Use Of Antiarrhythmic Therapy Research Articles

Abstract 17185: Percutaneous Intervention in Chronic Total Coronary Occlusion: Impact on Ventricular Arrhythmia and Mortality Compared to Medical Therapy

Background: The incidence of ventricular arrhythmias (VA) in patients with chronic total coronary occlusions (CTO) in the absence of advanced left ventricular dysfunction is not well described. Moreover, little is known about how revascularization may impact VA in this population compared to medical therapy alone. Methods: In this single-center retrospective cohort study from January 2010 to January 2019. We identified 100 patients with CTO on cardiac catheterization with a left ventricular ejection fraction (LVEF) >35% who did not undergo coronary artery bypass surgery following CTO diagnosis. Percutaneous revascularization was performed for 44 patients. The primary outcomes evaluated were VA and mortality rates at end of the study period. Secondarily, cardiovascular outcomes were compared between the intervention and optimal medical therapy (OMT) groups at the end of the study period. Survival analysis was performed via Kaplan Meier calculation for VA and mortality. Statistical analysis was performed using STATA 15 and R-studio. Results: Mean age was 59.91(± 13.05) and BMI was 31.8(± 7.41). Patients were 66% male, 64% White, and 23% Black. Baseline characteristics, use of antiarrhythmic therapy, baseline LVEF, and the number of CTOs and locations of CTOs were not significantly different between groups. During a median follow-up of 4.1(± 2.54) years, the OMT group experienced higher rates of VA (21.4% vs 7.7 %, p = 0.011), and mortality (37.5% vs 15.9%, p=0.031). Conclusion: CTO in the absence of severe LV systolic dysfunction (LVEF <35%) is associated with a high rate of VA and all-cause mortality, suggesting the need for further study on the impact of CTOs and their revascularization on VA and mortality in patients with LVEF >35%.

Catheter ablation of atrial fibrillation versus antiarrhythmic therapy in patients with left ventricular systolic dysfunction

Aim. To evaluate the efficacy of catheter ablation (CA) of atrial fibrillation (AF) in patients with left ventricular systolic dysfunction and the effect of the procedure on the course of chronic heart failure (CHF) compared with the use of antiarrhythmic therapy (AAT). Materials and methods. The study included patients (n=80) with left ventricular ejection fraction (LVEF) less than 50% and AF, who were divided into 2 groups: the first group (n=40) underwent CA, the second group included patients on AAT. At baseline and after 6 months of follow-up, transthoracic echocardiography, determination of NT-proBNP concentration, 6-minute walk test and The Minnesota Living With Heart Failure Questionnaire were performed. Results. After 6 months of follow-up, the absence of documented AF paroxysms was observed in 80% in the CA group versus 45% in the AAT group (p=0,001). A significant increase in LV EF was revealed in both groups, however, in CA group it was more significant (57% [50,5; 60] in the CA group versus 46% [40; 50] in the AAT group (p=0,0001)). There was a decrease in the left ventricle ESD and the left atrial size and volume in the CA group, while in the AAT group the dynamics of these parameters did not change within six months (p=0.0001). An improvement in the clinical course of CHF was observed in both groups: the level of NT-proBNP was 196,6 [116,5; 327,1] pg/ml and 540.5 [382,8; 861,2] pg/ml (0,0001), the 6-minute walk distance increased to 470 m [400; 500] and 368 [330; 400] m (p=0,0001), respectively, the improvement of the functional class (1,15±0,67 and 2,05±0,55 (p=0,0001)) and the quality of life (p=0,0001) were observed. Conclusion . CA is an effective method for patients with AF and CHF. The use of CA in patients with CHF promotes reverse remodeling, a decrease in the level of NT-proBNP, as well as an improvement in the quality of life and an increase in exercise tolerance.

Amiodarone and ventricular fibrillation amplitude of spectral area in patients with out-of-hospital cardiac arrest. Is there an effect?

Abstract Background The use of antiarrhythmic drug therapy is usually recommended in addition to defibrillation in shockable cardiac arrest. The role of the amplitude spectral area (AMSA) of ventricular fibrillation as a predictor of defibrillation efficacy has been established, but little is known about how amiodarone could affect AMSA values. Purpose The aim of our study was to evaluate whether the administration of amiodarone during resuscitation could affect AMSA and to verify if AMSA preserves its predictive role of shock success in OHCA patients treated with amiodarone. Material All the OHCAs with an attempted resuscitation and at least one shockable rhythm which occurred from January 2015 to December 2020 in the province of Pavia were considered. AMSA values were calculated by retrospectively analyzing the data collected by the Corpuls 3 monitors/defibrillators (Corpuls, Kaufering, Germany) used in the field and by considering a pre-shock interval of 2 seconds. Results Of 4619 OHCAs, 697 underwent attempted CPR with at least one shock delivered. Of these, AMSA was available on 250 patients (male 84%, median age 67 years), for a total of 830 shocks, of which 534 (64%) shocks were in patients receiving amiodarone. The success rate of each single shock was similar in the two groups (amiodarone 42% vs no amiodarone 41%, p=0.68). The AMSA median values were significantly lower in the amiodarone group as compared to the non-amiodarone group when shocks were delivered to patients older than 67 years old [median difference: 1.55 mV Hz (95% CI 0.6–2.5), p=0.0013] or receiving bystander CPR [median difference 0.9 mV Hz (95% CI 0.1–1.8), p=0.03] or after more than 33 minutes from the emergency call to each single shock [median difference: 0.91 mV Hz (95% CI 1.9–0.01), p=0.047]. AMSA value lower than the median (8.3 Hz mV) was associated with a lower probability of shock success (19% vs 64%, p<0.001). According to a multivariate analysis corrected for age, sex, witnessed status, call to shock time and bystander CPR, the probability of having AMSA lower than the median was independently associated with the administration of amiodarone [OR 1.5 (95% CI 1.1–2.1) p=0.009]. At ROC curves analysis, amongst patients receiving amiodarone, AMSA was confirmed to be a predictor of both shock success and ROSC [AUC 0.755 (95% CI 0.72–0.79), p<0.001 and AUC 0.826 (95% CI 0.79–0.86), p<0.001 respectively], similarly to the general population [AUC 0.778 (95% CI0.75–0.81), p<0.001; AUC 0.817 (95% CI 0.79–0.84), p<0.001]. Conclusions Amiodarone administration is independently associated with lower values of AMSA. This could justify the lack of benefit from amiodarone administration in term of defibrillation success which would be expected by the administration of an antiarrhythmic drug during the resuscitation. Moreover, AMSA maintains its predictive value for shock success and ROSC rate in patients receiving amiodarone as well as in the general population. Funding Acknowledgement Type of funding sources: None.

Amiodarone and amplitude spectral area of ventricular fibrillation in patients with out-of-hospital cardiac arrest

Abstract Background Ventricular fibrillation is the most common cause of out-of-hospital cardiac arrest (OHCA) and the use of antiarrhythmic drug therapy is usually recommended in addition to defibrillation. The role of the amplitude spectral area (AMSA) of ventricular fibrillation as a predictor of defibrillation efficacy has been established, while the existing data in favour of the use of amiodarone has been assessed with poor evidence and controversy. Purpose The aim of our study is to evaluate whether the administration of amiodarone during resuscitation could affect AMSA values. Materials All the OHCAs with a shockable presenting rhythm and attempted resuscitation which occurred from January 2015 to June 2019 in the province of Pavia were considered. Both the end-tidal CO2 (ETCO2) and AMSA values were calculated by retrospectively analyzing the data collected by the Corpuls 3 monitors/defibrillators (Corpuls, Kaufering, Germany) used in the territory and by considering a pre-shock interval of 2 seconds. Results Among a total of 3413 OHCAs, resuscitation was attempted in 2195 cases (64%), 377 (17%) had a shockable presenting rhythm and in 112 cases (3.4%) it was possible to obtain the values of ETCO2 and AMSA for a total of 391 shocks. Among these, 301 shocks (77%) were delivered to patients who received amiodarone during resuscitation. The success rate of each single shock was similar in the two groups but with an unfavorable trend for amiodarone (amiodarone 43.5% vs no amiodarone 54.4%, p=0.07). AMSA was significantly lower in patients treated with amiodarone (7.9 mV·Hz, IQR 5.4–12.2 vs 10.6 mV·Hz, IQR 7.1–14.1; p<0.001). According to a multivariate analysis, the administration of amiodarone and the time to shock were independent predictors of AMSA values. Lastly, on a sample of 124 shocks, homogeneous for age, sex, ETCO2, outcome of resuscitation and randomly matched, the AMSA of patients who received amiodarone was significantly lower (7.2 mV·Hz, IQR 7.2–11.7 vs 9.7 mV·Hz, IQR 6.7–12.5; p=0.02). Conclusions Our results indicate that amiodarone administration is associated with lower values of AMSA. Since higher AMSA values are known to be associated with a higher probability of shock rate success, this could help to better clarify the controversial role of amiodarone administration in patients with OHCA. Funding Acknowledgement Type of funding sources: None.

Cryoablation may be superior to drug therapy for initial management of AFib

Results from two studies published in the New England Journal of Medicine support the use of catheter cryoballoon ablation over antiarrhythmic therapy as initial therapy for patients with symptomatic, paroxysmal atrial fibrillation (AFib). The research was based on two trials, known as EARLY-AF and STOP AF First, which both showed that initial use of cryoablation resulted in a significantly lower rate of AFib recurrence compared with drug therapy without increasing the risk for serious adverse events. “We can now offer pulmonary vein isolation–based ablation with greater confidence as first-line therapy for selected patients with paroxysmal atrial fibrillation, particularly those who are disinclined to take antiarrhythmic drugs,” said Joseph E. Marine, MD, from the division of cardiology at Johns Hopkins University School of Medicine, in an accompanying editorial. “The new data will inform shared decision-making discussions with all patients with paroxysmal atrial fibrillation.” The EARLY-AF (Early Aggressive Invasive Intervention for Atrial Fibrillation) trial included 303 adult patients with symptomatic, paroxysmal, untreated AFib who were randomized to catheter ablation with a cryothermy balloon (n = 154) or antiarrhythmic drug therapy (n = 149) as their initial rhythm control. Patients were followed for 12 months. The primary endpoint was the first documented recurrence of any atrial tachyarrhythmia (i.e., AFib, atrial flutter, or atrial tachycardia) lasting 30 seconds or longer between 91 and 365 days after catheter ablation or initiation of an antiarrhythmic drug. At 1 year, documented recurrence occurred in 42.9% of patients who underwent cryoablation compared with 67.8% in the antiarrhythmic group (hazard ratio 0.48 [95% CI 0.35–0.66]). The occurrence of serious adverse events was similar among the two groups: 3.2% of patients in the cryoablation group and 4.0% of patients in the antiarrhythmic group. The STOP AF First (Cryoballoon Catheter Ablation in Antiarrhythmic Drug Naive Paroxysmal Atrial Fibrillation) trial included 203 adult patients with paroxysmal AFib who had not previously received rhythm-control therapy. They were randomized to treatment with a class I or III antiarrhythmic (n = 99) or cryoballoon ablation (n = 104). The results were similar to those of the EARLY-AF trial. A higher percentage of patients in the cryoballoon ablation group had treatment success, defined as freedom from initial failure of the procedure or atrial arrhythmia recurrence after a 90-day period. The estimated percentage of treatment success at 12 months was 74.6% in the ablation group compared with 45.0% in the drug therapy group. Serious adverse events occurred in 14% of patients in both treatment groups. AFib is common, affecting approximately 0.4% to 1% of the general U.S. population, and recurrence rates are high, especially in individuals who are not receiving preventive treatments. Current guidelines by the American Heart Association/American College of Cardiology/Heart Rhythm Society and European Society of Cardiology have generally recommended the use of antiarrhythmic drugs as initial therapy for maintenance of sinus rhythm in patients with AFib. However, these medications tend to have limited efficacy and substantial adverse effects. Once an initial course of treatment fails, catheter ablation is superior to antiarrhythmic drug therapy for preventing further recurrences of atrial arrhythmias. Results of the EARLY-AF and STOP AF First trials could result in some modifications to these current recommendations, with catheter cryoballoon ablation used as initial management to prevent AFib recurrences in select patients. In his editorial, Marine noted that clinicians should consider the populations included in these trials when applying the data in clinical practice. As in the trials, most patients will need to have normal left ventricular function, normal left atrial size, and few coexisting conditions to be eligible for cryoablation. The results cannot be readily extrapolated to patients with persistent AFib, significant structural heart disease, or substantial coexisting conditions that may reduce the efficacy and safety of ablation. Clinicians will need to discuss with patients the benefits and risks of cryoablation compared with initial use of antiarrhythmic therapy. A shared clinical decision-making approach may be beneficial.

Ablation of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy: Treatment Strategy, Characteristics of Consecutive Atrial Tachycardia and Long-Term Outcome.

BackgroundAtrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and is associated with a deterioration of clinical status. Ablation of symptomatic AF is an established therapy, but in HCM, the characteristics of recurrent atrial arrhythmias and the long‐term outcome are uncertain.Methods and ResultsSixty‐five patients with HCM (aged 64.5±9.9 years, 42 [64.6%] men) underwent AF ablation. The ablation strategy included pulmonary vein isolation in all patients and ablation of complex fractionated atrial electrograms or subsequent atrial tachycardias (AT) if appropriate. Paroxysmal, persistent AF, and a primary AT was present in 13 (20.0%), 51 (78.5%), and 1 (1.5%) patients, respectively. Twenty‐five (38.4%) patients developed AT with a total number of 54 ATs. Stable AT was observed in 15 (23.1%) and unstable AT in 10 (15.3%) patients. The mechanism was characterized as a macroreentry in 37 (68.5%), as a localized reentry in 12 (22.2%), a focal mechanism in 1 (1.9%), and not classified in 4 (7.4%) ATs. After 1.9±1.2 ablation procedures and a follow‐up of 48.1±32.5 months, freedom of AF/AT recurrences was demonstrated in 60.0% of patients. No recurrences occurred in 84.6% and 52.9% of patients with paroxysmal and persistent AF, respectively (P<0.01). Antiarrhythmic drug therapy was maintained in 24 (36.9%) patients.ConclusionsAF ablation in patients with HCM is effective for long‐term rhythm control, and especially patients with paroxysmal AF undergoing pulmonary vein isolation have a good clinical outcome. ATs after AF ablation are frequently observed in HCM. Freedom of atrial arrhythmia is achieved by persistent AF ablation in a reasonable number of patients even though the use of antiarrhythmic drug therapy remains high.

Антиаритмические препараты: механизмы действия, клинические эффекты, показания к применению

The lecture is devoted to one of the most difficult problems of modern cardiology – the use of antiarrhythmic therapy in clinical practice. The basic mechanisms of arrhythmias, aspects of their onset, maintenance and termination are briefly described. The current evidence on the electrophysiological mechanisms of cardiac arrhythmias – re-entry, abnormal impulse formation, and trigger activity – is presented. The article contains information about the remodeling of ion channels properties. The Sicilian gambit is analyzed, in which the mechanisms of arrhythmias are compared to the mechanisms of anti-arrhythmic action of drugs. Classification of anti-arrhythmic drugs, their mechanisms of action, indications and contraindications, side effects, and interaction with other drugs are presented.

Antiarrhythmic drugs: mechanisms of action, indications for use, side effects

The lecture is devoted to one of the most difficult problems of modern cardiology – the use of antiarrhythmic therapy in clinical practice. The basic mechanisms of arrhythmias, aspects of their onset, maintenance and termination are described briefly. The current evidence on the electrophysiological mechanism of cardiac arrhythmias - re-entry, enhanced or abnormal impulse formation, and trigger activity – is presented. The article contains information about the remodeling of ion channels properties. The Sicilian gambit, in which the mechanisms of arrhythmias are corresponded to the mechanisms of action of anti-arrhythmic drugs, is discussed. There are described the classification of anti-arrhythmic drugs, their mechanisms of action, indications and contraindications, side effects, and the drug interaction.

How to Prevent, Detect and Manage Complications Caused by Cryoballoon Ablation of Atrial Fibrillation.

Atrial fibrillation is the most common cardiac arrhythmia and the prevalence is increasing every year. Patients who fail to maintain sinus rhythm with use of anti-arrhythmic drug therapy are referred for catheter ablation. Cryoballoon (CB) ablation has emerged as an effective and alternative treatment option to traditional point-by-point radiofrequency ablation, but there can be complications. This article reviews the incidence, presentation, risk factors, management and preventative strategies of three major complications associated with CB ablation: phrenic nerve injury, atrial oesophageal fistula and bronchial injury. Although these complications are rare, electrophysiologists should institute measures to identify high-risk patients, implement best-practice techniques to minimise risks and maintain a high index of suspicion to recognise the complications quickly and implement correct treatment strategies.

Prediction of ineffective elective cardioversion of atrial fibrillation: a retrospective multi-center patient cohort study

BackgroundElective cardioversion (ECV) of atrial fibrillation (AF) is a standard procedure to restore sinus rhythm. However, predictors for ineffective ECV (failure of ECV or recurrence of AF within 30 days) are unknown.MethodsWe investigated 1998 ECVs performed for AF lasting >48 h in 1,342 patients in a retrospective multi-center study. Follow-up data were collected from 30 days after ECV.ResultsMedian number of cardioversions was one per patient with a range of 1–10. Altogether 303/1998 (15.2%) ECVs failed. Long (>5 years) AF history and over 30 days duration of the index AF episode were independent predictors for ECV failure and low (<60/min) ventricular rate of AF predicted success of ECV. In patients with successful ECVs an early recurrence of AF was detected in 549 (32.4%) cases. Female gender, high (>60/min) ventricular rate, renal failure and antiarrhythmic agents at discharge were the independent predictors for recurrence. In total ECV was ineffective in 852 (42.6%) cases. Female gender (OR 1.44, CI95% 1.15–1.80, p < 0.01), young (<65 years) age (OR 1.31, CI95% 1.07–1.62, p = 0.01), ventricular rate >60/min (OR 1.92, CI95% 1.08–3.41, p = 0.03), antiarrhythmic medication at discharge (OR 1.48, CI95% 1.14–1.93, p < 0.01) and low (<60/ml/min) estimated glomerular filtration rate (OR 1.59, CI95% 1.08–2.33, p = 0.02) were predictors of ineffective ECV.ConclusionsFemale gender, use of antiarrhythmic drug therapy and renal failure predicted both recurrence of AF and the composite end point. For the first time in a large real-life study several clinical predictors for clinically ineffective ECV were identified.

Primary and key secondary results from the ROCKET AF trial, and their implications on clinical practice.

The safety and efficacy of the oral anticoagulant rivaroxaban were studied in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF trial). A number of subanalyses of the ROCKET AF trial have subsequently analyzed the use of rivaroxaban in special patient populations. The outcomes of the ROCKET AF trial were reviewed. The use of rivaroxaban in higher risk populations, as determined by the presence of co-morbidities included in the CHADS2 criteria, was analyzed. Requirements for dose adjustment in patients with renal impairment and in East Asian patients were described. Finally, clinical management challenges, including interruptions in therapy, drug discontinuation, management of bleeding events, drug interactions, and management of patients requiring cardioversion/ablation were reviewed. Rivaroxaban is efficacious in high-risk populations, including elderly patients, patients with diabetes, heart failure, history of stroke, prior myocardial infarction, or peripheral arterial disease (PAD). Patients with PAD have a higher risk of bleeding with rivaroxaban compared with warfarin. East Asian populations do not require a dose adjustment for rivaroxaban, while a reduced dose of 15 mg daily is required for patients with moderate renal impairment. Rivaroxaban remains effective with temporary interruptions in therapy and in patients requiring cardioversion/ablation. Rates of major bleeding and subsequent outcomes were similar in patients on warfarin and rivaroxaban, although rates of gastrointestinal bleeding were higher with rivaroxaban. Concurrent use of antiarrhythmic therapy was not associated with adverse outcomes. Rivaroxaban represents an efficacious alternative to warfarin in high-risk patients with AF. Dose adjustment is required for patients with moderate renal impairment. Rivaroxaban can be used safely in a number of challenging clinical management scenarios although the concurrent use of amiodarone requires more study.

Updates in antiarrhythmic therapy for atrial fibrillation in geriatric patients.

To provide a review of the current evidence for the use of antiarrhythmic therapy in the geriatric population. A PubMed search of articles in the English language published from 1990 through August 2014 was performed using a combination of the following words: amiodarone, antiarrhythmic, atrial fibrillation, dofetilide, dronedarone, elderly, flecainide, geriatric, propafenone, sotalol. Relevant original studies, review articles, and guidelines were assessed for use of antiarrhythmic therapy to manage atrial fibrillation (A fib) in the elderly. References from the above literature were also evaluated and included based on their relevance. The incidence of A fib increases as the population ages, which creates an increased need for clinicians to understand the place of antiarrhythmic therapy in management of A fib. This article provides a review of the current literature regarding this high-risk class of medications in the elderly population, with a focus on monitoring parameters and clinical considerations in the geriatric population. Elderly patients are more susceptible to the adverse effects of antiarrhythmic medications as a result of multiple factors, including decreased clearance and metabolism of medications as well as interactions caused by comorbid conditions and medications. Pharmacists can play a key role in a multidisciplinary team to monitor and educate patients on their antiarrhythmic therapy.

Use of antiarrhythmic drug therapy and clinical outcomes in older patients with concomitant atrial fibrillation and coronary artery disease.

Atrial fibrillation (AF) and coronary artery disease (CAD) are common in older patients. We aimed to describe the use of antiarrhythmic drug (AAD) therapy and clinical outcomes in these patients. We analysed AAD therapy and outcomes in 1738 older patients (age ≥65) with AF and CAD in the Duke Databank for cardiovascular disease. The primary outcomes were mortality and rehospitalization at 1 and 5 years. Overall, 35% of patients received an AAD at baseline, 43% were female and 85% were white. Prior myocardial infarction (MI, 31%) and heart failure (41%) were common. Amiodarone was the most common AAD (21%), followed by pure Class III agents (sotalol 6.3%, dofetilide 2.2%). Persistence of AAD was low (35% at 1 year). After adjustment, baseline AAD use was not associated with 1-year mortality [adjusted hazard ratio (HR) 1.23, 95% confidence interval (CI) 0.94-1.60] or cardiovascular mortality (adjusted HR 1.27, 95% CI 0.90-1.80). However, AAD use was associated with increased all-cause rehospitalization (adjusted HR 1.20, 95% CI 1.03-1.39) and cardiovascular rehospitalization (adjusted HR 1.20, 95% CI 1.01-1.43) at 1 year. This association did not persist at 5 years; however, these patients were at very high risk of death (55% for those >75 and on AAD) and all-cause rehospitalization (87% for those >75 and on AAD) at 5 years. In older patients with AF and CAD, antiarrhythmic therapy was associated with increased rehospitalization at 1 year. Overall, these patients are at high risk of longer-term hospitalization and death. Safer, better-tolerated, and more effective therapies for symptom control in this high-risk population are warranted.

Get with the guidelines

This editorial refers to ‘Inappropriate use of antiarrhythmic drugs in paroxysmal and persistent atrial fibrillation in a large contemporary international survey: insights from RealiseAF’ by C.-E. Chiang et al ., on page 1733. That clinicians fail to follow practice guidelines and consensus statements as provided by established clinical societies of note is not new, and not really a surprise. For treatment of atrial fibrillation patients, that not only means failing to follow the guidelines on the use of antiarrhythmic drug therapy, the subject of the paper by Chiang et al .,1 but also on the use of anticoagulant therapy and catheter/surgical ablation therapy, as well.1 Nevertheless, for patients with atrial fibrillation, the RealiseAF (REAl LIfe global Survey Evaluating patients with Atrial Fibrillation) data are important and informative, and provide an opportunity to offer some clinical perspective. At the outset, we must always remember that the guidelines are just guides, not laws. Although guidelines from professional medical societies are almost always well and carefully thought out, and should serve as an excellent guide to therapy, we must accept the fact that there will be instances when either the guidelines do not apply, or patient's circumstances understandably create reasons to deviate from the guidelines. However, to the point of this commentary, the RealiseAF data provide an opportunity to put some context into the application of guidelines regarding the use of antiarrhythmic drug therapy in pursuit of a rhythm control strategy. Specific to the atrial …

RF versus cryoballoon in atrial fibrillation ablation: outcome data from the German ablation registry I

Background: Catheter ablation is extensively used with curative intention in Atrial Fibrillation (AF). Radiofrequency ablation has long been standard of care, cryoballoon technology has emerged a feasible approach with promising results. Prospective multicenter registry data referring to both ablation technologies in AF ablation are lacking so far. We report data of the German ablation registry I with respect to efficacy and complication rates in PV ablation after the first index ablation with different energy sources for paroxysmal AF after 1 year follow-up (FU). Methods: All 2256 consecutively enrolled patients with symptomatic px AF of the German ablation registry I who underwent their 1 year FU were included in this analysis. The cohort was devided into two groups according to the ablation energy source used: cryoballoon ablation (group 1, n=604 [26.8%], median age 61 years, 64.2% men) and RF ablation (group 2, n=1652 [73.2%], median age 62 years, 62.8% men). Results: Procedural outcome is given in the Table. Acute success rates were similar in both groups (97.0% in cryo vs. 96.9% in RF; p=0.84). AF recurrence rate at 1 year FU was not significantly different between both groups (45.8% after cryoablation and 45.4% after RF ablation; p=0.87). Use of antiarrhythmic therapy at 1 year follow-up was slightly more common after RF ablation (32.1% vs. 27.5% after cryoablation; p<0.05). Major complication rate was significantly higher in RF vs. cryoablation (5.1% in RF vs. 2.3% in cryo; p<0.01). Also minor bleedings (4.2% in RF vs. 2.5% in cryo; p<0.05) were more common in RF ablation. Phrenic nerve palsy was more often in cryo (2.3%) vs. RF ablation (0.1%; p<0.001). View this table: Table 1 Conclusion: At 1 year FU a similar AF recurrency rate was found in cryoballoon compared to RF ablation. The periprocedural major complication rate was lower in cryoballoon compared to RF ablation whereas phrenic nerve palsy was more frequent in cryoballoon ablation. Procedural and fluoroscopy times were higher in cryoballoon compared of RF ablation.

Predictors of Short-Term Complications After Implantable Cardioverter-Defibrillator Replacement

Background— Complications after implantable cardioverter-defibrillator (ICD) replacement are often clinically devastating, particularly when infection or reoperation occurs. Identifying factors contributing to complications may permit identification of high-risk individuals that warrant incremental monitoring and therapy to attenuate risk. In addition, replacement may be a discretionary decision in the context of an advisory or borderline device performance and patient, device, and implanter factors that predict adverse outcome may assist in clinical decision-making. Methods and Results— In a prospective, multicenter, population-based registry of all ICD patients at 18 centers in Ontario, Canada, we examined 45-day complication and all-cause mortality rates from February 2007 to August 2009 in patients undergoing ICD generator replacement. Complications were determined longitudinally and were categorized as major or minor. ICD replacement was performed in 1081 of 5176 patients (20.8%) undergoing ICD implantation (age, 64.3±12.7 years; 78.5% men). In patients undergoing ICD replacement, 47 patients (4.3%) had a complication within 45 days, with 47 major complications in 28 patients (2.6%), most commonly infection (n=23), lead revision (n=35), electrical storm (n=14), and pulmonary edema (n=13). Minor complications occurred in 2.3% of patients, most commonly incisional infection (n=10) and pocket hematoma (n=10). On multivariable analysis, risk factors associated with major complications were Canadian Cardiovascular Society angina class (adjusted hazard ratio [HR], 3.70 for class 2 to 4 versus 0 to 1; P =0.027) and multiple previous procedures on the pocket (adjusted HR, 3.35 for &gt;1 versus 1; P =0.058). Risk factors associated with any complication were the use of antiarrhythmic therapy (adjusted HR, 6.29; P =0.001), implanter volume (adjusted HR 10.4 for &lt;60/y versus &gt;120/y, P =0.026), and Canadian Cardiovascular Society angina class (adjusted HR, 3.00 for class 2 to 4 versus 0 to 1; P =0.031). In a Cox model with a time-dependent variable of major complication within 45 days after replacement, major complications after ICD replacement were associated with an increased risk of mortality at 45, 90, and 180 days (adjusted HR, 9.61, 12.69, and 6.41, respectively; P =0.002 to 0.039). Conclusions— Risk factors associated with complications after ICD replacement include the presence of angina, antiarrhythmic therapy, increased number of previous procedures, and low implanter volume. Major complications may be associated with increased risk of subsequent mortality.

Atrial fibrillation management strategies and early mortality after myocardial infarction: results from the Valsartan in Acute Myocardial Infarction (VALIANT) Trial

ObjectiveThe management of patients with atrial fibrillation (AF) following a myocardial infarction (MI) remains uncertain. This study compared a rate control strategy to an anti-arrhythmic-based rhythm control strategy for the...

Rethinking the reasons to treat atrial fibrillation? The role of dronedarone in reducing cardiovascular hospitalizations

The management of patients with atrial fibrillation has changed considerably over the past decade, largely because of data derived from clinical trials. Although studies comparing strategies of rate control vs. rhythm control consistently failed to demonstrate the benefit of a rhythm control strategy, to argue that rhythm control is of no value to argue with imprecision. AFFIRM, the largest of the rate vs. rhythm trials, showed, in multivariate analysis, that those patients who stayed in sinus rhythm had a reduced mortality, although this was offset by the use of antiarrhythmic drugs.1 In contrast, although no benefit of a rhythm control strategy was found in the AF-CHF study (in which all patients had left ventricular dysfunction and the predominant antiarrhythmic drug used was amiodarone), there was also no trend towards increased mortality with the use of antiarrhythmic therapy.2 Despite negative outcomes in terms of mortality, rhythm control does have some benefits. Analyses of patients who were able to maintain sinus rhythm (as opposed to being randomized to a rhythm control strategy regardless of outcome) does appear to show a benefit of rhythm control, at least in terms of quality of life.3 In addition, there are many patients with atrial fibrillation in whom the arrhythmia is clearly associated with unpleasant or intolerable symptoms and these patients benefit symptomatically from restoration of sinus rhythm. Antiarrhythmic drugs remain problematic, however, given their side effects and propensity for significant proarrhythmia. Until recently, clinical trials of antiarrhythmic drugs in patients with atrial fibrillation concentrated on suppression of the arrhythmia as determined by freedom from atrial fibrillation at a predetermined endpoint (usually 1 year or less) or by measuring time to first symptomatic recurrence. Data from antiarrhythmic trials that utilize daily transtelephonic monitoring and from interrogation of permanent pacemakers reveal a high prevalence of …

Systematic electrocardioversion for atrial fibrillation and role of antiarrhythmic drugs: A substudy of the SAFE-T trial

Energy levels for electrocardioversion in atrial fibrillation (AF) have been empiric, and the influence of antiarrhythmic therapy compared with placebo is largely unknown. The purpose of this study was to determine systematically the energy levels for electrocardioversion in patients with persistent AF and to define the influence of antiarrhythmic therapy. Patients (n = 665) with persistent AF were randomized to amiodarone, sotalol, or placebo. Rate control, if necessary, was achieved with digoxin, diltiazem, or verapamil. Among the 665 patients, 504 who did not achieve sinus rhythm at day 28 had electrocardioversion systematically by a prespecified four-step protocol as follows: monophasic shocks-100, 200, 360, 360 J; or biphasic shocks-150, 175, 200, 200 J sequentially. Energy levels and shock waveforms (monophasic/biphasic) for successful electrocardioversion (sinus rhythm for at least 1 minute) and use of antiarrhythmic therapy and calcium channel blockers were recorded. Electrocardioversion was successful in 371 (71.6%) of 504 patients: 72%, 73.5%, and 67.9% for patients assigned to amiodarone, sotalol, and placebo, respectively. Overall, after adjustments for age, body mass index (BMI), history of AF, shock waveforms, left atrial size, and ejection fraction, both amiodarone (odds ratio [OR]: 2.16, 95% confidence interval [CI]: 1.24-3.77, P <.01) and sotalol (OR: 1.92, 95% CI: 1.11-3.33, P = .02) significantly facilitated successful electrocardioversion compared with placebo. Calcium channel blockers had no effect on the success rate of electrocardioversion. Success of electrocardioversion was associated with lower BMI, AF history < or =1 year, and older age. Compared with placebo, patients taking amiodarone were significantly more likely to achieve successful electrocardioversion in step 1 (OR: 2.73, 95% CI: 1.11-6.74, P = .03) and step 3 (OR: 1.86, 95% CI: 1.00-3.44, P = .05) but not in steps 2 and 4. Sotalol was superior to placebo in step 4 (OR: 2.58, 95% CI: 1.02-6.52, P = .05) and trended in step 2 (OR: 1.7, 95% CI: 0.98-3.07, P = .06). Successful electrocardioversion was seen in 11%, 29%, 38%, and 29% in steps 1, 2, 3, and 4, respectively. Compared with monophasic shocks, biphasic shocks achieved higher success rates for step 1 (P <.001) and step 2 (P <.01), respectively. Antiarrhythmic therapy did not influence the total number of energy steps used for the patients with successful electrocardioversion. However, biphasic shocks, lower BMI, and AF duration < or =1 year were associated with less energy step used for successful cardioversion. Amiodarone and sotalol facilitated successful electrocardioversion, which could be achieved in a stepwise fashion. Upon achievement of successful electrocardioversion, amiodarone is superior to placebo, and sotalol has a lesser effect. Antiarrhythmic drugs had no effect on the total number of energy step use in patients who had successful electrocardioversion. Calcium channel blockers had no influence on the success rate in achieving sinus rhythm. Successful electrocardioversion was associated with lower BMI and AF history < or =1 year. Lower energy use was associated with biphasic shocks, lower BMI, and AF duration < or =1 year.

Management of atrial fibrillation in heart failure in the elderly

In elderly patients, atrial fibrillation prevalence exceeds 10% and is commonly associated with heart failure rendering their management even more challenging. Therapies to be considered for heart failure related atrial fibrillation include appropriate treatment of underlying disease, prevention of thromboembolism, rate or rhythm control. The debate regarding rate versus rhythm control in the management of this group of patients has yet to be resolved. For old patients, the management requires an individual approach, which largely depends on comorbid conditions, underlying cardiac disease, and patient and physician preferences. Use of antiarrhythmic drug therapy for maintenance of sinus rhythm carries concerns of risk and limited efficacy. Catheter ablation for rhythm control is feasible for some patients, but further studies are needed to define the risks and benefits especially in older patients. Atrioventricular nodal ablation associated with pacing therapy is an effective non-pharmacological therapy in selected patients with medically refractory permanent high heart rate atrial fibrillation and heart failure. Several studies are ongoing and will provide more insight into the management of such patients.