Rhythm Control Of Atrial Fibrillation Research Articles

Severity of tricuspid regurgitation predicts risk of atrial fibrillation recurrence after pulmonary vein isolation

Abstract Background Atrioventricular valve regurgitation (AVVR) results in atrial remodeling, thus promoting the formation of a substrate for atrial fibrillation (AF). On the other hand, AF may cause functional AVVR by annular dilatation of the atria. In this vicious circle, the identification of the leading pathomechanism and consequently the optimization of treatment can be challenging. Purpose Our aim was to investigate whether the presence of significant AVVR and especially of tricuspid regurgitation (TR) affects the efficacy of catheter-based pulmonary vein isolation (PVI) for AF. Furthermore, we evaluated whether rhythm control for AF through PVI could lead to an improvement of AVVR severity. Finally we examined the effect of concomitant right atrial flutter on the arrhythmic outcome in patients with significant TR . Methods We enrolled patients undergoing first-time PVI for symptomatic AF. We compared the severity of AVVR at the time of the procedure as well as after 6 months, using transthoracic echocardiography. Moderate to severe AVVR was defined as significant. Moreover, we evaluated whether the presence of significant AVVR, at baseline and 6 months after the procedure, could serve as an independent predictor for AF recurrence. Results Out of 320 consecutive patients (mean age 66.3 ± 10 years, 61.6% male, 60% paroxysmal AF) , significant TR at baseline was documented in 13.1%, while significant mitral regurgitation (MR) in 10.9%. Six months after PVI, the proportion of patients with moderate to severe TR (13.1% to 7.2%; p<0.001) and MR (10.9% to 6.6%; p<0.001) decreased significantly. Compared to patients with post-interventional improvement of significant TR, right atrial (RA) dilatation at baseline was more pronounced in patients with persistent significant TR (RA area 20.2 ± 4.4 vs. 26.6 ± 8.3 cm2; p=0.002). The presence of significant TR, particularly without improvement during the follow-up, independently increased the risk of atrial fibrillation recurrences. Even after propensity-score matching, TR at baseline remained an independent risk predictor regarding recurrent atrial fibrillation (HR 2.2 [95% CI, 1.1 - 4.9]; p=0.045). Among patients with significant TR, those with documented right atrial flutter were at high risk for recurrence of atrial arrhythmia (HR 2.69 [95% CI, 1.0 – 6.9]; p=0.039), despite the additional ablation of the cavo-tricuspid isthmus. Significant MR was not associated with increased risk of atrial arrhythmias. Conclusion In patients with symptomatic AF undergoing PVI, the presence of moderate to severe TR, particularly without improvement 6 months after the procedure, was associated with a worse arrhythmic outcome. Further investigations to enhance the understanding of the underlying electrophysiological substrate and the need for tailored ablation strategies are warranted.TR as predictor for AF(propensity score)AVVR improvement after PVI

Effectiveness of cryoballoon ablation for atrial fibrillation in patients with left common pulmonary vein variant: insights from a national multicenter catheter ablation registry

Abstract Background Pulmonary vein isolation (PVI) is the most effective therapy to achieve rhythm control in atrial fibrillation (AF). Yet, data regarding the safety and effectiveness of this procedure in left common pulmonary vein (LCPV) variant is limited. Purpose To explore the effectiveness of cryoballoon AF ablation in patients with LCPV variant. Methods A prospective cohort, based on a multicenter registry that included patients who underwent PVI during the years 2019-2021. The study end points were acute isolation success of the pulmonary veins (PVs), AF recurrence and the need for a repeat ablation procedure at 12 months. Results Seventy-four patients with LCPV variant and 822 patients with standard four pulmonary veins (PVs) were included in the study cohort. The acute isolation success rates of the left pulmonary veins were significantly lower in the LCPV variants compared to the standard 2 left PVs; 95.9% versus 98.9% respectively (P=0.03). The acute isolation success rates of the right pulmonary veins were not different among patients with LCPV versus standard anatomy; 98.6% versus 98.5% respectively (P=0.9). The rates of AF recurrence at 12 months were numerically higher in the LCPV variant compared to the standard anatomy group; 17.6% versus 11.1% respectively, but did not reach statistical significance (P=0.09) (Figure 1). The rates of repeat ablation did not differ between the study groups; 8.1% versus 6.2% respectively (P=0.51) (Figure 2). Conclusion In our study cohort, the acute isolation success rate of the LCPV was significantly lower compared to standard two left PVs, this finding emphasizes the challenge of isolating LCPV variants using cryoballoon PVI. However, in spite of the lower isolation success rates in the LCPV variants, the clinical effectiveness to prevent AF recurrences was preserved.Figure 1Figure 2

Procedural and outcome impact of body mass index on pulsed field ablation of atrial fibrillation: insights from the EU-PORIA Registry

Abstract Introduction Pulsed field ablation (PFA) is a "single-shot" non thermal ablation modality for atrial fibrillation (AF). In general, obesity is associated with increased risk of AF recurrence after catheter ablation with thermal energy sources. Purpose We aimed to assess the impact of body mass index (BMI) on procedural characteristics, safety, acute efficacy and long-term outcomes of PFA for symptomatic AF. Methods Of 1233 subjects enrolled in the EU-PORIA registry, in our subanalysis we included 1055 patients undergoing de novo pulmonary vein isolation (PVI)-only ablation procedure for symptomatic AF using the pentaspline PFA catheter from March 2021 until May 2022 at seven high-volume European centers. Patients were divided into two groups based on BMI: normal weight (nW, < 25 kg/m2) and overweight (oW, ≥ 25 kg/m2). Overweight patients were further categorized into three subgroups: pre-obesity (pOb, 25-29.9 kg/m2), obesity (Ob, 30-34.9 kg/m2) and severe obesity (sOb, ≥ 35 kg/m2). Clinical and procedural characteristics, complications and follow up data were collected. Results A total of 1055 patients (39% female, mean age 65,7±10,9 years, 65% paroxysmal AF) were enrolled. 32% of patients were normal weight (nW) and 68% overweight (oW). Among oW group, 438 subjects (41%) were assigned to pOb group, 204 (19%) to Ob, and 71 (7%) to sOb. Acute PVI was achieved in 100% of cases. The median skin-to-skin procedure and the median fluoroscopy time were similar between nW and oW and in all investigational subgroups, but radiation exposure increased in line with BMI (p<0.001). Periprocedural complications were 5% in nW, 1.6% in pOb, 3.9% in Ob, and 2.8% in sOb (p=0.06). The Kaplan-Meier estimate of arrhythmia-free survival was 80.2% in nW and 71.9% in oW (p=0.017). Each unit increment in BMI was associated with 4.2% increase in risk of AF/AT recurrence. Severe obese patients presented the highest 1-year AT/AF recurrence rate (37.2%). In the sOb group the rate of recurrence was not influenced by the type of AF (PAF 65.7% vs. pers AF 59.4%; p=0.484). Conclusion Overweight patients seem to experience more AF recurrences even after PFA PVI, mainly driven by a higher recurrence rate for BMI ≥ 35 kg/m2. Weight reduction programs remain crucial, nevertheless, reduced procedural times, good safety profile and acceptable 1-year observed AF/AT freedom make PFA a feasible strategy for AF rhythm control in patients with BMI ≥ 25 kg/m2.Freedom from AF/AT recurrence

One‐year outcomes of rate versus rhythm control of atrial fibrillation in the Kerala‐AF Registry

One‐year outcomes of rate versus rhythm control of atrial fibrillation in the Kerala‐AF Registry

Aproximación práctica para la caracterización de la miocardiopatía auricular en pacientes con fibrilación auricular

Atrial fibrillation (AF) causes progressive structural and electrical changes in the atria that can be summarized within the general concept of atrial remodeling. In parallel, other clinical characteristics and comorbidities may also affect atrial tissue properties and make the atria susceptible to AF initiation and its long-term persistence. Overall, pathological atrial changes lead to atrial cardiomyopathy with important implications for rhythm control. Although there is general agreement on the role of the atrial substrate for successful rhythm control in AF, the current classification oversimplifies clinical management. The classification uses temporal criteria and does not establish a well-defined strategy to characterize the individual-specific degree of atrial cardiomyopathy. Better characterization of atrial cardiomyopathy may improve the decision-making process on the most appropriate therapeutic option. We review current scientific evidence and propose a practical characterization of the atrial substrate based on 3 evaluation steps starting with a clinical evaluation (step 1), then assess outpatient complementary data (step 2), and finally include information from advanced diagnostic tools (step 3). The information from each of the steps or a combination thereof can be used to classify AF patients in 4 stages of atrial cardiomyopathy, which we also use to estimate the success on effective rhythm control.

Greater distance between ablation lines reduces the arrhythmia recurrence rate after pulmonary vein isolation.

Pulmonary vein isolation (PVI) is a recommended strategy for rhythm control in atrial fibrillation (AF), but its success rate remains unsatisfactory. Continuous research is being conducted to explore new technologies and modifications to the existing ablation workflow in order to reduce the arrhythmia recurrence rate. This study aimed to determine the influence of the distance between ablation lines (DBL) on AF recurrence rate in patients undergoing their first PVI; and thus to optimize the procedure outcomes. This is a retrospective cohort study conducted at a tertiary care center in Poland. A total of 146 patients (median age, 62 years; women, 34.3%) referred for a first PVI for either paroxysmal (n = 103) or persistent (n = 43) AF were evaluated. The procedures were performed with the use of a very‑high‑power, short‑duration catheter (QDot MicroTM, Biosense Webster, Inc., Irvine, California, United States) or a conventional, ablation index-guided ThermoCool Smarttouch SF catheter (Biosense Webster, Inc.). Freedom from AF recurrence was used as a primary end point. The impact of DBL on the outcome of PVI, accounting for conventional risk factors, was evaluated. Greater distance between opposite circumferential PVI lines and its ratio to the transverse diameter of the left atrium (DLB/TD) were associated with a lower risk of AF recurrence (hazard ratio [HR], 0.966; 95% CI, 0.935-0.998 [per 1 mm]; P = 0.04 and HR, 0.968; 95% CI, 0.944-0.993 [per 1%]; P = 0.01, respectively). There was no correlation between DBL or DBL/TD ratio and the impedance level. Close distance between PVI lines contributes to AF recurrence; thus, increasing the DBL and ensuring a higher DBL/TD ratio may be an advantageous ablation strategy.

Ventricular response as a predictor of the termination of sustained paroxysmal atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained atrial arrhythmia. Accurate detection of the timing and possibility of AF termination is vital for optimizing rhythm and rate control strategies. The present study evaluated whether the ventricular response (VR) in AF offers a distinctive electrocardiographic indicator for predicting AF termination. Patients experiencing sustained paroxysmal AF for more than 3h were observed using 24-h ambulatory Holter monitoring. VR within 5min before AF termination (VR 0-5min, BAFT) was compared with VR observed during the 60th to 65th min (VR 60-65min, BAFT) and the 120th to 125th min (VR 120-125min, BAFT) before AF termination. Maximum and minimum VRs were calculated on the basis of the average of the highest and lowest VRs across 10 consecutive heartbeats. Data from 37 episodes of paroxysmal AF revealed that the minimum VR0-5min, BAFT (64±20bpm) was significantly faster than both the minimum VR120-125min, BAFT (56±15bpm) and the minimum VR60-65min, BAFT(57±16bpm, p<.05). Similarly, the maximum VR0-5min, BAFT (158±49bpm) was significantly faster than the maximum VR120-125min, BAFT (148±45bpm, p<.05). In the daytime, the minimum VR0-5min, BAFT (66±20bpm) was significantly faster than both the minimum VR60-65min, BAFT (58±17bpm) and minimum VR120-125min, BAFT(57±15bpm, p<.05). However, the mean and maximum VR0-5min, BAFT in the daytime were similar to the mean and maximum VR120-125min in the daytime, respectively. At night, the minimum, mean, and maximum VR0-5min, BAFT were similar to the minimum, mean, and maximum VR120-125min, respectively. Elevated VR rates during AF episodes may be predictors for the termination of AF, especially during the daytime and in patients with nondilated left atria. These findings may guide the development of clinical approaches to rhythm control in AF.

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.

Digital twins for cardiac electrophysiology: state of the art and future challenges.

Cardiac arrhythmias remain amajor cause of death and disability. Current antiarrhythmic therapies are effective to only a limited extent, likely in large part due to their mechanism-independent approach. Precision cardiology aims to deliver targeted therapy for an individual patient to maximize efficacy and minimize adverse effects. In-silico digital twins have emerged as apromising strategy to realize the vision of precision cardiology. While there is no uniform definition of adigital twin, it typically employs digital tools, including simulations of mechanistic computer models, based on patient-specific clinical data to understand arrhythmia mechanisms and/or make clinically relevant predictions. Digital twins have become part of routine clinical practice in the setting of interventional cardiology, where commercially available services use digital twins to non-invasively determine the severity of stenosis (computed tomography-based fractional flow reserve). Although routine clinical application has not been achieved for cardiac arrhythmia management, significant progress towards digital twins for cardiac electrophysiology has been made in recent years. At the same time, significant technical and clinical challenges remain. This article provides ashort overview of the history of digital twins for cardiac electrophysiology, including recent applications for the prediction of sudden cardiac death risk and the tailoring of rhythm control in atrial fibrillation. The authors highlight the current challenges for routine clinical application and discuss how overcoming these challenges may allow digital twins to enable asignificant precision medicine-based advancement in cardiac arrhythmia management.

Flecainide sebagai Antiaritmia untuk Fibrilasi Atrium dan Aritmia Lainnya

Atrial fibrillation (AF) is one of the most common arrhythmias globally, and its prevalence is projected to increase, including in Indonesia. AF progression is related to lower quality of life and less responsive to therapy or even becomes irreversible. The progression of AF is significantly slower with the rhythm control strategy than with the rate control strategy alone. The options for therapy in Indonesia are limited to amiodarone and propafenone. Amiodarone is one of the most common drugs prescribed for AF rhythm control, but associated with multiple organ toxicities, thus increasing the risk of multiple side effects, especially on long-term usage, potentially leading to drug discontinuation. Flecainide is an antiarrhythmia with a favourable effectiveness and safety profile, especially for AF management, used for acute cardioversion, long-term rhythm control, and as a therapeutic modality for AF with preexcitation syndrome. Flecainide is a potential drug to address the unmet needs of amiodarone as a long-term management for AF.

Practical approach for atrial cardiomyopathy characterization in patients with atrial fibrillation

Atrial fibrillation (AF) causes progressive structural and electrical changes in the atria that can be summarized within the general concept of atrial remodeling. In parallel, other clinical characteristics and comorbidities may also affect atrial tissue properties and make the atria susceptible to AF initiation and its long-term persistence. Overall, pathological atrial changes lead to atrial cardiomyopathy with important implications for rhythm control. Although there is general agreement on the role of the atrial substrate for successful rhythm control in AF, the current classification oversimplifies clinical management. The classification uses temporal criteria and does not establish a well-defined strategy to characterize the individual-specific degree of atrial cardiomyopathy. Better characterization of atrial cardiomyopathy may improve the decision-making process on the most appropriate therapeutic option. We review current scientific evidence and propose a practical characterization of the atrial substrate based on 3 evaluation steps starting with a clinical evaluation (step 1), then assess outpatient complementary data (step 2), and finally include information from advanced diagnostic tools (step 3). The information from each of the steps or a combination thereof can be used to classify AF patients in 4 stages of atrial cardiomyopathy, which we also use to estimate the success on effective rhythm control.

Trajectory change of left ventricular ejection fraction after rhythm control for atrial fibrillation in heart failure.

Rhythm control therapy has shown great benefits for patients with atrial fibrillation (AF) and heart failure (HF). However, few studies have evaluated the effects of rhythm control on left ventricular ejection fraction (LVEF) trajectory across the whole HF spectrum. Our study explored the prevalence and predictors of LVEF trajectory changes and their prognostic implications following rhythm control. Depending on the treatment strategy, the cohort was classified into rhythm and rate control groups. Alterations in HF types and LVEF trajectory were recorded. The observational endpoints were all-cause mortality and HF-related admission. Predictors of LVEF trajectory improvement in the rhythm control group were evaluated. After matching, the two groups had similar age [mean age (years): rhythm/rate control: 63.96/65.13] and gender [male: rhythm/rate control: n=228 (55.6%)/233 (56.8%)]. Based on baseline LVEF measurement, the post-matched cohort had 490 HF with preserved ejection fraction (rhythm/rate control: n=260/230; median LVEF: 58.00%/57.00%), 99 HF with mildly reduced ejection fraction (rhythm/rate control: n=50/49; median LVEF: 45.00%/46.00%), and 231 HF with reduced ejection fraction (rhythm/rate control: n=100/131; median LVEF: 32.50%/33.00%). Trajectory analysis found that the rhythm control group had a greater percentage of LVEF trajectory improvement than the rate control group [80 (53.3%) vs. 71 (39.4%), P=0.012]. Cox regression analysis also showed that the rhythm control group was more likely to have improved LVEF trajectory compared with the rate control group {hazard ratio [HR] 1.671 [95% confidence interval (CI) 1.196-2.335], P=0.003}. In the survival analysis, the rhythm control group experienced significant lower risks of all-cause mortality [HR 0.600 (95% CI 0.366-0.983), P=0.043] and HF-related admission [HR 0.611 (95% CI 0.496-0.753), P<0.001]. In the rhythm control subgroup, E/e' [odds ratio (OR) 0.878 (95% CI 0.792-0.974), P = 0.014], left ventricular end-diastolic diameter [OR 0.874 (95% CI 0.777-0.983), P = 0.024], and CHA2DS2-VASc score (congestive HF, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischaemic attack, vascular disease, age 65-74 years, and sex category) [OR 0.647 (95% CI 0.438-0.955), P = 0.028] were identified as three independent predictors of LVEF trajectory improvement. Rhythm control is associated with improved LVEF trajectory and clinical outcomes and may thus be considered the optimal therapeutic strategy for patients with both HF and AF.

Inhibition of the KCa2 potassium channel in atrial fibrillation: a randomized phase 2 trial

Existing antiarrhythmic drugs to treat atrial fibrillation (AF) have incomplete efficacy, contraindications and adverse effects, including proarrhythmia. AP30663, an inhibitor of the KCa2 channel, has demonstrated AF efficacy in animals; however, its efficacy in humans with AF is unknown. Here we conducted a phase 2 trial in which patients with a current episode of AF lasting for 7 days or less were randomized to receive an intravenous infusion of 3 or 5 mg kg−1 AP30663 or placebo. The trial was prematurely discontinued because of slow enrollment during the coronavirus disease 2019 pandemic. The primary endpoint of the trial was cardioversion from AF to sinus rhythm within 90 min from the start of the infusion, analyzed with Bayesian statistics. Among 59 patients randomized and included in the efficacy analyses, the primary endpoint occurred in 42% (5 of 12), 55% (12 of 22) and 0% (0 of 25) of patients treated with 3 mg kg−1 AP30663, 5 mg kg−1 AP30663 or placebo, respectively. Both doses demonstrated more than 99.9% probability of superiority over placebo, surpassing the prespecified 95% threshold. The mean time to cardioversion, a secondary endpoint, was 47 (s.d. = 23) and 41 (s.d. = 24) minutes for 3 mg kg−1 and 5 mg kg−1 AP30663, respectively. AP30663 caused a transient increase in the QTcF interval, with a maximum mean effect of 37.7 ms for the 5 mg kg−1 dose. For both dose groups, no ventricular arrhythmias occurred and adverse event rates were comparable to the placebo group. AP30663 demonstrated AF cardioversion efficacy in patients with recent-onset AF episodes. KCa2 channel inhibition may be an attractive mechanism for rhythm control of AF that should be studied further in randomized trials. ClinicalTrials.gov registration: NCT04571385.

Rate Versus Rhythm Control for Atrial Fibrillation.

Atrial fibrillation (AF) is an arrhythmia characterized by disorganized atrial activity with an associated unevenly irregular ventricular response on an electrocardiogram. It is the most common sustained arrhythmia, with a lifetime risk of 25% in patients older than 40 years old. The incidence of AF increases with age and is associated with an increased risk for heart failure, stroke, adverse cardiac events, and dementia. The 2 main aims of AF treatment include anticoagulation for thromboembolism prophylaxis as well as rate vs rhythm control. The focus of this article will be on the treatment strategies in managing AF. Rate control refers to the use of atrioventricular nodal blocking medications, including beta blockers and calcium channel blockers, to maintain a goal heart rate. Rhythm control, on the other hand, refers to a treatment strategy focused on the use of antiarrhythmic drugs (AAD), cardioversion, and ablation to restore and to maintain a patient in sinus rhythm. Currently, the ideal treatment strategy remains greatly debated. Thus, we hope to compare the risks and benefits of rate to rhythm control to highlight how patients with AF are managed here at Kaiser Permanente Northern California.

Atrial Fibrillation Ablation: Current Practice and Future Perspectives.

Catheter ablation to perform pulmonary vein isolation (PVI) is established as a mainstay in rhythm control of atrial fibrillation (AF). The aim of this review is to provide an overview of current practice and future perspectives in AF ablation. The main clinical benefit of AF ablation is the reduction of arrhythmia-related symptoms and improvement of quality of life. Catheter ablation of AF is recommended, in general, as a second-line therapy for patients with symptomatic paroxysmal or persistent AF, who have failed or are intolerant to pharmacological therapy. In selected patients with heart failure and reduced left-ventricular fraction, catheter ablation was proven to reduce all-cause mortality. Also, optimal management of comorbidities can reduce AF recurrence after AF ablation; therefore, multimodal risk assessment and therapy are mandatory. To date, the primary ablation tool in widespread use is still single-tip catheter radiofrequency (RF) based ablation. Additionally, balloon-based pulmonary vein isolation (PVI) has gained prominence, especially due to its user-friendly nature and established safety and efficacy profile. So far, the cryoballoon (CB) is the most studied single-shot device. CB-based PVI is characterized by high efficiency, convincing success rates, and a beneficial safety profile. Recently, CB-PVI as a first-line therapy for AF was shown to be superior to pharmacological treatment in terms of efficacy and was shown to reduce progression from paroxysmal to persistent AF. In this context, CB-based PVI gains more and more importance as a first-line treatment choice. Non-thermal energy sources, namely pulsed-field ablation (PFA), have garnered attention due to their cardioselectivity. Although initially applied via a basket-like ablation tool, recent developments allow for point-by-point ablation, particularly with the advent of a novel lattice tip catheter.

Which Is Better? Rate Versus Rhythm Control in Atrial Fibrillation: A Systematic Review.

Atrial fibrillation (AF) is a common arrhythmia associated with significant morbidity and mortality. The optimal approach to managing AF, specifically rate control versus rhythm control, remains a topic of debate in clinical practice. This systematic review aims to compare the rate control and rhythm control strategies based on their clinical outcomes, quality of life, and adverse events associated with them. A comprehensive search was conducted using PubMed, Google Scholar, Science Direct, Research Gate, MEDLINE (Medical Literature Analysis and Retrieval System Online), Scopus, and Embase (Excerpta Medica dataBASE) databases. A total of 1657 research papers were identified through the search strategy, and after applying the eligibility criteria, 28 studies were selected for the analysis. The studies encompassed a range of methodologies, including randomized controlled trials, observational studies, and meta-analyses. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for study selection, data extraction, and analysis. The outcomes of interest included all: cause mortality, stroke, bleeding events, cardiovascular hospitalizations, quality of life, and adverse effects of treatment. Data were synthesized and presented in tables, charts, and forest plots for meta-analysis where appropriate. The results indicate that both rate control and rhythm control strategies have their own merits and limitations, with the outcomes varying based on patient characteristics and comorbidities. While rhythm control strategies may lead to better symptom control and improved quality of life, rate control strategies maybe associated with lower risks of adverse events and complications. This systematic review provides a comprehensive overview of the current evidence regarding rate and rhythm control strategies in AF management, offering insights for clinical decision-making and highlighting the need for individualized treatment approaches.

Abstract 18056: Transhepatic and Trans-Patent Foramen Ovale Ablation of Atrial Fibrillation in the Setting of Chronic Inferior Vena Cava Occlusion: Addressing Complex Anatomic Hurdles and Achieving Therapeutic Success

Background: Rhythm control for atrial fibrillation (AF) is the preferred approach for symptomatic patients, particularly those with reduced ejection fraction. Catheter ablation primarily consists of pulmonary vein isolation via a transseptal approach. In patients with chronic occlusion of inferior vena cava (IVC), surgical ligation of IVC, or congenital venous system abnormalities, conventional femoral venous access may not feasible. Case Report: A 78-year-old male with history of Hypertension, diabetes, coronary artery disease, bilateral DVTs s/p thrombectomy, prior IVC stenting, presented with persistent, symptomatic AF on apixaban. Given a moderately reduced EF of 40-45%, amiodarone intolerance, and contraindication to other AADs, he was referred for catheter ablation. CT venogram showed chronically occluded IVC with patent hepatic veins, therefore transhepatic access to the right atrium was obtained. Transesophageal echocardiography (TEE) was planned for transseptal puncture; however, this showed an incidental PFO. This PFO was easily engaged using a manual modification of a VersaCross transseptal sheath and after entering the left atrium, the sheath was exchanged with a bi-directional sheath (Vizigo). Using this single left atrial access, pulmonary vein isolation and posterior wall isolation were performed. The transhepatic access site was closed with coil embolization to prevent track bleeding (figure 1). Conclusion: We present a case where successful AF ablation was achieved via percutaneous transhepatic approach, with improvised utilization of a conveniently located PFO. This was guided by pre-operative CT, and intra-operative TEE which allowed us to minimize any transseptal puncture related complications. The utilization of a multidisciplinary team comprising electrophysiologists, advanced imaging cardiologists and interventional radiologists is invaluable in executing complex procedures of this nature.

Abstract 12324: Current Trends in Anticoagulation, Referral and Utilization of Procedures for Rhythm Control for Atrial Fibrillation

Introduction: Atrial fibrillation (AF) can reduce quality of life and cause thromboembolic events, heart failure and death. Prior studies have identified disparities in the treatment of AF based on sex, race, and ethnicity. Hypothesis: There will be disparities in procedures for rhythm control (RC) based on sex, race and ethnicity. Methods: Cohorts of patients with new AF from 2016 to 2021 were identified with 1 year follow up to identify referrals, anticoagulant prescription, and procedures for RC. We calculated the proportion of patients with each outcome overall stratified by sex and race/ethnicity. We used logistic regression to compare outcomes across sex and race/ethnicity after adjustment for confounding variables. Results: We identified 2,919 patients with a new onset AF. The mean age: 68 years, 53% were male, 66% had Medicare, 69% self-identified as White, 23% as Black, and 3% as Hispanic. There was no difference in referral rates between men and women. Compared to White patients, Black and Hispanic patients were more likely to be referred to Cardiology and more likely to complete a visit. Prescription of anticoagulants was high (83%) and did not differ between men and women (84% vs. 82%, p = 0.65). Compared to White patients, Black and Hispanic patients were more likely to receive a prescription for anticoagulation (86% and 88% vs. 81%, p = 0.006). Women were significantly less likely to receive cardioversion or ablation compared to men (17% vs. 25%, p &lt; 0.001). Similarly, Blacks and Hispanics were significantly less likely to receive procedures compared to Whites (17% vs. 23%, p = 0.01). Conclusions: Despite equal attendance at Cardiology visits, women and Black or Hispanic patients were significantly less likely to receive cardioversion or ablation compared to men and Whites respectively.

Abstract 14992: Impact of Coronary Artery Disease on Rate vs. Rhythm-Control of Atrial Fibrillation

Introduction: Atrial fibrillation (AF) is a common arrhythmia that can impair quality of life and increase cardiovascular mortality. Previous studies have shown potentially better outcomes with rate-control agents in patients with coronary artery disease (CAD). Yet, optimal treatment of AF is not yet known. Methods: Leveraging data from the AFFIRM trial, we performed a post-hoc analysis examining outcome differences in patients on rate vs. rhythm-control agents, based on CAD status. The primary outcome was defined as death from any cause; secondary outcomes included ischemic stroke, major bleeding, and hospitalization after baseline. Univariate and multivariate modeling were used to determine risk factors associated with designated outcomes. Results: Of 4060 patients enrolled, 1551 patients had CAD at baseline. There were no differences in treatment randomization based on CAD status; however, more patients with CAD had worse heart function and comorbid CHF. More patients with CAD ultimately used some form of rate-control compared to those without. Overall, CAD patients were more likely to experience death (HR 2.08 [1.79-2.42], P&lt;0.001), specifically those on rhythm-control (HR 1.24 [1.01-1.52], P=0.04, Figure). CAD patients were also more likely to have ischemic stroke (HR 1.24 [1.00-1.53], P=0.05). When comparing CVD vs. non-CVD death, only CAD patients on rhythm-control exhibited a significantly higher rate of CVD death (HR 1.39 [1.03-1.89], P=0.03), while no differences in primary outcomes were noted for all other groups (P&gt;0.05, Figure). In multivariate modeling, the effect of treatment arm on risk of CVD death in CAD patients diminished upon accounting for age, smoking, rhythm at randomization, first episode of AF, CHF, and LVEF&lt;50% (HR 1.18 [0.93-1.50], P=0.17). Conclusions: AF patients with CAD on rhythm-control agents exhibited worse CVD outcomes, which may be more reflective of heart disease severity rather than treatment effects.

Abstract 17275: Clinical Outcomes Following Maze and Left Atrial Appendage Occlusion Procedures for Patients With Atrial Fibrillation Undergoing Mitral Valve Surgeries: Insights From the National Readmission Database

Background: Maze procedure and left atrial appendage occlusion (LAAO) are often done as adjunctive procedures during mitral valve surgery in patients with atrial fibrillation (AF). We examined the effect of the Maze procedure and LAAO on AF-related clinical outcomes. Methods: We identified patients with AF from the Nationwide Readmission Database who underwent mitral valve surgery in the years 2016-2019 using ICD 10 codes. Patients were grouped by procedure type (Maze+/LAAO+, Maze+/LAAO-, Maze-/LAAO+, Maze-/LAAO- (control)). Outcomes were in-hospital and 180-day readmission rate for stroke and mortality, and 180-day AF/atrial flutter readmission. Multivariate regression analysis was conducted adjusting for demographics, hospital characteristics, comorbidities, and cardiac surgery type. Results: Of 14,979 patients with AF who underwent mitral valve surgery, adjunctive procedures were performed as follows: 2427 Maze+/LAAO+, 997 Maze+/LAAO-, 4052 Maze-/LAAO+, and 7503 Maze-/LAAO-. Stroke during the index admission and within 180 days occurred less frequently in the adjunctive procedure groups than in control group (2.5%, 2.3%, 3.4%, and 4.9% respectively, P&lt;0.001). Similar results were observed for in-hospital and 180-day mortality (3.9%, 7.6%, 4.8%, and 6.8% respectively, P&lt;0.001). However, readmission within 180 days for AF/atrial flutter was higher in the adjunctive procedure groups than the control group (5.6% vs 4.2% vs 5.4% vs 3.8%, P&lt;0.001). On multivariate analysis, patients who had either Maze or LAAO procedures (Maze+/LAAO+, Maze+/LAAO-, Maze-/LAAO+) had a lower 180-day stroke risk when compared to the control group (hazard ratio (HR) 0.7, P=0.01; HR 0.66, P=0.55; and HR 0.79, P=0.01 respectively). Similarly, 180-day mortality was lower in patients who underwent LAAO compared to the control group (HR 0.71, P=0.002; HR 1.27, P=0.05; and HR 0.78, P=0.004 respectively). Conclusion: Patients with AF who underwent Maze and/or LAAO procedures during mitral valve surgery had lower 180-day stroke and mortality rates. There was a higher rate of readmission for AF/atrial flutter, which may be a short-term proarrhythmic effect of these procedures or may reflect differences in AF type and rhythm control goals in the control group.