Rhythm Monitoring Research Articles

Prolonged cardiac monitoring for stroke prevention: A systematic review and meta-analysis of randomized-controlled clinical trials.

Prolonged cardiac monitoring (PCM) substantially improves the detection of subclinical atrial fibrillation (AF) among patients with history of ischemic stroke (IS), leading to prompt initiation of anticoagulants. However, whether PCM may lead to IS prevention remains equivocal. In this systematic review and meta-analysis, randomized-controlled clinical trials (RCTs) reporting IS rates among patients with known cardiovascular risk factors, including but not limited to history of IS, who received PCM for more than 7 days versus more conservative cardiac rhythm monitoring methods were pooled. Seven RCTs were included comprising a total of 9048 patients with at least one known cardiovascular risk factor that underwent cardiac rhythm monitoring. PCM was associated with reduction of IS occurrence compared to conventional monitoring (Risk Ratio: 0.76; 95% CI: 0.59-0.96; I 2 = 0%). This association was also significant in the subgroup of RCTs investigating implantable cardiac monitoring (Risk Ratio: 0.75; 95% CI: 0.58-0.97; I 2 = 0%). However, when RCTs assessing PCM in both primary and secondary prevention settings were excluded or when RCTs investigating PCM with a duration of 7 days or less were included, the association between PCM and reduction of IS did not retain its statistical significance. Regarding the secondary outcomes, PCM was related to higher likelihood for AF detection and anticoagulant initiation. No association was documented between PCM and IS/transient ischemic attack occurrence, all-cause mortality, intracranial hemorrhage, or major bleeding. PCM may represent an effective stroke prevention strategy in selected patients. Additional RCTs are warranted to validate the robustness of the reported associations.

Rhythm monitoring, success definition, recurrence, and anticoagulation after atrial fibrillation ablation: results from an EHRA survey.

Atrial fibrillation (AF) is a major challenge for the healthcare field. Pulmonary vein isolation is the most effective treatment for the maintenance of sinus rhythm. However, clinical endpoints for the procedure vary significantly among studies. There is no consensus on the definition of recurrence and no clear roadmap on how to deal with recurrences after a failed ablation. The purpose of this study was to perform a survey in order to show how clinicians currently approach this knowledge gap. An online survey, supported by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, was conducted between 1 April 2022 and 8 May 2022. An anonymous questionnaire was disseminated via social media and EHRA newsletters, for clinicians to complete. This consisted of 18 multiple-choice questions regarding rhythm monitoring, definitions of a successful ablation, clinical practices after a failed AF ablation, and the continuance of anticoagulation. A total of 107 replies were collected across Europe. Most respondents (82%) perform routine monitoring for AF recurrences after ablation, with 51% of them preferring a long-term monitoring strategy. Cost was reported to have an impact on the choice of monitoring strategy. Self-screening was recommended by most (71%) of the respondents. The combination of absence of symptoms and recorded AF was the definition of success for most (83%) of the respondents. Cessation of anticoagulation after ablation was an option mostly for patients with paroxysmal AF and a low CHA2DS2-VASc score. The majority of physicians perform routine monitoring after AF ablation. For most physicians, the combination of the absence of symptoms and electrocardiographic endpoints defines a successful result after AF ablation.

The influence of sex on early post-operative atrial fibrillation after cardiac surgery.

Early post-operative atrial fibrillation (EPOAF) occurs more frequently in male (M) patients. However, most patients included in EPOAF studies were also M. The aim of the present study was to compare, in a matched M and F population, the occurrence of EPOAF episodes and EPOAF characteristics using continuous rhythm monitoring (CRM) during the first five post-operative days. Our study population consisted of 30 F patients matched with 30 M patients admitted for elective cardiac surgery. After cardiac surgery, patients were continuously monitored for a maximum of 5 days, and the burden of EPOAF episodes was quantified. No significant differences in the onset, number, burden, total duration, shortest, median and longest EPOAF episode were detected between M and F patients. However, EPOAF occurred more frequently on the third post-operative day (F: 16 vs. M: 7; p=.013). Except for the occurrence of the EPOAF on the third post-operative day. EPOAF characteristics did not differ between M and F patients.

Abstract 13949: Age-Dependent Detection of Atrial Fibrillation With Implantable Cardiac Monitors in Patients With Cryptogenic Stroke

Introduction: Prolonged and intensified rhythm monitoring is recommended to detect atrial fibrillation (AF) in patients with cryptogenic stroke (CS). Continuous monitoring using implantable cardiac monitors (ICM) results in AF detection rates of up to 30%. Although higher age has been identified as an independent risk factor for AF after CS, there are no specific recommendations for the implantation of ICM in younger patients. Hypothesis: AF dectection in young patients (< 60 years) with CS and continuous rhythm monitoring is low. Methods: From 02/2014 to 11/2021, 186 patients (mean age 65 ± 12 years) with cryptogenic stroke were included in this analysis. All patients underwent 72-h ECG monitoring, transcranial Doppler Ultrasound and transthoracic echocardiography according to current guidelines. Follow-up was performed by means of a regular outpatient presentation every three months and included medical history, physical examination, and interrogation of the ICM. AF was defined as any episode of absolute arrhythmia >30 seconds. Results: AF was detected in 62 patients (33 %) during a mean follow-up of 36 ± 23 months. AF was found in 6 % (3/52), 27 % (17/62), 56 % (31/55) and 65 % (11/17) (p < 0.001) in patients aged < 60 years, 60-69 years, 70-79 years and ≥ 80 years, respectively (see Figure 1). All patients with AF under 60 years had an impaired systolic left ventricular function (left ventricular ejection fraction < 50 %). Conclusions: In cryptogenic stroke patients, detection of Atrial Fibrillation by implantable cardiac monitors increases with advanced age. In patients younger than 60 years, Atrial Fibrillation was only detected in patients with impaired systolic left ventricular function. The diagnostic benefit of ICM implantation in young patients with cryptogenic stroke and preserved LV function is limited. Possibly positive predictors for AF detection should be identified and considered in the decision to implant cardiac monitors.

Abstract 9262: The Clinical and Electrophysiologic Manifestations of Cardiac Tumors: A Single-Center Retrospective Study

Introduction: Cardiac tumors are rare and their effect on the cardiac conduction system is not well-described. Currently there is no recommendation for routine arrhythmia screening in this population. This study aimed to characterize the clinical presentation and electrophysiologic manifestations of patients with cardiac tumors. Methods: A radiologic database from a four-hospital health system was queried to identify patients with a cardiac tumor diagnosed on CMR from 2003-2021. The electronic health record, ECGs, arrhythmia monitors, echocardiograms and CMRs were reviewed for each patient. Results: Forty-nine patients were identified with intra-cardiac or pericardial tumors. The cohort had a mean age of 57.3 ±14.6 years old and was 53% female. Cardiovascular risk factors were prevalent: HTN (59%), HLD (43%), DM (26%), CAD (20%). Common presenting symptoms were SOB (30.6%), palpitations (24.5%) and chest pain (20.4%); many patients had no overt cardiac symptom (42.9%). By CMR, tumors were classified as pericardial (44.9%) vs myocardial (55.1%), primary tumor (57.1%) vs secondary tumor (42.9%) and located nearest the atrium (24.5%), ventricle (55.1%) or both (14.3%). Twenty-three patients (47%) had tumors that were labeled as malignant, with the most common diagnoses being diffuse large B-cell lymphoma (DLBCL, 10.2%), non-small cell lung cancer (8.2%) and melanoma (6.1%). Non-trivial pericardial effusions were common (24.5%), with one case complicated by tamponade. Seven patients (14.2%) were documented to have cardiac arrhythmias including one patient with sudden arrhythmic death (SAD). Neither pericardial effusion (OR 3.7, CI 0.5-29.6) nor atrial tumor location (OR 2.8, CI 0.4-21.8) was predictive of atrial fibrillation or SVT. Ventricular arrhythmias were observed in patients with ventricular tumors (11.8%), but not atrial tumors (0%). Sustained VT was found in two patients with invasive DLBCL. Conclusion: Cardiac tumors are associated with frequent cardiac symptoms, pericardial effusions and cardiac arrhythmia. Sustained VT was documented in two patients with DLBCL in the ventricle, one of whom experienced SAD. Prospective studies employing long-term rhythm monitoring may be warranted to inform the need for arrhythmia screening.

Abstract 10428: Probability of Atrial Fibrillation (AF) Diagnosis and Error in Estimation of Burden in People With Paroxysmal AF Based on the Duration of Monitoring

Introduction: In individuals with paroxysmal atrial fibrillation (PAF) undergoing heart rhythm monitoring, total duration of monitoring can influence both the probability of recognizing AF and estimation of burden. We estimate the probability of AF detection and quantify the error in burden estimation based on the duration of monitoring up to 10 days. Methods: Data included 5361 ECG patch recordings up to 14 days long with at least 1 episode of AF. 100 samples of pre-specified lengths were drawn at random from each recording. For each sample length, the probability of identifying any AF, and the AF burden over shorter periods of monitoring were determined. The absolute error in burden estimation over short monitoring divided by the true AF burden during up to 14 days of monitoring was used to determine relative deviation. We stratified the expected relative deviation and probability of detecting AF by high (>10%), moderate (2-10%), or low (<2%) true AF burden. Results: Estimated probability of detecting any AF was significantly affected by duration of monitoring (Fig): 1 day of monitoring identified 76% [75-77%], 52% [51-54%] and 35% [33-36%] of individuals with high, moderate, and low burden of AF. Relative deviation in the estimation of AF burden is also significantly impacted by monitoring duration with 1 day recording, with 0.89 [0.87-0.91], 1.45 [1.43-1.47], and 1.65 [1.63-1.67] for high, moderate, and low burden. Even for 7 days recording, the expected deviation is significant, with 0.31 [0.30-0.33], 0.60 [0.58-0.61], 0.79 [0.78-0.80] for high, moderate, and low burden (Fig). Conclusions: In people with PAF, known or unknown, the duration of continuous ECG recording can significantly impact both ability to diagnosis AF and accurate determination of AF burden. Even in individuals with true AF burden >10%, 24 hours of monitoring will not detect AF in >20% of people and provide an almost 90% relative error in the estimate of AF burden.

Abstract 15128: Are We Underestimating the Incidence of Significant Ventricular Ectopy in Pediatric Patients With Post-Covid Vaccine Myocarditis?

Background: The development of mRNA vaccines was essential in combatting the COVID-19 pandemic. Emergency use authorization for COVID-19 vaccine was granted to adolescents aged 12 and older in May 2021. Subsequently, an increase in myocarditis was observed related to the mRNA vaccine. Previous reports estimate a 5% incidence of ventricular arrhythmias in patients with vaccine-associated myocarditis. Hypothesis: The incidence of ventricular ectopy in patients with post-COVID vaccine myocarditis is higher than previously described. Methods: We analyzed data retrospectively for patients admitted to our cardiac center with clinically suspected myocarditis who received COVID-19 vaccine within 30-days prior to onset of symptoms and had no other clinical cause for myocarditis. We separated this cohort into 3 groups based on the presence of rhythm monitoring post discharge: normal monitor post discharge (Lown grade 0 or 1), abnormal monitor post discharge (Lown grade ≥ 2), and no monitor post discharge. Data are shown as mean ± standard deviation. Results: We included 16 patients with a mean age of 14.9 ± 3.1 years. 12 patients were discharged with ambulatory monitoring and 3 were categorized as abnormal (25%). Abnormal findings included non-sustained ventricular tachycardia, ventricular ectopy with bigeminy and trigeminy patterns, and sustained monomorphic ventricular tachycardia. 1 patient was readmitted for sustained ventricular tachycardia. Mean troponin levels were higher in the arrhythmia group (17.3 ±4) compared to the non-arrhythmia group (4.3 ±4.3). 2 of the 3 patients in the arrhythmia group had myocardial edema on cMRI. Only one patient had LGE. Conclusion: At our center, 25% of patients with post-COVID vaccine myocarditis experienced ventricular arrhythmias, and these patients had higher troponin levels during acute illness. Awareness of this increased rate of arrhythmia is necessary to safely monitor patients with post-COVID vaccine myocarditis.

Abstract 14899: Ten Year Performance of Convergent Cryoballoon Hybrid Ablation With Left Atrial Appendage Exclusion in Persistent and Long Standing Persistent Atrial Fibrillation: A Trac-Af Registry Outcome Study

Introduction: Catheter ablation (CA) efficacy in persistent and long standing persistent atrial fibrillation (AF) remains poor. The Convergent procedure with endocardial cryoballoon and left atrial appendage exclusion (LAAE) addresses multiple epicardial/endocardial targets offering a comprehensive approach. We report clinical outcomes in a prospectively collected registry supplemented by continuous device monitoring in a diseased AF patient population. Methods: Single center patient data were retrospectively analyzed in the TRAC-AF registry (NCT05111015) between November 2011-November 2021. Epicardial ablations were performed by cardiothoracic surgeon and endocardial CA performed by electrophysiologist. Clinical follow up was performed at 3, 6, and 12 months and every 6 months thereafter. AF burden was determined from patients with ≥30 days of 24 hr continuous rhythm monitoring following a 90 day blanking period. Results: A total of 228 patients (69% male) received hybrid Convergent ablation. Mean age was 66 yrs, mean BMI was 30.2 ± 6.2, and in 70% of patients, CHA2DS2-VASc was ≥2. Baseline AF types were paroxysmal (7%), persistent (43%), and longstanding persistent (50%). Mean AF duration was 5.1 ± 6.2 yrs. Fifty-seven percent of patients had failed CA prior to hybrid ablation and 30.6% had LAAE with an epicardial clip. Of 228 patients, 114 (50%) had continuous rhythm monitoring. Mean residual AF burden was 5.2 ± 16.3% and of those, 77% had ≤1% mean residual AF burden, and 88% had ≤5% mean residual AF burden. A repeat CA after hybrid Convergent occurred in 23% (53/228) of patients at a mean 645.8 ± 511.4 days from the index procedure with 4.4% requiring >1; 88.5% of all repeat ablations included a mitral annular line. Conclusions: The hybrid Convergent ablation with endocardial cryoballoon and LAAE provides long term sustainable low AF burden despite rigorous endpoint surveillance in a significantly diseased AF population which includes prior failed CA patients over a decade of follow up.

Abstract 10570: Inflammation During Early Post-Acute Covid-19 is Associated With Reduced Exercise Capacity and Long Covid Symptoms After 1 Year

Introduction: Mechanisms underlying cardiopulmonary symptoms following SARS-CoV-2 infection (post-acute sequelae of COVID-19 “PASC” or “Long COVID”) remain unclear. The purpose of this study was to elucidate the pathophysiology of PASC using cardiopulmonary exercise testing (CPET), cardiac magnetic resonance imaging (CMR) and ambulatory rhythm monitoring. Methods: We performed CMR, CPET, and ambulatory rhythm monitoring among adults > 1 year after confirmed SARS-CoV-2 infection in the UCSF Long-Term Impact of Infection with Novel Coronavirus cohort (LIINC; NCT04362150) and correlated findings with previously measured biomarkers. We used logistic regression to estimate associations with PASC symptoms and linear regression to estimate differences by symptoms adjusted for confounders. Results: Out of 120 participants, 46 participants (unselected for symptom status) had cardiac testing performed at median 17 months after infection. Median age was 52, 18 (39%) were female, and 6 (13%) were hospitalized for severe acute infection. On CPET (n=39), 13/23 (57%) with symptoms had reduced exercise capacity (peak VO2<85% predicted) compared to 2/16 (13%) without symptoms (p=0.008). Adjusted peak VO 2 was 5.9 ml/kg/min lower (-9.6 to -2.3; p=0.002) or -21% predicted (-35 to -7; p=0.006) among those with symptoms. Chronotropic incompetence was present among 9/15 (60%) with reduced peak VO2 (adjusted heart rate reserve<80%: OR 15.6 for reduced peak VO2, 95%CI 1.30-187; p=0.03). Inflammatory markers (hsCRP, IL-6, TNF-α) and SARS-CoV-2 antibody levels measured early in PASC (median 3.5-6 months after infection) were negatively correlated with peak VO2 more than 1 year later (Figure). Conclusions: Cardiopulmonary symptoms and elevated inflammatory markers present early in PASC are associated with reduced exercise capacity during CPET >1 year following COVID-19. Chronotropic incompetence may explain reduced exercise capacity among some individuals with PASC.

Abstract 10856: Artificial Intelligence-Guided Screening for Atrial Fibrillation Using the Electrocardiogram in Sinus Rhythm

Introduction: Prior AF screening trials demonstrated low yield, highlighting the need for more targeted approaches. An AI algorithm was developed to identify ECG signatures of AF risk during normal sinus rhythm, which has been validated in diverse external populations. Hypothesis: An AI-guided, targeted screening approach could improve the diagnosis of AF. Methods We conducted a pragmatic decentralized trial to prospectively recruit patients with stroke risk factors but no prior AF. The AI algorithm was applied to the ECGs performed in routine practice and divided patients into high- or low-risk groups. The primary endpoint was AF lasting ≥ 30 seconds on a subsequent 30-day continuous cardiac rhythm monitor. In a secondary analysis, trial participants were 1:1 propensity score-matched to real-world controls derived from the eligible but unenrolled population. Results A total of 1,003 patients from 40 U.S. states completed the study, with a mean age of 74 [SD 8.8] years. Over a mean of 22.3 days of continuous monitoring, AF was detected in 6 (1.6%) of low-risk patients and 48 (7.6%) of high-risk patients (OR 4.98 [2.11-11.75], p<0.001). Compared to usual care, AI-guided AF screening was associated with increased detection of AF (high-risk group: 4.2% vs. 11.1%, p<0.001; low-risk group: 0.9% vs. 2.4%, p=0.12) over a median follow-up of 10 months. Conclusions A prospective pragmatic study found that the AI a can risk-stratify a relatively uniform population (i.e., older adults at risk for stroke) to detect AF during short-term cardiac monitoring. Furthermore, when compared with usual care, AI-guided cardiac monitoring was associated with increased AF detection. As such, an AI-guided AF screening approach, leveraging existing EHR data and infrastructure, could be effective, patient-centered, and massively scalable, thereby reducing unnecessary health utilization and diagnosis-related anxiety (Clinicaltrials.gov: NCT04208971).

Posterior wall isolation in persistent atrial fibrillation. Long-term outcomes of a repeat procedure strategy.

Posterior wall isolation (PWI) added to pulmonary vein isolation (PVI) is increasingly used in ablation for persistent atrial fibrillation (PeAF) despite limited evidence of clinical benefit. We investigated the 5-year outcomes of a PVI + PWI ablation strategy with mandatory repeat procedures in PeAF. Twenty-four patients with PeAF participated in this single-arm prospective study and underwent radiofrequency ablation (RFA) with wide area circumferential ablation (WACA), roof, and inferior lines for PVI + PWI which was reinforced if required during mandated repeat procedures after 6months. Then, patients were followed for 60months using continuous heart rhythm monitoring by implanted cardiac monitors (ICM) and atrial fibrillation effect on quality-of-life scoring (AFEQT; range: 20-100 points) for the initial 30months. ICM-verified cumulated AF recurrence was 54% after 30months but the ensuing AF burden was only median 0‰ [0 to 4.8‰] overall and 1‰ [0 to 8 ‰] among patients with any recurrence. AFEQT scores increased from baseline 60 points [48 to 72] to 93 points [84 to 96] at repeat procedures P < 0.0001 and further to 96 points [93 to 99] P = 0.03 after 30months. After 60months, at least one episode of AF had been documented in 63% and two patients (8%) were in permanent AF. Reinforced PVI + PWI was associated with low long-term AF burden and corresponding improvements in quality-of-life. Reinforced (or durable) PVI + PWI appears to be a promising strategy to treat PeAF. ClinicalTrials.gov. Identifier: NCT05045131.

Role of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in cryoballoon ablation outcomes for paroxysmal atrial fibrillation.

Cryoballoon ablation (CBA) is recommended for patients with paroxysmal atrial fibrillation (AF) refractory to antiarrhythmic drugs. However, only 80% of patients benefit from initial CBA. There is growing evidence that pretreatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) decreases the recurrence of AF postablation, particularly in nonparoxysmal AF undergoing radiofrequency ablation. The role of ACEIs and ARBs in patients with paroxysmal AF in CBA remains unknown. We decided to investigate the role of ACEIs and ARBs in preventing the recurrence of atrial arrhythmia (AA) following CBA for paroxysmal AF. To investigate the role of ACEIs and ARBs in preventing recurrence of AA following CBA for paroxysmal AF. We followed 103 patients (age 60.6 ± 9.1 years, 29% women) with paroxysmal AF undergoing CBA 1-year post procedure. Recurrence was assessed by documented AA on electrocardiogram or any form of long-term cardiac rhythm monitoring. A multivariable Cox proportional hazard model was used to assess if ACEI or ARB treatment predicted the risk of AA recurrence. After a 1-year follow-up, 19 (18.4%) participants developed recurrence of AA. Use of ACEI or ARB therapy was noted in the study population. Patients on ACEI/ARB had a greater prevalence of hypertension and coronary artery disease. On a multivariate model adjusted for baseline demographics and risk factors for AF, ACEI or ARB therapy did not prevent recurrence of AA following CBA (P = 0.72). Similarly, on Kaplan-Meier analysis pretreatment with ACEI/ARB did not predict the time to first recurrence of AA (P = 0.2173). In our study population, preablation treatment with an ACEI or ARB had no influence on the recurrence of AA following CBA for paroxysmal AF.

Ventricular arrhythmias in arrhythmic mitral valve syndrome-a prospective continuous long-term cardiac monitoring study.

Arrhythmic mitral valve syndrome is linked to life-threatening ventricular arrhythmias. The incidence, morphology and methods for risk stratification are not well known. This prospective study aimed to describe the incidence and the morphology of ventricular arrhythmia and propose risk stratification in patients with arrhythmic mitral valve syndrome. Arrhythmic mitral valve syndrome patients were monitored for ventricular tachyarrhythmias by implantable loop recorders (ILR) and secondary preventive implantable cardioverter-defibrillators (ICD). Severe ventricular arrhythmias included ventricular fibrillation, appropriate or aborted ICD therapy, sustained ventricular tachycardia and non-sustained ventricular tachycardia with symptoms of hemodynamic instability. During 3.1 years of follow-up, severe ventricular arrhythmia was recorded in seven (12%) of 60 patients implanted with ILR [first event incidence rate 4% per person-year, 95% confidence interval (CI) 2-9] and in four (20%) of 20 patients with ICD (re-event incidence rate 8% per person-year, 95% CI 3-21). In the ILR group, severe ventricular arrhythmia was associated with frequent premature ventricular complexes, more non-sustained ventricular tachycardias, greater left ventricular diameter and greater posterolateral mitral annular disjunction distance (all P < 0.02). The yearly incidence of ventricular arrhythmia was high in arrhythmic mitral valve syndrome patients without previous severe arrhythmias using continuous heart rhythm monitoring. The incidence was even higher in patients with secondary preventive ICD. Frequent premature ventricular complexes, non-sustained ventricular tachycardias, greater left ventricular diameter and greater posterolateral mitral annular disjunction distance were predictors of first severe arrhythmic event.

The HF-AF ENERGY Trial: Nicotinamide Riboside for the Treatment of Atrial Fibrillation in Heart Failure Patients

BackgroundThe presence of atrial fibrillation (AF) in heart failure (HF) patients with reduced ejection fraction is common and associated with an increased risk of stroke, hospitalization and mortality. Recent research findings indicate that a reduction in nicotinamide adenine dinucleotide (NAD+) levels results in mitochondrial dysfunction, DNA damage and consequently cardiomyocyte impairment in experimental and clinical HF and AF. The HF-AF ENERGY trial aims to investigate the cardioprotective effects of the NAD+ precursor nicotinamide riboside (NR) treatment in ischemic heart disease patients diagnosed with AF.Study designThe HF-AF ENERGY trial is a prospective intervention study. The study consists of a (retrospective) 4 months observation period and a 4 months intervention period. The cardioprotective effect of NR on AF burden is investigated by remote monitoring software of implantable cardiac defibrillators (ICDs), which enables continuous atrial rhythm monitoring detection. Cardiac dimension and function are examined by echocardiography. Laboratory blood analysis is performed to determine mitochondrial function markers and energy metabolism. All the study parameters are assessed at two fixed time points (pre- and post-treatment). Pre- and post-treatment outcomes are compared to determine the effects of NR treatment on AF burden, mitochondrial function markers and energy metabolism.ConclusionThe HF-AF ENERGY trial investigates the cardioprotective effects of NR on AF burden and whether NR normalizes blood-based mitochondrial function markers and energy metabolites of the NAD metabolome in ischemic heart disease patients diagnosed with AF. The study outcomes elucidate whether NAD+ metabolism can be used as a future therapy for HF patients with AF.

Screening, diagnosis and follow-up of Brugada syndrome in children: aDutch expert consensus statement.

Brugada syndrome (BrS) is a rare inherited arrhythmia syndrome. Affected children may experience life-threatening symptoms, mainly during fever. The percentage of SCN5A variant carriers in children is higher than in adults. Current diagnostic and follow-up policies for children with (a family history of) BrS vary between centres. Here, we present a consensus statement based on the current literature and expert opinions to standardise the approach for all children with BrS and those from BrS families in the Netherlands. In summary, BrS is diagnosed in patients with a spontaneous type 1 electrocardiogram (ECG) pattern or with a Shanghai score ≥ 3.5 including ≥ 1 ECG finding. A sodium channel-blocking drug challenge test should only be performed after puberty with a few exceptions. A fever ECG is indicated in children with suspected BrS, in children with a first-degree family member with definite or possible BrS according to the Shanghai criteria with a SCN5A variant and in paediatric SCN5A variant carriers. In-hospital rhythm monitoring during fever is indicated in patients with an existing type 1 ECG pattern and in those who develop such a pattern. Genetic testing should be restricted to SCN5A. Children with BrS and children who carry an SCN5A variant should avoid medication listed at www.brugadadrugs.org and fever should be suppressed. Ventricular arrhythmias or electrical storms should be treated with isoproterenol infusion.Supplementary InformationThe online version of this article (10.1007/s12471-022-01723-6) contains supplementary material, which is available to authorized users.

Does transcatheter ventricular septal defect closure affect heart rate variability in children?

BackgroundHeart rate variability (HRV) is a sign of the cardiac autonomic nervous system. Its evaluation in pediatric ventricular septal defect (VSD) cases before and after transcatheter closure contributes to an understanding of cardiac autonomic control. MethodsNineteen children with VSDs treated with transcatheter closure and 18 healthy children were enrolled in this study. A 24-h Holter rhythm monitor was applied to all patients before VSD closure and to those in the control group. Holter rhythm monitoring was repeated at three months in the patient group. HRV parameters were measured using the Cardio Scan Premier 12® program. Frequency-domain (total power; very-low-frequency, low-frequency (LF), and high-frequency (HF) indices; and the LF/HF ratio) and time-domain (standard deviation of all RR intervals (SDNN), standard deviation of 5-min averages of RR intervals (SDANN), the SDNN index, percentage of the difference between adjacent RR intervals, and the square root of the mean of the sum of square differences between adjacent filtered RR intervals) parameters were assessed. ResultsBefore the procedure, SDNN, SDANN, and total power values were lower in the patient group than in the control group; other parameters were similar in the two groups. No significant difference in the SDNN, SDANN, or total power was detected between the patient and control groups in the third month, indicating that autonomic control of patients’ hearts became normal during the third postoperative month. No correlation was detected between any hemodynamic parameters and any time-domain or frequency-domain parameters before closure. ConclusionThis study showed that transcatheter closure of VSDs changed HRV parameters in pediatric patients.

MHealth-based assessment of rate control during recurrent paroxysms after an emergency department visit for recent-onset atrial fibrillation: a subanalysis of the RACE 7 ACWAS trial

Abstract Introduction Achieving adequate rate control is a mainstay in the treatment of atrial fibrillation (AF). In the Rate Control versus Electrical Cardioversion Trial 7 – Acute Cardioversion versus Wait and See (RACE 7 ACWAS) trial, an early cardioversion approach was compared to a delayed cardioversion approach for patients with recent-onset symptomatic AF, followed by a four-week monitoring period using mobile health (mHealth). Purpose To assess the adequacy of rate control during recurrences of AF in the four weeks after an emergency department visit for recent-onset AF using mHealth. Methods After restoration of sinus rhythm (spontaneous or through cardioversion), patients (n=335) were asked to record one minute heart rate and rhythm recordings three times daily and in case of symptoms by using an electrocardiographic-based handheld device to monitor for recurrences for four weeks after the index visit. Recordings from the handheld device were collected at the end of the follow-up period. For this subanalysis, a cut-off for lenient rate control during AF recurrences was used and this was defined as a heart rate of &amp;lt;110 beats per minute. A p-value of &amp;lt;0.05 was considered statistically significant. Results mHealth-based monitoring identified 99 patients with a total of 314 recurrences (29.6% of the included patients; median age 67 [interquartile range (IQR) 13] years, 60.6% male, 49.5% delayed cardioversion group, median number of recurrences 2 [IQR 2]). Two recurrences in one patient were excluded from analysis because heart rate could not be adequately assessed due to too much interference. Rate control was always adequate during 126 recurrences (40.4%), always inadequate during 111 recurrences (35.6%) and varying between adequate and inadequate in the remaining 75 recurrences (24.0%). On a patient level, rate control was always adequate in 26 patients (26.5%), always inadequate in 20 patients (20.4%) and varying between or within recurrences in the remaining 52 patients (53.1%) (Figure 1). Although there were no differences in clinical characteristics of the patients based on their adequacy of rate control, there is a trend towards significance regarding randomisation group (p=0.051), with patients with adequate rate control being more often in the delayed cardioversion group compared to those with varying and inadequate rate control (18 (69.2%) vs 24 (46.2%) vs 7 (35.0%), respectively). Conclusion It is feasible to assess heart rate and the adequacy of rate control during recurrences of recent-onset AF using mHealth. Whether real time mHealth-based rate and rhythm monitoring can be integrated in a remote management pathway to adapt rate control in AF patients warrants further studies. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Organization for Health Research and Development–Health Care Efficiency Research Program

Cryoballoon ablation of atrial fibrillation in octogenarians: one year results from the Cryo Global Registry

Abstract Background A few studies have demonstrated the safety and efficacy of cryoballoon ablation (CBA) in elderly patients (≥75 years old) with atrial fibrillation (AF). However, global utilization and outcomes of CBA in the octogenarian population (≥80 years old) have not been reported. Purpose To evaluate the efficacy and safety of CBA of AF in patients ≥80 years old. Methods The Cryo Global Registry (NCT02752737) is an ongoing, prospective, multicenter registry. In this analysis, 1674 patients with paroxysmal or persistent AF were included in 37 global centers who treated at least one octogenarian with CBA. Analysis cohorts were defined as patients ≥80 and patients &amp;lt;80 years old (control). To address safety issues of CBA in octogenarians, serious procedure-related complications were assessed. Utilizing Kaplan-Meier estimates, 12-month freedom from a ≥30sec AF/atrial flutter (AFL)/atrial tachycardia (AT) recurrence following a 90-day blanking period was evaluated. Results The average age of the octogenarians (n=101) was 82±2 years vs 62±10 years in the control group (n=1573). More females were found in the octogenarian population (51.5% vs 35.7%, p&amp;lt;0.01). The ≥80-year-old cohort had lower BMI (26±4 kg/m2 vs 27±5 kg/m2), higher CHA2DS2-VASc-Scores (4.2±1.3 vs 2.0±1.5), and a higher proportion of heart failure (all p&amp;lt;0.01). The patient cohort ≥80 years was similar compared to the control group regarding the AF history (70.3% vs 74.4% paroxysmal AF), years diagnosed with AF (2.9±4.9 vs 3.2±4.8), and left atrial diameter (43±8 mm vs 42±8 mm) (all p&amp;gt;0.05). Success rates of acute pulmonary vein isolation did not differ between the groups (95.0% vs 96.2%, p=0.59). No differences were observed between ≥80- (5.9%) and &amp;lt;80-year-old patients (3.5%) with respect to serious adverse events (p=0.26). Rhythm monitoring, comprising of Holter and 12-lead ECG, was performed on average 3.1±3.1 times in the elder population and 3.2±3.1 times in the control group through 12 months (p=0.84). Efficacy at 12 months was not different between groups, resulting in 80.6% (95% CI: 71.0–87.3%) freedom from AF/AFL/AT recurrence at 12 months in the octogenarians compared to 78.9% (95% CI: 76.7–80.9%) in the control group (p=0.70). Fewer patients were prescribed AADs at 12 months (32.2%, 23.7%) compared to discharge (47.8%, 49.1%), octogenarians and control, respectively. Further, octogenarians were less likely to receive a repeat ablation 3.3% (95% CI: 1.1–9.7%) in comparison to the control cohort 9.2% (95% CI: 7.8–10.8%) (p=0.052). The 12-month Kaplan-Meier estimate of freedom from cardiovascular-related hospitalization was 81.1% (95% CI: 71.7–87.7%) in the octogenarian and 84.8% (95% CI: 82.9–86.6%) in the control group, respectively (p=0.21). Conclusion Cryoballoon ablation for the treatment of AF is a safe procedure in octogenarians, with efficacy and complication rates comparable to younger patients. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic, Inc.

A service evaluation of Zio XT: the Liverpool experience

Abstract Introduction The Zio XT is an adhesive, ambulatory heart rhythm monitoring device that can be worn for up to 14 days. It can be fitted by patients and utilises an Artificial Intelligence-based algorithm for rhythm analysis, offering potential convenience, accuracy and efficiency compared to Holter monitors. However, there is a lack of data regarding its efficacy and long-term impact. Thus, until further evidence ensues, NICE guidelines recommend Zio XT as a potential option for those requiring prolonged rhythm monitoring. Purpose We evaluated the efficacy of Zio XT for heart rhythm monitoring compared to Holter monitors. Methods 200 sequential patients that had Holter monitors and 204 that had Zio XT were included. Zio cases were randomly selected over 6 months to avoid the learning curve effect. Primary outcomes included time to results and the arrhythmia detection rate. Secondary outcomes included the proportion of patients that had heart rhythm monitoring in the 12 months preceding their investigation, those who required further tests as well as rates of outpatient appointments (OPAs) for device fitting and follow-up, and procedures such as device implantation and ablations. Results Data from 22 (10.8%) Zio patches was unavailable due to these being lost/not returned/unwearable, thus post-investigation outcomes were analysed for 182 Zio and 200 Holter cases. Zio XT was associated with a significantly shorter time to results compared to Holter monitors (median time: 21 days (interquartile range (IQR) 18–25) vs. 46 days (IQR 37.3–87.8), p&amp;lt;0.001), and a higher significant arrhythmia detection rate (55.4% vs. 17.5%, p&amp;lt;0.001). 26.5% of Zio patients had heart-rhythm monitoring in the preceding 12 months, compared to the 14.5% in the Holter group, p=0.003, with 55.8% having Holters and 28.8% having Zios previously, in the Zio group. A higher proportion of Zio recipients also required repeat tests (19.4 vs. 8.5%, p=0.002). Reasons for this included post-intervention monitoring (44.1%), lack of results due to devices being lost/faulty/not returned (41.2%) and a lack of diagnosis (14.7%). Zio monitoring was associated with a significant reduction in the need for OPAs for fitting (0.5% vs. 96%, p&amp;lt;0.001) and follow-up (70.1% vs. 87.0, p&amp;lt;0.001), and resulted in a significant increase in ablations (5.9% vs. 1.0%, p=0.005) but not device implantations (5.9% vs. 3.9, p=0.209). Conclusion Our findings indicate that Zio XT is associated with a statistically significant reduction in time to results, higher arrhythmia detection rate and a reduced need for OPAs. We demonstrated a higher rate of both Holter and Zio testing before and Zio testing after these investigations. We postulate that this has partly been due to a learning curve effect with the introduction of a new technology compared to the Holter which has been in use for many decades. Further large-scale evaluation is recommended to yield vital information on management pathways and cost efficacy. Funding Acknowledgement Type of funding sources: None.

Pseudo-V1 ECG lead recording with quality smartwatches and medical interpretation may be necessary for timely and accurate remote detection of atrial flutter/fibrillation

Abstract Background Remote rhythm monitoring with wearable devices is increasingly used especially for early detection of atrial fibrillation/flutter (AF/Afl), being the access to hospital discouraged, especially for frail elderly patients, due to the burden and risk of COVID-19 pandemic. Whereas devices using photo plethysmography (PPG) may misinterpret as AF pulse irregularities due to extrasystoles, patient-directed recording of a single (usually wrist-to-wrist) lead ECG (LEAD I) with hand-held devices or smartwatches have been developed to increase accuracy in AF detection. However, although recent studies validating such devices single-lead ECG recording have shown high sensitivity and specificity, false negative findings such as those reported here are still possible and must be prevented [1]. Purpose Given previous experience of diagnostic uncertainty or failure of the smartwatch ECG (SW-ECG) LEAD I to detect AF/Afl, we have tested if false negative diagnosis could be avoided by recording in addition at least one right precordial (pseudo-V1) lead analyzed by a trained healthcare professional. Method Over one calendar year observation, five patients with previous history of ablated supraventricular arrhythmias suffering sudden palpitations suspected of paroxysmal AF/Afl were instructed to record with their smartwatch at least one precordial lead in addition to LEAD I, to monitor ECG until the termination of symptoms. The SW-ECG strips were sent by telephone for professional interpretation. Diagnostic accuracy based on LEAD I and pseudo-V1 were independently validated by two cardiologists (diagnostic goldstandard - DGS). Results 22 AF/Afl events occurred. Pharmacological cardioversion to sinus rhythm (SR) was obtained in 64%. 192 ECG strips were transmitted. 43,7% of the strips were automatically classified as “not significant” (or “not valid”). Compared to DGS, out of 108 “valid” strips, correct automatic identification of AF/Afl was obtained in 36,4% with LEAD I, in 33,3% with pseudo V1 and in 54,5% with combined leads, respectively. Interestingly, the SW algorithm has wrongly diagnosed as SR, not only LEAD I, but also 39,4% of pseudo-V1 strips, despite clear-cut evidence of typical flutter waves (Figure 1), when RR intervals were regular due to high degree (e.g., 4:1) A-V block. Conclusions With simple instructions, patients (or their relatives) can easily record an additional precordial (pseudo-V1) SW-ECG lead, that may enhance sensitivity and specificity for remote detection of AF/Afl. However, at present, visual interpretation of SW-ECG by a trained healthcare professional is still needed to guarantee 100% correct diagnosis of AF/Afl, crucial to reduce thromboembolic risk and timely initiate the appropriate treatments. The automatic interpretation of SW's ECG could be improved by appropriate training of a machine learning approach to detect and analyze the atrial waveform provided by an additional pseudo-V1 lead. Funding Acknowledgement Type of funding sources: None.