional, and tissue Doppler imaging modalities was performed before cardioversion. Patients who maintained SR after six months underwent a second TTE evaluation. SR was restored successfully in all 23 patients and 15 patients (65.2%) maintained SR after six months. SR group had significantly lower baseline cardiac output (CO)and indexed left ventricular end-systolic volume (LVESVi), and better European Heart Rhythm Association (EHRA) scores after six months. Within the SR group, patients exhibited significant changes in mitral regurgitation, tricuspid regurgitation, EHRA score, LVESVi, stroke volume, left ventricle ejection fraction, left ventricle global longitudinal strain, indexed minimum left atrial volume, left atrial emptying fraction, and left and right atrial diameters. Reduced CO was associated with AF recurrence. Receiver operating curve analysis revealed that CO value can predict six-month AF recurrence with a cut-off point of 2.3. Our study underscores the beneficial effects of SR restoration on cardiac parameters in AF patients post EC. Notably, CO value emerged as a predictor of AF recurrence, emphasizing the importance of comprehensive assessments for predicting long-term outcomes.

CLASS 1C AGENTS ARE EFFECTIVE AND SAFE IN TERMINATING RECENT–ONSET ATRIAL FIBRILLATION IN ELDER PATIENTS TOO

Abstract Background Amiodarone is still widely used in recent–onset atrial fibrillation (AF), mainly in elder people, for its presumed safety. Nevertheless the growing experience with class 1c agents could encourage their use in order to improve the management of AF in elderly too. Aim: To assess whether class 1c agents could be considered effective and safe in elder people, as well in younger, in terminating recent–onset AF. Methods We retrospectively evaluated a three–years experience in over 75 patients treated in the Emergency Department of University Hospital of Verona for recent–onset AF (< 48 h). We excluded patients submitted to electrical cardioversion and those in whom the choice of treatment was forced by clinical conditions or coronary and structural heart disease. Then we compared the results in terms of effectiveness and safety between the two groups of treatment, class 1c agents vs amiodarone. Statistical analysis was performed using Chi–square test, with significance level set at p<0.05. Results We attempted at restoration of sinus rhythm in 264 patients older than 75 years observed for recent–onset AF from January 2018 to December 2020. According to exclusion criteria, the study population was restricted to 147 patients (53 males, 94 females; mean age 80 years, range 75–95) where the treatment depended on the physician‘s choice only. Most of these patients (61.2%) was treated with amiodarone, while in 38.8% class 1c agents were administered. Mean age was not significantly different between the groups (81 vs 78.5). After treatment, stable restoration of sinus rhythm was reported in 43 patients (47.7%) in amiodarone and in 47 (82.4%) in class 1c group (p<0.01). Median time of conversion was 240 minutes (range 30–680) in amiodarone while 60 (range 15–530) in class 1c group (p<0.01), as shown in fig. 1. Surprisingly, even the narrow sample did not allow any significance, the incidence of adverse events was notably superior in amiodarone patients, both in number (5 cases) and seriousness (2 cases). Whereas in class 1c group we reported only one mild adverse event. At the end of observation, 43 patients (75.4%) in class 1c but only 38 (42.2%) in amiodarone group were discharged with stable sinus rhythm (p<0.02). Conclusions Class 1c agents appear to be more effective and as safe as amiodarone in terminating recent–onset AF even in selected elder people. However these preliminary results need to be confirmed in a larger and prospective study.

CARDIOVASCULAR CONSIDERATIONS IN ANTIDEPRESSANT THERAPY: SINUS ARREST DUE TO SERTRALINE

Abstract A 39–year–old Caucasian woman with a silent cardiac anamnesis and no family history of cardiovascular diseases, and a history of mood disorder treated with Sertraline for about 1 month, went to the Emergency Department reporting several syncopal episode, all with rapid and complete recovery of consciousness. In the Emergency Department, another syncopal episode occurred in the supine position, characterized by sinus bradycardia evolving into a brief asystole, with spontaneous restoration of normal sinus rhythm. Admitted to the Cardiovascular Intensive Care Unit, the patient showed no abnormalities in laboratory testsas well as in echocardiography results. The patient received appropriate hydration, and home medication was discontinued. A non–contrast head CT scan showed no acute lesions. Cardiac MR revealed normal morpho–functional findings, with no evidence of myocardial edema or pericardial effusion and no pathological late gadolinium enhancement areas. Brain MRI demonstrated normal anatomical and functional findings, with no signal abnormalities. Considering the patient‘s young age and the suspicion of an iatrogenic origin of the rhythm disorder, the decision to postpone pacemaker implantation was made, and cardiac electrical activity was monitored using a loop recorder. At the one–month follow–up, the patient, who had been off Sertraline since admission, was in good health, reporting no further syncopal or pre–syncopal episodes. Loop recorder monitoring revealed no significant arrhythmias. The only relevant anamnestic data was the use of Sertraline, and the application of the Adverse Drug Reaction Probability Scale suggests that the iatrogenic origin of this event as a pharmacological adverse effect is at least probable (score: 7). Limited literature connects Sertraline directly to documented cases of asystole, but reports indicate that drugs in the same pharmacological class may induce cardiac rhythm disturbances, including tachyarrhythmias and bradyarrhythmias. This case draws attention to sinus arrest during sertraline therapy and how an appropriate pharmacological washout led to the resolution of the pathology.

PROSTHETIC GRAFT INFECTION: WHEN ECHOCARDIOGRAPHY IS NOT ENOUGH!

Abstract A 68–year–old Caucasian male, post–Bentall procedure with a bioprosthetic valve following extensive aortic dissection involving the ascending aorta and aortic arch, presented to the Emergency Department with persistent fever for over a month. During his hospitalization, he experienced ventricular fibrillation in the setting of hypokalemia, successfully managed with Advanced Cardiovascular Life Support (ACLS) and DC shock, leading to the restoration of sinus rhythm. Subsequently, he was admitted to the Cardiovascular Intensive Care Unite. Blood tests revealed neutrophilic leukocytosis with elevated inflammatory markers, anemia, and a troponin curve consistent with myocardial injury in the context of sepsis and anemia. Echocardiography demonstrated a left ventricle of normal dimensions with globally depressed function (EF 45%), attributed to apical akinesia. The prosthetic valve was functioning normally, and there were no signs of endocarditic vegetations or pericardial involvement. A transesophageal echocardiogram confirmed the absence of vegetations. Given echocardiographic signs of myocardial ischemia, coronary angiography was performed, revealing a coronary circulation free from significant stenosis. Cultural exams showed positivity for Enterococcus faecalis. A PET–CT revealed the presence of radioisotope uptake around the vascular prosthesis situated in the aortic arch. An Infectious Disease specialist recommended antibiotic therapy with Piperacillin/Tazobactam and Teicoplanin. At the one–month follow–up, the patient remained asymptomatic, free from new febrile episodes. The follow–up echocardiogram indicated improved global systolic function, and inflammatory markers remained consistently negative. Repeat blood cultures were negative. This case illustrates a suspected endocarditis on a prosthetic valve where both transthoraci and transesophageal echocardiography yielded negative results. The use of PET–CT, on the other hand, revealed the presence of vascular graft infection, proving to be a valuable method in this clinical setting.

Borg's exertion scale did not coincide with ventilatory anaerobic threshold in atrial fibrillation patients with restored sinus rhythm after ablation.

The determination of precise exercise intensity is essential for effective exercise rehabilitation. The Borg rating of perceived exertion category ratio (CR) scale is utilized to prescribe an appropriate level of exertion intensity. A Borg CR of approximately 13 coincides with the ventilatory aerobic threshold (VAT). Patients with atrial fibrillation (AF) exhibit various symptoms. We hypothesized that the workload at Borg CR13 (Borg CR13-Watt) differs from the workload at the VAT level (VAT-Watt) in AF patients with restored sinus rhythm (SR) following ablation. Accordingly, the relationship between Borg CR13-Watt and VAT-Watt was studied in patients with restored SR. Cardiopulmonary exercise testing (CPET) was performed at 101±88 days after ablation in 150 patients using a bicycle ergometer. No adverse events were observed during CPET. Borg CR13-Watt was significantly higher than VAT-Watt (67.2±27.8 Watt vs. 54.7±17.6 Watt, P<0.0001). Borg CR13-Watt showed significant linear regression with VAT-Watt (regression coefficient, 0.49, P<0.01; correlation coefficient, 0.80, P<0.01). Higher Borg CR13-Watt was associated with greater differences between Borg CR13-Watt and VAT-Watt (ΔWatt). The Bland-Altman plot showed nonconcordance between the two. Male sex, use of antiarrhythmic drugs, and smoking had contributed to the increased ΔWatt. Duration from ablation to time of CPET did not correlate with ΔWatt. Therefore, Borg CR13-Watt did not coincide with VAT-Watt in patients with restored SR. Higher Borg CR13-Watt was associated with greater ΔWatt. Prescribing exertion intensity as determined solely by perceived exertion is inadequate. CPET is required to determine the precise exercise intensity in AF patients with restored SR after ablation.

Effectiveness of antazoline versus amiodarone, flecainide and propafenone in restoring sinus rhythm at the emergency department

PurposeLittle is known about the effectiveness of pharmacological cardioversion (PCV) with antazoline in comparison to flecainide. The aim of this study was to compare the effectiveness of antazoline in restoring sinus rhythm (SR) versus amiodarone, flecainide and propafenone in a group of emergency department (ED) patients. Materials/methodsThis was a single-centre retrospective analysis of patient records from an ED in a large hospital in Poland. We analysed a total of 1878 patient records, divided based on the anti-arrhythmic drug (AAD) administered during PCV: antazoline (n ​= ​1080), antazoline ​+ ​β-blocker (n ​= ​479), amiodarone (n ​= ​129), flecainide (n ​= ​102), propafenone (n ​= ​88). Of the patients, 63.5 ​% were female (median 65 years, [19–100]). ResultsThe percentage of successful PCV was significantly higher in the antazoline group (84.3 ​%) than in the antazoline ​+ ​β-blocker (75.8 ​%, p ​= ​0.0001), propafenone (75.6 ​%, p ​= ​0.0364) and amiodarone (68.8 ​%, p ​< ​0.0001) groups. Post-hoc analysis revealed that patients who received PCV with antazoline, antazoline ​+ ​β-blocker, flecainide and propafenone had significantly shorter time to SR than those who received amiodarone (p ​< ​0.0001). Univariate regression analysis revealed that patients who underwent PCV with antazoline were almost twice as likely to return to SR compared to the other groups (p ​< ​0.0001, OR 1.81, 95 ​% CI 1.44–2.27). ConclusionsThis is the first study comparing the effectiveness of antazoline in PCV versus flecainide in addition to the previously studied amiodarone and propafenone. Our results indicate that antazoline is more effective in restoring SR than amiodarone, flecainide and propafenone. In addition, antazoline restored SR significantly faster than amiodarone or propafenone.

Prognostic Impact of Sinus Rhythm in Atrial Fibrillation Patients: Separating Rhythm Outcomes From Randomized Strategy Findings From the CABANA Trial.

Clinically detected atrial fibrillation (AF) is associated with a significant increase in mortality and other adverse cardiovascular events. Since the advent of effective methods for AF rhythm control, investigators have attempted to determine how much these adverse prognostic AF effects could be mitigated by the restoration of sinus rhythm (SR) and whether the method used mattered. The CABANA trial (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) randomized 2204 AF patients to ablation versus drug therapy, of which 1240 patients were monitored in follow-up using the CABANA ECG rhythm monitoring system. To assess the prognostic benefits of SR, we performed a prespecified analysis using Cox survival modeling with heart rhythm as a time-dependent variable and randomized treatment group as a stratification factor. In the 1240 patient study cohort, 883 (71.2%) had documented AF at some point during their postblanking follow-up. Among the 883 patients, 671 (76.0%) experienced AF within the first year of postblanking follow-up, and 212 (24.0%) experienced their first AF after ≥1 year of postblanking follow-up. The primary CABANA end point (death, disabling stroke, serious bleeding, or cardiac arrest) occurred in 95 (10.8%) of the 883 patients with documented AF and in 29 (8.1%) of the 357 patients with no AF recorded during follow-up. In multivariable time-dependent analysis, the presence of SR (compared with non-SR) was associated with a significantly reduced risk of the primary end point (adjusted hazard ratio, 0.57 [95% CI, 0.38-0.85]; P=0.006; independent of treatment strategy [ablation versus drugs]). Corresponding results for all-cause mortality were adjusted hazard ratio of 0.59 [95% CI, 0.35-1.01]; P=0.053). In patients in the CABANA trial with detailed long-term rhythm follow-up, increased time in SR was associated with a clinically consequential decrease in mortality and other adverse prognostic events. The predictive value of SR was independent of the therapeutic approach responsible for reducing the burden of detectable AF. URL: https://clinicaltrials.gov; Unique Identifier: NCT00911508.

(1134) - Beta Blocker Withdrawal and Restoration of Sinus Rhythm in Physiology-Guided Management of Restrictive Heart Failure with Preserved Ejection Fraction

(1134) - Beta Blocker Withdrawal and Restoration of Sinus Rhythm in Physiology-Guided Management of Restrictive Heart Failure with Preserved Ejection Fraction

Plasma amino acids spectrum and Holter ECG monitoring indexes in coronary artery disease patients with atrial fibrillation

The research was conducted with the aim of establishing a connection between plasma amino acid peculiarities and Holter ECG monitoring indexes in Coronary Artery Disease (CAD) and Atrial Fibrillation (AF) patients. 300 patients were examined divided into 3 groups: I – 149 patients with CAD without arrhythmias, II – 124 patients with CAD and AF paroxysm, and the Control Group (CG) – 27 patients without CAD and arrhythmias. Holter ECG monitoring was performed for the patients with AF within 24 hours after sinus rhythm restoration, and for the patients without AF on the first day of observation. Plasma AA level was detected by the method of ion exchange liquid column chromatography. It was established that there is a significant increase glutamate and Branched-Chain Amino Acids (BCAA) levels in patients of the II group, and significant depletion in glycine levels comparison with the I group patients (p&lt;0.05). In the II group patients, an increase in SupraVentricular (SVE) and Ventricular Extrasystoles (VE) was checked in comparison with the I group patients (p&lt;0.05). Total SVE was significantly correlated with threonine (r=-0.316), serine (r=-0.336), glycine (r=-0.397), isoleucine (r=0.317), BCAA (r=0.356), and glycine+serine sum (r=-0.302), p&lt;0.05. AF paroxysm was significantly correlated with taurine (r=-0.302), serine (r=-0.328), glycine (r=-0.311), glutamine (r=-0.304), and glycine+serine sum (r=-0.379), p&lt;0.05. Total VE was significantly correlated with glycine (r=-0.370) and tyrosine (r=0.325), p&lt;0.05. Changes in ST-segment were significantly correlated with tyrosine (r=0.307), phenylalanine (r=0.318), and Aromatic Amino Acids (AAA) (r=0.379), p&lt;0.05. We concluded that glycine, serine, and BCAA are significantly correlated with cardiac arrhythmias. Changes in ST segment are significantly correlated with AAA levels. Keywords: heart rhythm violations, ischemia, arrhythmia, metabolomics.

The Effect of the Use of Activation 3D Mapping on the Patient X-Ray Load During Radiofrequency Ablation of Typical Atrial Flutter

Supraventricular macro re-entry tachyarrhythmias occupy the leading places among all types of tachyarrhythmias. The most common in this category is typical atrial flutter (AFL). This heart rhythm disorder has a negative impact on the patients’ quality of life. Its complications can lead to disability and death due to possible thromboembolism. Therapeutic treatment is limited in effectiveness. The main method of intervention is catheter radiofrequency ablation (RFA). The standard approach of RFA of AFL is performed without the use of navigation systems under fluoroscopy guidance. However, this results in an increased radiation exposure to the patient and the medical personnel. Modern technologies in the field of invasive electrophysiology make it possible to create anatomical models of heart and reproduce the spread of electrical excitation. However, the routine use of additional navigation methods remains controversial.&#x0D; The aim. To compare the duration of RFA of typical AFL and radiation exposure with the use of anatomical and propagation mapping.&#x0D; Materials and methods. This study is based on the analysis of the treatment results obtained for 53 patients at the National Amosov Institute of Cardiovascular Surgery in the period from 2014 to 2023. Depending on imaging methods, the patients were divided into two groups. The first group included 27 patients with an anatomical mapping of the right atrium. The second group included 26 patients with propagation mapping.&#x0D; Results. In all the patients we have achieved a bidirectional conduction block through cavotricuspid isthmus. In the first group, the total duration of confirming the diagnosis and creating the anatomical model was 312 ± 26 seconds. The mean time to the moment of AFL termination and restoration of sinus rhythm was 230 ± 19 seconds. The average duration of the procedure was 41.5 ± 3.5 minutes, the average fluoroscopy time was 120 ± 10 seconds, the average dose area product (DAP) was 15 ± 1.3 Gy·cm2. In the second group, the average time for creating a 3D propagation model of right atrium and verifying the diagnosis was 748 ± 65 seconds. The average time from the first application to the termination of tachycardia was 227 ± 20 seconds. The average duration of the procedure was 55 ± 4.7 minutes, X-ray time was 93 ± 8 seconds, average DAP was 13 ± 1.1 Gy·cm2. The duration of the procedure in the second group was significantly longer (p = 0.03), however, the radiation exposure and DAP were not statistically different (p = 0.31) between the observation groups.&#x0D; Conclusions. The use of propagation mapping increases the time of the procedure by 24.5% and does not give a significant advantage in reducing the radiation exposure. The use of a navigation system during cavotricuspid isthmus RFA is recommended for concomitant radical treatment of complex supraventricular arrhythmias, such as atrial fibrillation.

Arrhythmias in Patients with Pulmonary Hypertension and Right Ventricular Failure: Importance of Rhythm Control Strategies.

Arrhythmias frequently complicate the course of advanced pulmonary hypertension, often leading to hemodynamic compromise, functional impairment, and mortality. Given the importance of right atrial function in this physiology, the restoration and maintenance of sinus rhythm are of critical importance. In this review, we outline the pathophysiology of arrhythmias and their impact on right heart performance; describe considerations for antiarrhythmic drug selection, anesthetic and periprocedural management; and discuss the results of catheter ablation techniques in this complex and challenging patient population.

Intravenous Landiolol for Rate Control in Supraventricular Tachyarrhythmias in Patients with Left Ventricular Dysfunction: A Systematic Review and Meta-Analysis.

Background: This systematic review explores the effects of landiolol administration in individuals presenting with supraventricular tachyarrhythmia (SVT) and concurrent left ventricular dysfunction, without being septic or in a peri-operative period. Methods: We systematically searched PubMed, Cochrane, Web of Science, and Scopus databases, retrieving a total of 15 eligible studies according to prespecified eligibility criteria. Results: Patients treated with landiolol experienced a substantial reduction in heart rate (HR) (mean HR reduction: 42 bpm, 95% confidence intervals (CIs): 37-47, I2 = 82%) and were more likely to achieve the target HR compared to those receiving alternative antiarrhythmic therapy (pooled odds ratio (OR): 5.37, 95% CIs: 2.87-10.05, I2 = 0%). Adverse events, primarily hypotension, occurred in 14.7% of patients receiving landiolol, but no significant difference was observed between the landiolol and alternative antiarrhythmic receiving groups (pooled OR: 1.02, 95% CI: 0.57-1.83, I2 = 0%). No significant difference was observed between the two groups concerning sinus rhythm restoration (pooled OR: 0.97, 95% CI: 0.25-3.78, I2 = 0%) and drug discontinuation due to adverse events (pooled OR: 5.09, 95% CI: 0.6-43.38, I2 = 0%). Conclusion: While further research is warranted, this systematic review highlights the potential benefits of landiolol administration in the management of SVTs in the context of left ventricular dysfunction.

Robotic-Assisted Epicardial Hybrid Ablation and Left Appendage Closure in Persistent Atrial Fibrillation: First European Experience.

Background: Pulmonary vein isolation is currently considered to be the gold standard for ablating paroxysmal atrial fibrillation. However, its efficacy is limited in patients with persistent atrial fibrillation. The convergent procedure has emerged as a hybrid ablation. This study aims, for the first time in the literature, to introduce a hybrid approach that includes epicardial ablation with cutting-edge robotic technology and subsequent electrophysiological study to verify and an endocardial ablation to complete the ablation lines. Methods: We present 18 cases of robotic-assisted epicardial hybrid ablation performed between April and December 2023 on patients with long-standing persistent atrial fibrillation (mean age: 64 ± 5 years; mean duration: 4 ± 2 years). All of the procedures were performed at "Humanitas Gavazzeni Hospital", Bergamo, Italy. Robot-assisted epicardial ablation performed using the "Epi-Sense AtriCure" device was guided by monitoring electrogram morphology and point-by-point impedance drop. This approach also included left atrial appendage occlusion and the disconnection of the ligament of Marshall. An electrophysiological study and endocardial ablation were planned three months after the procedure. Results: The procedure was successfully executed in all patients with no major complications and a mean operative time of 142 ± 22 min. None of the cases required conversion to full sternotomy or minithoracotomy. The procedure was performed in all cases without extracorporeal circulation and on a beating heart. Fifteen patients (83%) were extubated in the operating room. The length of stay in the intensive care unit was less than 24 h. Acute restoration of sinus rhythm was achieved in 12 out of the 18 patients (67%); the median duration of their hospital stay was two days. In the electrophysiological study, seven pts had sinus rhythm, two had atrial fibrillation, and one patient developed atrial flutter at 3-month follow-up. Patients underwent transcatheter ablation to complete the lesion set and, at the time of discharge, were all in sinus rhythm. Conclusions: In our initial experience, surgical atrial fibrillation ablation consisting of a unilateral thoracoscopic technique facilitated by a robotic platform and continuous EGM monitoring has proven to be safe and feasible. For the electrophysiological study at 3 months, completing the gaps in the surgical ablation lines could improve the clinical results of the technique in terms of sinus rhythm stability. However, mid- and long-term follow-up is required to demonstrate this.

How to establish a successful and sustainable surgical atrial fibrillation program: key considerations on the arrhythmia, training and treatment strategies.

Establishing a successful and sustaining atrial fibrillation (AF) program should be current standard of care in cardiac surgery by providing not only sinus rhythm restoration but improving survival significantly. Recognition of AF as a serious cardiac disease impacting a considerable number of patients in terms of stroke, heart failure development and mortality is key when implementing a protocol to identify patients suitable for surgical ablation and a treatment standard according to the underlying pathology. The ablation strategy resulting in the best potential rhythm outcome should be chosen, and the applied access should follow this decision in a way that the optimal lesion set can be executed completely. A thorough follow-up is required to confirm results or make necessary adjustments to the implemented treatment protocol. This should be done in close collaboration with other treatment specialists such as cardiologists, electrophysiologists, primary care physicians, or neurologists. This collaboration might also facilitate an expansion of the program towards stand-alone ablation, ventricular tachycardia ablation, and inappropriate sinus tachycardia ablation.

Surgical options for atrial fibrillation treatment during concomitant cardiac procedures.

Current guidelines recommend concomitant surgical ablation (SA) of atrial fibrillation (AF) in the context of mitral valve disease. A variety of energy sources have been tested for SA to perform effective transmural lesions reliably. To date, only radiofrequency and cryothermy energies are considered viable options. The gold standard for SA is the Cox-Maze ablation set, especially for non-paroxysmal AF (nPAF), with the aim of interrupting macro-reentrant drivers perpetuating AF, without hampering the sinus node activation of both atria, and to maintain the atrioventricular synchrony. Although the efficacy of SA in terms of early and late sinus rhythm restoration has been clearly demonstrated over the years, concomitant AF ablation is still underperformed in patients with AF undergoing cardiac surgery. From a surgical standpoint, concerns have been raised about whether a single (left) or double atriotomy would be justified in AF patients undergoing a "non-atriotomy" surgical procedure, such as aortic valve or revascularization surgery. Thus, an array of simplified lesion sets have been described in the last decade, which have unavoidably hampered procedural efficacy, somewhat jeopardizing the standardization process of ablation surgery. As a matter of fact, the term "Maze" has improperly become a generic term for SA. Surgical interventions that do not align with the principles of forming conduction-blocking lesions according to the Maze pattern, cannot be classified as Maze procedures. In this complex scenario, a tailored approach according to the different AF patterns has been proposed: for patients with concomitant nPAF, a biatrial Cox-Maze ablation is recommended. Conversely, it might be reasonable to limit lesions to the left atrium or the pulmonary veins in patients with paroxysmal AF (PAF) in some clinical scenarios. The aim of this review is to provide an overview of the current ablation strategies for patients with AF undergoing concomitant cardiac surgery.

Very-early detection of atrial fibrillation after ablation evaluated by a wearable ECG-patch predicts late blanking period recurrence: Preliminary data from a prospective registry

IntroductionAtrial fibrillation (AF) ablation represents a safe and effective procedure to restore sinus rhythm. The idea that post-procedural AF episodes - during theblanking period-are not considered treatment failure has been increasingly challenged. The E-Patch, a single-use adhesive electrode, facilitates extended continuous ECG monitoring for 120 h. This pilot study aims to assess the effectiveness of this ambulatory monitoring device and investigate whether very-early AF recurrence correlates with delayed blanking period ablation outcomes. MethodsWe conducted a single-center, prospective, longitudinal study, including consecutive post-ablation patients monitored with the E-patch. The ability of the device to continuously record was analyzed, as well as the occurrence of AF episodes during external 7-day loop-recorder in the 2nd-month post-ablation. ResultsWe included 40 patients, median age 62 years (IQR 56–70). E-Patch monitoring was obtained for a median of 118 h (IQR 112–120), with no discomfort nor interpretation artefacts. Very-early AF recurrence was detected in 11 (27.5 %) patients, with a median AF burden of 7 % (IQR 6 %–33 %). Late-blanking period AF was detected in 13 (33 %) of theexternal 7-day looprecordings.Of the 11 patients that had very-early AF recurrence, 10 (91 %) had late-blanking AF. Very-early AF detectionshowed77 % (95 % CI 64 %-90 %) sensitivityand 96 % (95 % CI 90–100 %) specificity inpredictinglate-blanking AF, with a non-parametric ROCcurve AUC of 0.903 (95 % 0.797––1.0). ConclusionThe E-Patch was able to detect very-early AF during an extended period. Very-early AF detection emerges as a predictor of AF recurrence during the late blanking period post-ablation.