Maintenance Of Sinus Rhythm In Patients Research Articles

Предиктори утримання синусового ритму в пацієнтів із пізньою персистентною фібриляцією передсердь після електричної кардіоверсії під час 6-місячного проспективного спостереження

The aim – to study the predictors of sinus rhythm (SR) maintenance in patients with persistent atrial fibrillation (AF) and duration of AF episode ≥90 days at 6-months follow-up after elective direct current (DC) cardioversion.Materials and methods. The cohort single-center study analyzed clinical and instrumental data from 59 persistent AF patients with duration of its episode ≥90 days (up to 12 months), who underwent an elective DC cardioversion. At 6-months follow-up, patients were subdivided into the groups depending on SR maintenance: 32 (54 %) patients with a maintained SR (G1), and 27 (46 %) patients with a failure to maintain SR (G2).Results. G2, as compared to G1, demonstrated more advanced heart failure (stage C occurred in 74 % and 44 %, respectively [p=0,019]). According to transthoracic echocardiography (TTE) data, G1, as opposed to G2, was characterized by better baseline structure parameters of left heart chambers, particularly the diameter of left atrium (LA), end-diastolic and end-systolic volumes left ventricular (LV) volumes, higher LV systolic function (by LV ejection fraction [EF]), and the majority of the cases without or with mild pulmonary hypertension (PH). Transesophageal echocardiography data suggested the cases of LA spontaneous (echo) contrast and LA appendage flow velocity (LAAFV) ≤ 40 cm/s to be more frequent in G2, in contrast to G1. We revealed the following predictors of SR maintenance after DC cardioversion at 6-months follow-up: higher LV EF (OR 1,07 (95 % CI 1,01–1,13); р=0,021); LAAFV > 40 cm/s (OR 4,33 (95 % CI 1,06–17,78); р=0,042), and less advanced PH (OR 0,24 (95 % CI 0,06–0,93); р=0,038). TTE data from G1 at 6-months follow-up after DC cardioversion suggested the reverse remodeling of both atria (the decrease of LA diameter, LA and right atrium volumes and their indexes). Additionally, G2 demonstrated a worsening in LV systolic function (the rise of LV end-systolic volume and decrease of LV EF), as opposed to G1. Moreover, at 6-months follow-up, G2 patients presented with more advanced severity of PH, as well as mitral and tricuspid regurgitation, in contrast to G1.Conclusions. Better LV systolic function, LAAFV > 40 cm/s and less advanced PH were the predictors of SR maintenance in patients with persistent AF and duration of its episode ≥ 90 days at 6-months follow-up after elective DC cardioversion. The SR maintenance at 6-months follow-up associated with the reverse remodeling of let heart chambers and right atrium. On the contrary, a failure to maintain SR associated with the decrease of LV systolic function, and more advanced PH, mitral and tricuspid regurgitation.

Study of ECG-derived atrial fibrillatory rate for prediction of the outcome of cardioversion of short duration atrial fibrillation (CASAF)

AimsThe present study aimed at testing the hypothesis that atrial fibrillatory rate (AFR) is predictive of sinus rhythm maintenance after electrical cardioversion. Methods and resultsThe study comprised 32 patients admitted for cardioversion of atrial fibrillation of short duration (mean duration 3.8 ± 7.7 days). AFR was estimated using frequency power spectrum analysis of QRST-cancelled ECG.At six-weeks follow-up 22% of the patients had relapsed to AF. The pre-cardioversion mean AFR of those was 332 ± 64 fpm compared to 378 ± 59 fpm among patients maintaining sinus rhythm (p = 0.12). ConclusionAFR was not predictive of sinus rhythm maintenance in patients of short duration AF undergoing cardioversion. This is in stark contrast with the earlier reported findings. Clinical trial registrationNCT02112318 (http://www.clinicaltrials.gov).

Vein of Marshall Collateralization during Ethanol Infusion in Atrial Fibrillation: Solution for Effective Myocardium Staining

The vein of Marshall (VOM) ethanol infusion improves sinus rhythm maintenance in patients with atrial fibrillation (AF). Distal collateral circulation of VOM can be a challenge to effective ethanol infusion. This study aimed to evaluate the feasibility and efficacy of ethanol infusion in VOM with distal collateral circulation. Patients with AF scheduled for catheter ablation and VOM ethanol infusion were consecutively enrolled. During the procedure, non-occluded coronary sinus angiography was first performed for VOM identification. After VOM identification, an over-the-wire angioplasty balloon was used for cannulation and occluded angiography of the VOM. Those with distal VOM collateral circulation were included in this study. A method of slower ethanol injection (2 mL over 5 min) plus additional balloon occlusion time for 3 min after each injection was used. Of 162 patients scheduled for VOM ethanol infusion, apparent distal VOM collateral circulation was revealed in seven (4.3%) patients. Five patients had collateral circulation to the left atrium, one to the right superior vena cava, and one to the great cardiac vein. Two patients did not undergo further ethanol infusion because of our inadequate experience during the early stage of the project. Five patients had successful VOM ethanol infusion with manifest localized myocardium staining. Ethanol infusion in VOM with distal collateral circulation can be solved by slow injection of ethanol and enough balloon occlusion time between multiple injections.

Echocardiography markers of myocardial deformation as independent predictors of sinus rhythm maintenance after catheter ablation for paroxysmal atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Speckle Tracking Echocardiography (STE) provides a comprehensive and quantitative assessment of myocardial function. However, the accuracy of STE-derived indices to predict maintenance of sinus rhythm (SR) following radio-frequency catheter ablation (CA) is still under debate. Therefore, the aim of the present study is to define the accuracy of STE-derived parameters to predict long-term maintenance of SR in patients with paroxysmal AF undergoing CA. Methods We prospectively enrolled 218 consecutive patients (age: 62 ± 10 years, 30% females) with paroxysmal AF undergoing first-CA. All patients with preserved ejection fraction (EF ≥ 50%) underwent comprehensive transthoracic echocardiography at baseline, including assessment of left ventricular (LV) global longitudinal strain (GLS), left atrial (LA) reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile strain (LASct) using two-dimensional STE in apical views. Results At 12 months follow up, a total of 39 (18%) patients had a documented recurrence of AF. Among imaging parameters, LASr > 23% showed the largest area under the curve (0.80) to predict long-term maintenance of SR with sensitivity of 79% and specificity of 72%. Other parameters of LA function, LA diameter, maximum or minimum LA volume index, LV GLS or ejection fraction, and indices of LV diastolic function had lower area under the curve (Figure 1). Using multi-variable logistic regression, LASr (OR 1.19, 95% CI 1.10-1.23, p < 0.001) and LASct (OR 1.21, 95% CI 1.07-1.37, p = 0.002) were independently associated with long-term SR while maximum or minimum LA volume index was not. Conclusion In patients with paroxysmal AF undergoing radio-frequency CA, preserved LA reservoir and contractile strain is independently associated with long-term maintenance of SR, whereas LA diameter or volumes were not. LA strain may therefore be useful in management of patients with paroxysmal AF. Figure 1: Receiver-operating characteristic curves of left atrial reservoir strain (LASr), LA conduit strain (LAScd), LA contractile strain (LASct), LA emptying fraction (LAEF), LA expansion index (LAEI), LA end-systolic (LAES) and end-diastolic (LAED) volume index (VI) to predict long-term maintenance of sinus rhythm. Abstract Figure.

Sinus Rhythm Maintenance After Electrical Cardioversion for Atrial Fibrillation in High-Risk Patients — Comparative Efficacy of Antiarrhythmic Medications

Abstract Atrial fibrillation (AF) conversion to sinus rhythm by electrical cardioversion (ECV) is followed by the challenge of preventing arrhythmia recurrence, especially in high-risk patients. The properties of class IC, class III and also class II antiarrhythmic medications have been established, but not all effects have been studied. The aim of the study was to compare efficacy of class IC and class III antiarrhythmic medications, and additionally medication with a class II mechanism of action, or taken concomitantly with a beta-blocker, for post-cardioversion sinus rhythm maintenance in patients with high-risk AF. A total of 112 patients who underwent successful ECV in Latvian Centre of Cardiology were included. Data was acquired by a face-to-face interview and 1-, 3-, 6-month follow-up interviews. Comparing class IC (used by 34.8%) and class III (used by 65.2%) drugs, there was no statistically significant difference between six-month sinus rhythm maintenance rates (53.8% vs. 63.0%, p = 0.346) and arrhythmia-free survival (p = 0.313). Comparing amiodarone (used by 57.1%) and ethacizine, concurrently with a beta-blocker (used by 25.9%), no statistically significant difference was found between six-month sinus rhythm maintenance (64.1% vs. 58.6%, p = 0.616) and arrhythmia-free survival (p = 0.706). The results showed that specific antiarrhythmic drug choice was not associated with superior effectiveness, highlighting that, if not contraindicated, ethacizine, concomitantly with a beta-blocker, could be used as a similarly effective alternative for amiodarone, which has adverse health effects.

Cryoballoon ablation of atrial fibrillation in patients with atypical right pulmonary vein anatomy

Cryoballoon ablation is widely used for pulmonary vein isolation in patients with atrial fibrillation. There are no data regarding the clinical efficacy of cryoballoon ablation in patients with atypical right pulmonary vein anatomy. We aimed to evaluate the impact of right pulmonary vein anatomy on the safety and efficacy of cryoballoon ablation. Patients referred for cryoballoon ablation of paroxysmal atrial fibrillation were enrolled prospectively. Left atrial computed tomography was performed before cryoballoon ablation to determine whether the right pulmonary vein anatomy was "normal" or "atypical". For patients with atypical anatomy, cryoballoon ablation was only performed for right superior and right inferior pulmonary veins, neglecting accessory pulmonary veins. Overall, 303 patients were included: 254 (83.8%) with normal and 49 (16.2%) with atypical right pulmonary vein anatomy. First-freeze isolation for right superior and right inferior pulmonary veins occurred in 44 (89.8%) and 37 (75.5%) patients with atypical pulmonary vein anatomy, and in 218 (85.8%) and 217 (85.4%) patients with typical pulmonary vein anatomy, respectively (P not significant). Phrenic nerve palsies were only observed in patients with normal anatomy (0 vs. 26 [8.6%]; P=0.039). Mid-term survival free from atrial arrhythmia was similar, regardless of right pulmonary vein anatomy. A significant proportion of patients have atypical right pulmonary vein anatomy. Procedural characteristics, acute pulmonary vein isolation success and mid-term procedural efficacy were similar, regardless of right pulmonary vein anatomy. In addition to left-side pulmonary vein isolation, cryoballoon ablation of right superior and right inferior pulmonary veins only, neglecting accessory pulmonary veins, is sufficient to obtain acute right-side pulmonary vein isolation and mid-term sinus rhythm maintenance in patients with atypical anatomy.

Targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent atrial fibrillation: results of the RACE 3 trial.

Atrial fibrillation (AF) is a progressive disease. Targeted therapy of underlying conditions refers to interventions aiming to modify risk factors in order to prevent AF. We hypothesised that targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent AF. We randomized patients with early persistent AF and mild-to-moderate heart failure (HF) to targeted therapy of underlying conditions or conventional therapy. Both groups received causal treatment of AF and HF, and rhythm control therapy. In the intervention group, on top of that, four therapies were started: (i) mineralocorticoid receptor antagonists (MRAs), (ii) statins, (iii) angiotensin converting enzyme inhibitors and/or receptor blockers, and (iv) cardiac rehabilitation including physical activity, dietary restrictions, and counselling. The primary endpoint was sinus rhythm at 1 year during 7 days of Holter monitoring. Of 245 patients, 119 were randomized to targeted and 126 to conventional therapy. The intervention led to a contrast in MRA (101 [85%] vs. 5 [4%] patients, P < 0.001) and statin use (111 [93%] vs. 61 [48%], P < 0.001). Angiotensin converting enzyme inhibitors/angiotensin receptor blockers were not different. Cardiac rehabilitation was completed in 109 (92%) patients. Underlying conditions were more successfully treated in the intervention group. At 1 year, sinus rhythm was present in 89 (75%) patients in the intervention vs. 79 (63%) in the conventional group (odds ratio 1.765, lower limit of 95% confidence interval 1.021, P = 0.042). RACE 3 confirms that targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent AF. Clinicaltrials.gov NCT00877643.

The efficacy of amiodarone combined with enalapril in cardioversion of atrial fibrillation and maintenance of sinus rhythm in patients with hypertension and paroxysmal atrial fibrillation

Objective To observe the efficacy of amiodarone combined with enalapril in cardioversion of atrial fibrillation and maintenance of sinus rhythm in patients with hypertension and paroxysmal atrial fibrillation. Methods 60 patients with hypertension and paroxysmal atrial fibrillation were selected as study objects.They were divided into study group and control group according to the random number table, 30 cases in each group.The control group was treated with amiodarone combined with nifedipine, the observation group was given amiodarone combined with enalapril.After 1, 3 and 7 days of treatment, the rates of cardioversion of atrial fibrillation were observed.The rates of maintenance of sinus rhythm were observed after 3, 6, 9 and 12 months of treatment.The left atrial diameter was calculated by echocardiography.The systolic blood pressure (SBP) and diastolic blood pressure (DBP) were detected by blood pressure monitor. Results The rates of cardioversion of atrial fibrillation in the study group and the control group after 3 and 7 days of treatment were 86.67% and 63.33%, 100.00% and 86.67%, respectively, the differences were statistically significant (all P<0.05). The rates of maintenance of sinus rhythm in the study group and the control group after 6, 9, and 12 months of treatment were 83.33% and 57.69%, 80.00% and 53.85%, 76.67% and 50.00%, the differences were statistically significant (χ2=4.487, 4.368, 4.314, all P<0.05). There were no significant differences in SBP and DBP between the study group and the control group at 3, 6, 9 and 12 months after treatment (all P<0.05). The left atrial diameter of the study group after 12 months of treatment was (36.73±2.66)mm, which was significantly lower than (38.78±2.64)mm in the control group, the difference was statistically significant (P<0.05). Conclusion Amiodarone combined with enalapril can improve the conversion rate and the rate of sinus rhythm maintenance in patients with hypertension and paroxysmal atrial fibrillation, and effectively control the atrial enlargement and improve the clinical prognosis. Key words: Hypertension; Atrial fibrillation; Enalapril; Amiodarone

Linear Ablation Following Pulmonary Vein Isolation in Patients with Atrial Fibrillation: A Meta-Analysis.

Previous studies have given conflicting data regarding the long-term adjunctive efficacy of linear lesions (LLs) on top of pulmonary vein isolation (PVI) as an ablation strategy in patients with atrial fibrillation (AF). The aim of this meta-analysis was to provide a detailed analysis of the available randomized controlled trials (RCTs) regarding the efficacy of LL following PVI in AF patients. Current databases were searched until October 2015. The primary outcome end point of the meta-analysis was recurrence of any symptomatic or documented episode of AF or atrial tachycardia after a single ablation procedure with or without the use of antiarrhythmic drugs. Ten RCTs with a total of 1,446 patients were included in the meta-analysis. The pooled analysis of five trials concerning persistent AF (PeAF) patients (400 in PVI plus LL group and 182 in PVI alone group) suggested that the addition of LL following PVI does not lead to a significant reduction in recurrent atrial tachyarrhythmias compared with PVI alone (relative ratio [RR] = 0.73, 95% confidence interval [CI]: 0.44-1.21, P = 0.22). Similarly, there was no incremental benefit of additional LL in long-term outcomes in paroxysmal AF (PAF) patients (RR = 0.85, 95% CI: 0.68-1.05, P = 0.13). Pooling the results of all eligible trials suggested that PVI plus LL compared with PVI alone significantly increased radiofrequency time (P = 0.0002), fluoroscopy time (P < 0.00001), and procedure time (P < 0.0001). This meta-analysis suggests that LL following PVI does not provide additional benefit to sinus rhythm maintenance in patients with PeAF and PAF.

Hybrid approach for the treatment of long-standing persistent atrial fibrillation: electrophysiological findings and clinical results†

The sequential, staged hybrid approach has recently emerged as a novel strategy for the treatment of long-standing persistent atrial fibrillation (AF); nevertheless, the potential modifications in terms of electrophysiological findings and their correlation with mid-term results have not been fully elucidated so far. Forty-five patients with long-standing persistent AF underwent a hybrid procedure combining surgical closed-chest posterior left atrium (LA) and pulmonary veins (PV) isolation (box lesion) first, followed by transcatheter evaluation at least 1 month afterwards. Electrophysiological findings and their correlation with rhythm outcomes were assessed at different time points, i.e. following the surgical ablation (T1), during (T2) and at the end (T3) of the transcatheter evaluation and at 28-month follow-up (T4). At T1, exit and entrance blocks were achieved in 100 and 91.1% (41 of 45) of patients, respectively. At T2, the percentage of conduction block was unchanged, while at T3 also entrance block was achieved in all instances. In terms of electrophysiological findings (at T2), PV reconnection occurred in 6.7% (3 of 45) of patients, fractionated electrograms were targeted in 44.4% (20 of 45) while right atrium isthmus lesion was performed in 24.4% (11 of 45) of patients. Sinus rhythm was restored in 75.6% (34 of 45) at T1, at T2 (with AF induction) in 68.9% (31 of 45), at T3 in 93.3% (42 of 45) and at T4 in 88.9% (40 of 45) of patients, respectively. In those patients with a bidirectional block at T1, sinus rhythm restoration steadily improved from 78 (32 of 41) at T1 to 82.9 (34 of 41) at T2 and finally 92.6% (38 of 41) at T4. Complete posterior LA and PV isolation with the box lesion in a staged hybrid approach is associated with incremental benefits in terms of sinus rhythm maintenance in patients with long-standing persistent AF.

Increased Plasma Aldosterone during Atrial Fibrillation Declines following Cardioversion

Objective: The renin-angiotensin-aldosterone system (RAAS) may be activated during atrial fibrillation (AF); our aim was to evaluate the level of aldosterone in patients with either permanent AF, persistent AF scheduled for cardioversion or patients in sinus rhythm (SR). We hypothesized that an increased level of aldosterone is found in patients with AF, decreasing in patients with restored SR. Methods: The study included 60 patients with persistent AF scheduled for elective cardioversion, 19 patients with permanent AF, and a control group of 19 healthy individuals. All patients were examined and their aldosterone levels were measured. Measurement of aldosterone was repeated at follow-up 1, 30 and 180 days after successful cardioversion was achieved. Statistical analysis was conducted using the Kruskal-Wallis rank sum test and the paired t test. Results: At follow-up, 1, 30, and 180 days after successful cardioversion of the patients with persistent AF, data showed that 49, 27, and 21 patients, respectively, were still in SR. At baseline, median values of plasma aldosterone in the healthy controls, the patients with persistent AF and those with permanent AF were 52, 68, and 80 pg/ml, respectively. The log aldosterone in patients with persistent AF was significantly increased when compared to the control group (p = 0.026). No effect of age and gender was observed. The level of aldosterone decreased over time in patients with AF undergoing cardioversion and maintaining SR, both at a follow-up of 30 days (p = 0.0032) and 180 days (p = 0.037). Conclusions: Patients with AF had a raised aldosterone level compared to the healthy control individuals. Restoration and maintenance of SR in patients with persistent AF significantly lowered the level of aldosterone up to 180 days after cardioversion, indicating activation of RAAS during AF.

Maintenance of Sinus Rhythm and Survival in Patients With Heart Failure and Atrial Fibrillation

The goal of this study was to evaluate the relationship between the presence of sinus rhythm and outcomes in patients with a history of congestive heart failure (CHF) and atrial fibrillation (AF). The value of sinus rhythm maintenance in patients with AF and heart failure (HF) is uncertain. A total of 1,376 patients with AF, ejection fraction < or =35%, and heart failure symptoms were randomized to a rhythm- or rate-control strategy. Detailed efficacy analyses were used to evaluate the independent effects of treatment strategy and the presence of sinus rhythm on cardiovascular outcomes. Overall, 445 (32%) patients died and 402 (29%) experienced worsening HF. The rhythm-control strategy was not predictive of cardiovascular mortality (hazard ratio [HR]: 0.90, 95% confidence interval [CI]: 0.70 to 1.16; p = 0.41), all-cause death (HR: 0.86, 95% CI: 0.69 to 1.08; p = 0.19), or worsening HF (HR: 0.86, 95% CI: 0.68 to 1.10; p = 0.23). In analyses devised to isolate the effect of underlying rhythm, sinus rhythm was not associated with cardiovascular mortality [HR: 1.22, 95% CI: 0.80 to 1.87; p = 0.35), total mortality [HR: 1.11, 95% CI: 0.78 to 1.58; p = 0.57), or worsening HF [HR: 0.62, 95% CI: 0.37 to 1.02; p = 0.059). A rhythm-control strategy or the presence of sinus rhythm are not associated with better outcomes in patients with AF and CHF.

Catheter ablation vs. amiodarone plus losartan for prevention of atrial fibrillation recurrence in patients with paroxysmal atrial fibrillation

Although amiodarone plus angiotensin II receptor blockers (ARBs) and catheter ablation may improve sinus rhythm maintenance of paroxysmal atrial fibrillation (AF), their clinical efficacies have not been compared. This prospective cohort study was designed to compare clinical efficacy of catheter ablation and amiodarone plus losartan on sinus rhythm maintenance in patients with paroxysmal AF. A total of 240 patients with paroxysmal AF were assigned to four groups. CPVA group (n = 60) was treated with circumferential pulmonary vein ablation (CPVA), SPVI group (n = 60) with segmental pulmonary vein isolation, AMIO group (n = 60) with amiodarone and AMIO + LO group (n = 60) with amiodarone plus losartan. The endpoint was documented recurrence of AF > 30 s by Holter or conventional 12-lead ECG in the 1-year follow-up period. During 12 months of follow-up, the primary end point was reached in 28 patients in CPVA group, 14 patients in SPVI group, 25 patients in AMIO group and 13 patients in AMIO + LO group, respectively. The sinus rhythm in SPVI and AMIO + LO group were significant higher than that in CPVA and AMIO group (P < 0.01 and 0.025), and no difference between CPVA and AMIO group. The maintenance rate of sinus rhythm in SPVI group was similar to that in AMIO + LO group. This study demonstrates that segmental pulmonary vein isolation in preventing AF recurrence is similar to amiodarone plus losartan, but it is superior to CPVA and amiodarone alone in patients with paroxysmal AF. Larger multicentre studies are needed to confirm its long-term outcomes.

Atrial fibrillatory rate and sinus rhythm maintenance in patients undergoing cardioversion of persistent atrial fibrillation

The study set out to explore whether an index of atrial electrical electrophysiology can be used to predict atrial fibrillation (AF) relapse, and if the predictive properties differ as a result of arrhythmia duration. The study comprised 175 consecutive patients with persistent AF (median duration 94 days, range 2 to 1044) referred for cardioversion. Twenty-nine patients had arrhythmia duration under 30 days (median 5 days, range 2-26). Atrial fibrillatory rate (AFR) was estimated using a frequency power spectrum analysis of QRST-cancelled ECG. At 1-month follow-up, 56% of the patients had relapsed to AF. The pre-cardioversion mean AFR of those patients was 399+/-52 fibrillations per minute (fpm) compared with 363+/-63 fpm among patients maintaining SR (P<0.0001). In patients with short AF duration, the difference was even more pronounced (424+/-52 vs. 345+/-65 fpm, P<0.01). In this group, a finding of an AFR above the mean value of the study population predicted AF relapse with high accuracy. In patients undergoing cardioversion of persistent AF, AF relapse is predicted by a higher AFR. A stronger association is seen in patients with short arrhythmia duration, reflecting either rapid remodelling or pre-existing changes in those who relapse to AF.

The clinical study of circumferential ablation around orifice of pulmonary vein by radiofrequency energy with chronic atrial fibrillation undergoing rheumatic valvular heart surgery

To evaluate the clinical efficiency of circumferential ablation around orifice of pulmonary vein by radiofrequency (RF) energy in the cure of chronic atrial fibrillation (AF) in patients with rheumatic valvular disease. Radiofrequency catheter ablation was performed in 20 patients with rheumatic valvular disease and chronic AF who underwent heart valve surgery. The ablation temperature was 50 - 60 degrees C and the linear RF ablations were performed encircling the four openings of pulmonary veins and connecting the posterior mitral annulus with the probe made by ourselves especially for this ablative procedure. And amiodarone was given from the third day before the surgery and lasted for 3 months thereafter. Twenty patients with chronic AF who underwent valvular surgery but refused RF ablation were considered as the control group. Sinus rhythm (SR) restored in 19 patients either spontaneously or after intraoperative direct current cardioversion, immediately after the operation, as compared with 16 patients in the control group. During the follow-up (24 +/- 3) months, 16 of 20 patients (80%) remained in sinus rhythm in patients received ablation, but in control group, SR was presented in only 7 of 20 patients (35%). Circumferential ablation around orifice of pulmonary vein by RF energy is safe and effective in restoration and maintenance of SR in patients with rheumatic valvular disease and chronic AF.

Atrial fibrillation signal organization predicts sinus rhythm maintenance in patients undergoing cardioversion of atrial fibrillation

Electrical remodelling is believed to influence the outcome following cardioversion of patients with persistent atrial fibrillation (AF). However, the results in clinical studies are conflicting. We assessed the hypothesis that non-invasively obtained atrial fibrillatory organization can be used as a predictor of sinus rhythm (SR) maintenance. Fifty-four patients (37 men, age 67+/-11) with persistent AF (median duration 3 months, 1 day to 18 months), without anti-arrhythmic drug treatment, referred for cardioversion were studied. Assessment of the atrial harmonic decay was made by time-frequency analysis of the ECG. At 1-month follow-up, 30 patients had relapsed into AF. The mean harmonic decay at inclusion of those relapsing into AF was 1.5+/-0.3 compared with 1.1+/-0.3 among those maintaining SR (P=0.0004). Using a cut-off value of harmonic decay <or=1.5 to determine suitability for cardioversion would have resulted in a clinically useful discriminator (sensitivity=92%, specificity=47%, PPV=59%, and NPV=88%). This study shows that patients relapsing rapidly to AF have a higher harmonic decay than those maintaining SR. The degree of AF signal organization (harmonic decay) was a superior discriminator to other patient parameters. Further studies are needed to confirm these results and to determine the electrophysiological correlate of harmonic decay.

Efficacy of Long-term Flecainide Therapy in Patients with Paroxysmal Atrial Fibrillation —Analysis Based on Time of Onset—

This study sought to evaluate the efficacy of long‐term flecainide therapy in maintaining sinus rhythms in patients with paroxysmal atrial fibrillation (AF. based on time of onset. Flecainide (150 mg/day. was administered as an antiarrhythmic drug to a total of 70 patients (54 men and 16 women: mean age 65 ± 10 years. after sinus rhythm was restored spontaneously or by electrical and/or pharmacological cardioversion. Paroxysmal AF was divided into three categories based on time of onset: diurnal type (N = 11), nocturnal type (N = 13), and mixed type (N = 46). The mean follow‐up period was 37.7 ± 17.7 months. The duration of sinus rhythm maintenance in patients with diurnal and nocturnal paroxysmal AF was 32.4 ± 10.4 months and 20.8 ± 8.3 months, respectively; the duration of sinus rhythm maintenance in those with mixed paroxysmal AF was only 7.2 ± 2.1 months. Significant differences were observed in duration between diurnal and mixed cases (mean ± S.E., P &lt; 0.05). Actuarial recurrence‐free rates at 1, 3, 6, 9 and 12 months were 90.9%, 63.6%, 63.6%, 54.5%, and 54.5%, respectively, for diurnal cases; 84.6%, 76.9%, 53.8%, 38.5%, and 30.8%, respectively, for nocturnal cases; and 58.7%, 39.1%, 28.3%, 21.7%, and 15.2% respectively, for mixed cases. Significant differences in rates at 12 months were observed between diurnal and mixed cases (P &lt; 0.05). These results suggest that flecainide is highly effective in preventing AF recurrence in patients with diurnal paroxysmal AF.

294 Left atrial appendage flow velocity predicts long-term sinus rhythm maintenance in patients with atrial fibrillation of unknown duration

294 Left atrial appendage flow velocity predicts long-term sinus rhythm maintenance in patients with atrial fibrillation of unknown duration

Bepridil Revisited: Efficacy for Persistent Atrial Fibrillation

The purpose of this study is to clarify the efficacy and safety of bepridil for persistent atrial fibrillation (AF). Bepridil (100-200mg/day) was administered to 159 patients (141 males, 58 years) with persistent AF. The effects of conversion and maintenance of sinus rhythm (SR) were evaluated. If sinus restoration was not obtained until 3 months observation, DC cardioversion was performed. In 87 of 159 patients (55%), SR was restored within an average 2.1 months following administration of bepridil. 74 of those 87 patients (85%) have been maintained in SR for the average follow-up of 16 months. The 31 out of remaining 72 patients failed pharmacological conversion were performed DC cardioversion. All of patients restored SR, and 18 of them (58%) could be maintained SR for an average of 20 months. Although ECG revealed significant prolongation of QT interval from 0.38 to 0.42 sec, QTc was unchanged and no serious adverse complications including torsade de pointes were recognized. Bepridil is clinically safe and useful with favorable efficacy for conversion and maintenance of SR in patients with persistent AF.

837 Clinical and echocardiographic predictors of 30-days sinus rhythm maintenance in patients with nonvalvular atrial fibrillation

837 Clinical and echocardiographic predictors of 30-days sinus rhythm maintenance in patients with nonvalvular atrial fibrillation