Topic Editors

Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, 1090 Brussels, Belgium
Dr. Cristina Chimenti
IRCCS Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, Rome, Italy
Prof. Dr. Gian Battista Chierchia
Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, 1090 Brussels, Belgium
Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, 1090 Brussels, Belgium

Atrial Fibrillation: State-of-the-Art Techniques and Future Perspectives for Diagnosis, Rhythm Control, and Stroke Prophylaxis

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closed (30 November 2022)
Manuscript submission deadline
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Topic Information

Dear Colleagues,

Atrial Fibrillation (AF) is the most common sustained arrhythmia in adults, with an estimated prevalence ranging between 2% and 4%. AF has a significant impact on quality of life and functional status, which may lead to depression in up to 20% of cases. Among other clinical features, AF is responsible for 20%–30% of all ischemic strokes and significantly increases the risk of heart failure and dementia. As such, AF poses a substantial burden for healthcare systems, requiring a multidisciplinary approach for early detection, effective treatment, and complication prevention. In recent years, substantial efforts have been devoted to optimizing rhythm control strategies and stroke prophylaxis. As a result of technological advancements, transcatheter ablation has become the most effective arrhythmia control strategy currently available. Specifically, the adoption of novel non-thermal energy sources for cardiac tissue ablation has substantially improved the safety and efficacy of this approach. Similarly, new-generation devices to exclude the left atrial appendage from systemic circulation have proven noninferior in preventing thromboembolic events compared to oral anticoagulation in high-risk patients. The aim of this Topic is to provide new insights into the pathophysiology, prevention, and treatment of AF, with particular emphasis on ablation and stroke prophylaxis.

Dr. Domenico G. Della Rocca
Dr. Cristina Chimenti
Prof. Dr. Gian Battista Chierchia
Prof. Dr. Carlo De Asmundis
Topic Editors

Keywords

  • atrial fibrillation
  • ablation
  • stroke
  • early diagnosis
  • rhythm control
  • arrhythmia
  • pulsed field ablation
  • atrial flutter
  • tachycardia
  • thromboembolism
  • cryoablation
  • atrial remodeling
  • pathophysiology
  • mapping
  • dementia
  • comorbidities
  • prevention
  • left atrial appendage

Participating Journals

Journal Name Impact Factor CiteScore Launched Year First Decision (median) APC
Cardiogenetics
cardiogenetics
0.6 - 2011 53.4 Days CHF 1400
Hearts
hearts
- - 2020 32.3 Days CHF 1000
Journal of Cardiovascular Development and Disease
jcdd
2.4 2.6 2014 20.3 Days CHF 2700
Journal of Clinical Medicine
jcm
3.9 5.7 2012 17.9 Days CHF 2600
Medicina
medicina
2.6 3.3 1920 19.6 Days CHF 1800

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Published Papers (21 papers)

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13 pages, 1754 KiB  
Review
ECG Smart Monitoring versus Implantable Loop Recorders for Atrial Fibrillation Detection after Cryptogenic Stroke—An Overview for Decision Making
by Thomas Pezawas
J. Cardiovasc. Dev. Dis. 2023, 10(7), 306; https://doi.org/10.3390/jcdd10070306 - 18 Jul 2023
Cited by 2 | Viewed by 2794
Abstract
Up to 20% of patients with ischemic stroke or transient ischemic attack have a prior history of known atrial fibrillation (AF). Additionally, unknown AF can be detected by different monitoring strategies in up to 23% of patients with cryptogenic or non-cardioembolic stroke. However, [...] Read more.
Up to 20% of patients with ischemic stroke or transient ischemic attack have a prior history of known atrial fibrillation (AF). Additionally, unknown AF can be detected by different monitoring strategies in up to 23% of patients with cryptogenic or non-cardioembolic stroke. However, most studies had substantial gaps in monitoring time, especially early after the index event. Following this, AF rates would be higher if patients underwent continuous monitoring early after stroke, avoiding any gaps in monitoring. The few existing randomized studies focused on patients with cryptogenic stroke but did not focus otherwise specifically on prevention strategies in patients at high risk for AF (patients at higher age or with high CHA2DS2-VASC scores). Besides invasive implantable loop recorders (ILRs), external loop recorders (ELRs) and mobile cardiac outpatient telemetry (MCOT) are non-invasive tools that are commonly used for long-term ECG monitoring in cryptogenic-stroke patients in the ambulatory setting. The role of MCOT and hand-held devices within ECG smart monitoring in the detection of AF for the prevention of and after cryptogenic stroke is currently unclear. This intense review provides an overview of current evidence, techniques, and gaps in knowledge and aims to advise which patients benefit most from the current available devices. Full article
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5 pages, 715 KiB  
Editorial
Left Atrial Appendage Occlusion in Patients with Failure of Antithrombotic Therapy: Good Vibes from Early Studies
by Alberto Preda, Matteo Baroni, Marisa Varrenti, Sara Vargiu, Marco Carbonaro, Federica Giordano, Lorenzo Gigli and Patrizio Mazzone
J. Clin. Med. 2023, 12(11), 3859; https://doi.org/10.3390/jcm12113859 - 5 Jun 2023
Cited by 4 | Viewed by 1546
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and predisposes patients to an increased risk of cardioembolic events (CE), such as ischemic stroke, TIA, or systemic embolism [...] Full article
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14 pages, 1009 KiB  
Review
Long-Term Sports Practice and Atrial Fibrillation: An Updated Review of a Complex Relationship
by Mattia Petrungaro, Liuba Fusco, Elena Cavarretta, Antonio Scarà, Alessio Borrelli, Silvio Romano, Renata Petroni, Flavio D’Ascenzi and Luigi Sciarra
J. Cardiovasc. Dev. Dis. 2023, 10(5), 218; https://doi.org/10.3390/jcdd10050218 - 16 May 2023
Cited by 7 | Viewed by 2230
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice, and it is an enormous burden worldwide because of its high morbidity, disability and mortality. It is generally acknowledged that physical activity (PA) is strongly associated with a significant reduction in [...] Read more.
Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice, and it is an enormous burden worldwide because of its high morbidity, disability and mortality. It is generally acknowledged that physical activity (PA) is strongly associated with a significant reduction in the risk of cardiovascular (CV) disease and all-cause mortality. Moreover, it has been observed that moderate and regular physical activity has the potential to reduce the risk of AF, in addition to improving overall well-being. Nevertheless, some studies have associated intense physical activity with an increased risk of AF. This paper aims to review the main related literature to investigate the association between PA and AF incidence and draw pathophysiological and epidemiological conclusions. Full article
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12 pages, 1766 KiB  
Article
An Artificial Intelligence-Enabled ECG Algorithm for Predicting the Risk of Recurrence in Patients with Paroxysmal Atrial Fibrillation after Catheter Ablation
by Junrong Jiang, Hai Deng, Hongtao Liao, Xianhong Fang, Xianzhang Zhan, Wei Wei, Shulin Wu and Yumei Xue
J. Clin. Med. 2023, 12(5), 1933; https://doi.org/10.3390/jcm12051933 - 1 Mar 2023
Cited by 6 | Viewed by 1981
Abstract
Background: Catheter ablation (CA) is an important treatment strategy to reduce the burden and complications of atrial fibrillation (AF). This study aims to predict the risk of recurrence in patients with paroxysmal AF (pAF) after CA by an artificial intelligence (AI)-enabled electrocardiography (ECG) [...] Read more.
Background: Catheter ablation (CA) is an important treatment strategy to reduce the burden and complications of atrial fibrillation (AF). This study aims to predict the risk of recurrence in patients with paroxysmal AF (pAF) after CA by an artificial intelligence (AI)-enabled electrocardiography (ECG) algorithm. Methods and Results: 1618 ≥ 18 years old patients with pAF who underwent CA in Guangdong Provincial People’s Hospital from 1 January 2012 to 31 May 2019 were enrolled in this study. All patients underwent pulmonary vein isolation (PVI) by experienced operators. Baseline clinical features were recorded in detail before the operation and standard follow-up (≥12 months) was conducted. The convolutional neural network (CNN) was trained and validated by 12-lead ECGs within 30 days before CA to predict the risk of recurrence. A receiver operating characteristic curve (ROC) was created for the testing and validation sets, and the predictive performance of AI-enabled ECG was assessed by the area under the curve (AUC). After training and internal validation, the AUC of the AI algorithm was 0.84 (95% CI: 0.78–0.89), with a sensitivity, specificity, accuracy, precision and balanced F Score (F1 score) of 72.3%, 95.0%, 92.0%, 69.1% and 0.707, respectively. Compared with current prognostic models (APPLE, BASE-AF2, CAAP-AF, DR-FLASH and MB-LATER), the performance of the AI algorithm was better (p < 0.01). Conclusions: The AI-enabled ECG algorithm seemed to be an effective method to predict the risk of recurrence in patients with pAF after CA. This is of great clinical significance in decision-making for personalized ablation strategies and postoperative treatment plans in patients with pAF. Full article
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14 pages, 1708 KiB  
Article
Serum Catestatin Concentrations Are Increased in Patients with Atrial Fibrillation
by Josip Katic, Zrinka Jurisic, Marko Kumric, Josip A. Borovac, Ante Anic, Toni Breskovic, Daniela Supe-Domic and Josko Bozic
J. Cardiovasc. Dev. Dis. 2023, 10(2), 85; https://doi.org/10.3390/jcdd10020085 - 17 Feb 2023
Cited by 1 | Viewed by 1439
Abstract
The autonomic nervous system is crucial in initiating and maintaining atrial fibrillation (AF). Catestatin is a multipurpose peptide that regulates cardiovascular systems and reduces harmful, excessive activity of the sympathetic nervous system by blocking the release of catecholamines. We aimed to determine whether [...] Read more.
The autonomic nervous system is crucial in initiating and maintaining atrial fibrillation (AF). Catestatin is a multipurpose peptide that regulates cardiovascular systems and reduces harmful, excessive activity of the sympathetic nervous system by blocking the release of catecholamines. We aimed to determine whether serum catestatin concentrations are associated with AF severity, duration indices, and various clinical and laboratory indicators in these individuals to better define the clinical value of catestatin in patients with AF. The present single center study enrolled 73 participants with AF and 72 healthy age-matched controls. Serum catestatin concentrations were markedly higher in AF patients than controls (14.11 (10.21–26.02) ng/mL vs. 10.93 (5.70–20.01) ng/mL, p = 0.013). Furthermore, patients with a more severe form of AF had significantly higher serum catestatin (17.56 (12.80–40.35) vs. 10.98 (8.38–20.91) ng/mL, p = 0.001). Patients with higher CHA2DS2-VASc scores (17.58 (11.89–37.87) vs. 13.02 (8.47–22.75) ng/mL, p = 0.034) and higher NT-proBNP levels (17.58 (IQR 13.91–34.62) vs. 13.23 (IQR 9.04–22.61), p = 0.036) had significantly higher serum catestatin concentrations. Finally, AF duration correlated negatively with serum catestatin levels (r = −0.348, p = 0.003). The results of the present study implicate the promising role of catestatin in the intricate pathophysiology of AF, which should be explored in future research. Full article
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16 pages, 2588 KiB  
Systematic Review
Direct Oral Anticoagulants as the First Choice of Anticoagulation for Patients with Peripheral Artery Disease to Prevent Adverse Vascular Events: A Systematic Review and Meta-Analysis
by Enikő Pomozi, Rita Nagy, Péter Fehérvári, Péter Hegyi, Boldizsár Kiss, Fanni Dembrovszky, Annamária Kosztin, Sándor Nardai, Endre Zima and Zoltán Szeberin
J. Cardiovasc. Dev. Dis. 2023, 10(2), 65; https://doi.org/10.3390/jcdd10020065 - 3 Feb 2023
Cited by 7 | Viewed by 3740
Abstract
The best method of anticoagulation for patients with peripheral artery disease (PAD) is still a topic of interest for physicians. We conducted a meta-analysis to compare the effects of direct oral anticoagulants (DOACs) with those of vitamin-K-antagonist (VKA) anticoagulants in patients with peripheral [...] Read more.
The best method of anticoagulation for patients with peripheral artery disease (PAD) is still a topic of interest for physicians. We conducted a meta-analysis to compare the effects of direct oral anticoagulants (DOACs) with those of vitamin-K-antagonist (VKA) anticoagulants in patients with peripheral artery disease. Five databases (Medline (via PubMed), EMBASE, Scopus, Web of Science, and CENTRAL) were searched systematically for studies comparing the effects of the two types of anticoagulants in patients with PAD, with an emphasis on lower-limb outcomes, cardiovascular events, and mortality. In PAD patients with concomitant non-valvular atrial fibrillation (NVAF), the use of DOACs significantly reduced the risk of major adverse limb events (HR = 0.58, 95% CI, 0.39–0.86, p < 0.01), stroke/systemic embolism (HR 0.76; 95% CI 0.61–0.95; p < 0.01), and all-cause mortality (HR 0.78; 95% CI 0.66–0.92; p < 0.01) compared with warfarin, but showed similar risks of MI (HR = 0.81, 95% CI, 0.59–1.11, p = 0.2) and cardiovascular mortality (HR = 0.77, 95% CI, 0.58–1.02, p = 0.07). Rivaroxaban at higher doses significantly increased the risk of major bleeding (HR = 1.16, 95% CI, 1.07–1.25, p < 0.01). We found no significant difference in terms of revascularization (OR = 1.49, 95% CI, 0.79–2.79, p = 0.14) in PAD patients in whom a poor distal runoff was the reason for the anticoagulation. DOACs have lower rates of major limb events, stroke, and mortality than VKAs in PAD patients with atrial fibrillation. Rivaroxaban at higher doses increased the risk of major bleeding compared with other DOAC drugs. More high-quality studies are needed to determine the most appropriate anticoagulation regimen for patients with lower-limb atherosclerosis. Full article
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14 pages, 1656 KiB  
Article
NT-pro-BNP as a Predictor for Recurrence of Atrial Fibrillation after Primary Cryoballoon Pulmonary Vein Isolation
by Hermann Blessberger, Thomas Lambert, Alexander Nahler, Denis Hrncic, Simon Hönig, Julian Maier, Stefan Rechberger, Armin Windhager, Christian Reiter, Joerg Kellermair, Juergen Kammler, Helga Wagner and Clemens Steinwender
J. Clin. Med. 2022, 11(24), 7400; https://doi.org/10.3390/jcm11247400 - 14 Dec 2022
Cited by 3 | Viewed by 1967
Abstract
NT-pro-BNP is produced in the cardiac atria and ventricles in response to increased wall stress. It may be a marker of both AF disease progression and co-morbidities that affect success after pulmonary vein isolation (PVI). This single-center retrospective study analyzed the association between [...] Read more.
NT-pro-BNP is produced in the cardiac atria and ventricles in response to increased wall stress. It may be a marker of both AF disease progression and co-morbidities that affect success after pulmonary vein isolation (PVI). This single-center retrospective study analyzed the association between pre-procedural NT-pro-BNP serum levels and the long-term outcome after a first-ever PVI in cryo-technique. Patients were followed by searching the hospital information system and conducting structured telephone interviews. Treatment failure was defined as any relapse of atrial fibrillation (AF) occurring 90 days after the index PVI at the earliest. Kaplan–Meier survival curves and Cox proportional hazards models were computed to assess the impact of NT-pro-BNP on AF recurrence. Following 374 patients over a median of 3.8 years (range: 0.25–9.4 years), baseline NT-pro-BNP was associated with the combined endpoint in univariate analysis (HR 1.04 per 100 pg/mL increase, 95% CI: 1.02–1.07, p < 0.001). Results were virtually unchanged in the multivariate model or if the data were log-transformed. Intraprocedural left atrial pressure correlated positively with log NT-pro-BNP. NT-pro-BNP was associated with AF relapse during a long-term follow-up after first-ever cryo-PVI in our cohort of patients with predominantly normal left ventricular function. This lab parameter is easy to obtain and has significant potential to guide treatment decisions. Full article
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10 pages, 2826 KiB  
Article
Prognostic Impact of Severe Atrial Functional Tricuspid Regurgitation in Atrial Fibrillation Patients
by Ancuța Elena Vîjan, Ioana Cristina Daha, Caterina Delcea, Elisabeta Bădilă and Gheorghe-Andrei Dan
J. Clin. Med. 2022, 11(23), 7145; https://doi.org/10.3390/jcm11237145 - 1 Dec 2022
Cited by 1 | Viewed by 1867
Abstract
Background and Aim: Atrial fibrillation (AF) is an epidemic disease with a significant global health impact. Atrial functional tricuspid regurgitation (AF-TR) is a more recently acknowledged complication of AF. The main purpose of this study was to determine the prognostic value of severe [...] Read more.
Background and Aim: Atrial fibrillation (AF) is an epidemic disease with a significant global health impact. Atrial functional tricuspid regurgitation (AF-TR) is a more recently acknowledged complication of AF. The main purpose of this study was to determine the prognostic value of severe AF-TR in patients with AF, and its determinants. Methods: In this retrospective, observational study, we included AF patients admitted consecutively to a tertiary clinical hospital between January 2018 and February 2020, irrespective of cause of hospitalization. Patients with organic TR, significant pulmonary hypertension, left ventricular ejection fraction < 50%, those with implanted cardiac devices and those with in-hospital mortality were excluded. Severe TR was defined according to current guidelines. Median follow-up time was 34 (28–39) months. Primary endpoint was all-cause mortality. Results: We included 246 AF patients, with a mean age of 71.5 ± 9.4 years. 86.2% had AF-TR, while 8.1% had severe AF-TR. Mortality rate was 8.5%. Right atrial diameter (p = 0.005), systolic pulmonary artery pressure (sPAP) (p = 0.015) and NT-proBNP (p = 0.026) were independent predictors for the presence of severe valvular dysfunction. In multivariable survival analysis, severe AF-TR, was an independent predictor of all-cause mortality (HR 5.4, 95% CI 1.1–26.2, p = 0.035). Conclusion: Severe AF-TR was an independent predictor of mortality in AF patients, while mild/moderate AF-TR apparently had no impact on prognosis. Full article
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11 pages, 988 KiB  
Article
Feasibility of Left Bundle Branch Area Pacing Combined with Atrioventricular Node Ablation in Atrial Fibrillation Patients with Heart Failure
by Qi-Qi Jin, Cheng Zheng, Yao-Ji Wang, Jia-Xuan Lin, Dao-Zhu Wu, Jia-Feng Lin and Xue-Qiang Guan
J. Cardiovasc. Dev. Dis. 2022, 9(10), 338; https://doi.org/10.3390/jcdd9100338 - 5 Oct 2022
Cited by 6 | Viewed by 1717
Abstract
Background: Pacemaker implantation combined with atrioventricular node ablation (AVNA) could be a practical choice for atrial fibrillation (AF) patients with heart failure (HF). Left bundle branch area pacing (LBBaP) has been widely reported. Objectives: To explore the safety and efficacy of LBBaP combined [...] Read more.
Background: Pacemaker implantation combined with atrioventricular node ablation (AVNA) could be a practical choice for atrial fibrillation (AF) patients with heart failure (HF). Left bundle branch area pacing (LBBaP) has been widely reported. Objectives: To explore the safety and efficacy of LBBaP combined with AVNA in AF patients with HF. Methods and results: Fifty-six AF patients with HF attempted LBBaP and AVNA from January 2019 to December 2020. Standard LBBaP was achieved in forty-six patients, and another ten received left ventricular septal pacing (LVSP). The cardiac function indexes and pacemaker parameters were evaluated at baseline, and we conducted a 1-month and 1-year follow-up. Result: At the time of implantation and 1-month and 1-year follow-up, QRS duration of LVSP group was longer than that of LBBaP group. The pacemaker parameters remained stable in both the LBBaP and LVSP groups. At 1-month and 1-year follow-up after LBBaP and AVNA, left ventricular ejection fraction, left ventricular end-diastolic diameter, and NYHA classification continued to improve. Baseline left ventricular ejection fraction and QRS duration change at implantation can predict the magnitude of improvement of left ventricular ejection fraction at 1-year after LBBaP. Baseline right atrial left-right diameter, the degree of tricuspid regurgitation, and interventricular septum thickness may be the factors affecting the success of LBBaP. Conclusion: LBBaP combined with AVNA is safe and effective for patients with AF and HF. Baseline right atrial left-right diameter, the degree of tricuspid regurgitation, and interventricular septum thickness may be the factors affecting the success of LBBaP. Full article
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16 pages, 1636 KiB  
Article
Reablation in Atrial Fibrillation Recurrence and Pulmonary Vein Reconnection: Cryoballoon versus Radiofrequency as Index Ablation Procedures
by Ana Isabel Molina-Ramos, Amalio Ruiz-Salas, Carmen Medina-Palomo, Francisco Javier Pavón-Morón, Jorge Rodríguez-Capitán, Mario Gutiérrez-Bedmar, Germán Berteli-García, Ignacio Fernández-Lozano, Juan José Gómez-Doblas, Manuel Jiménez-Navarro, Javier Alzueta-Rodríguez and Alberto Barrera-Cordero
J. Clin. Med. 2022, 11(19), 5862; https://doi.org/10.3390/jcm11195862 - 3 Oct 2022
Cited by 2 | Viewed by 2843
Abstract
Pulmonary vein (PV) isolation is a well-established rhythm control therapy in atrial fibrillation (AF). Currently, there is no consensus on which ablation technique to use for the first procedure, cryoballoon (CB) or radiofrequency (RF). A retrospective cohort study was conducted on 1055 patients [...] Read more.
Pulmonary vein (PV) isolation is a well-established rhythm control therapy in atrial fibrillation (AF). Currently, there is no consensus on which ablation technique to use for the first procedure, cryoballoon (CB) or radiofrequency (RF). A retrospective cohort study was conducted on 1055 patients who underwent a first ablation, to assess both techniques based on the need for reablation. Patients with CB (n = 557) and RF (n = 498) ablations were clinically characterized and the need for reablation during a 30-month follow-up was used as the primary endpoint. Independent variables were analyzed to identify potential predictors. The need for reablation was significantly lower in the CB group than in the RF group (hazard ratio = 0.45 and 95% confident interval = 0.32–0.61; p < 0.001); in both paroxysmal and persistent AF, using a full-adjusted regression Cox model by age, sex, smoking, hypertension, diabetes mellitus, dyslipidemia, severe obstructive sleep apnea, dilated left atrium, persistent AF and early recurrence. RF ablation, dilated left atrium, persistent AF and early recurrence were identified as independent predictors of reablation. In addition, the CB-redo subgroup had a lower PV reconnection than the RF-redo subgroup. In conclusion, CB ablation suggests a reduction in the need for reablation and lower PV reconnection during the follow-up than RF ablation. Full article
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15 pages, 3796 KiB  
Article
Catheter Ablation versus Medical Therapy of Atrial Fibrillation in Patients with Heart Failure: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials
by Michele Magnocavallo, Antonio Parlavecchio, Giampaolo Vetta, Carola Gianni, Marco Polselli, Francesco De Vuono, Luigi Pannone, Sanghamitra Mohanty, Filippo Maria Cauti, Rodolfo Caminiti, Vincenzo Miraglia, Cinzia Monaco, Gian-Battista Chierchia, Pietro Rossi, Luigi Di Biase, Stefano Bianchi, Carlo de Asmundis, Andrea Natale and Domenico Giovanni Della Rocca
J. Clin. Med. 2022, 11(19), 5530; https://doi.org/10.3390/jcm11195530 - 21 Sep 2022
Cited by 11 | Viewed by 2945
Abstract
Background: Atrial fibrillation (AF) and heart failure (HF) often coexist and synergistically contribute to an increased risk of hospitalization, stroke, and mortality. Objective: To compare the efficacy of catheter ablation (CA) versus medical therapy (MT) in HF patients with AF. Methods: Electronic databases [...] Read more.
Background: Atrial fibrillation (AF) and heart failure (HF) often coexist and synergistically contribute to an increased risk of hospitalization, stroke, and mortality. Objective: To compare the efficacy of catheter ablation (CA) versus medical therapy (MT) in HF patients with AF. Methods: Electronic databases were queried for randomized controlled trials (RCTs) of CA versus MT of AF in patients with HF. Risk ratios (RRs), mean differences (MDs), and 95% confidence intervals (CIs) were measured using the Mantel–Haenszel method. Results: A total of nine RCTs enrolling 2155 patients met the inclusion criteria. Compared to MT, CA led to a significant reduction in the composite of all-cause mortality and HF hospitalization (24.6% vs. 37.1%; RR: 0.65 (95% CI: 0.53–0.80); p < 0.0001), all-cause mortality (8.8% vs. 13.6%; RR: 0.65 (95% CI: 0.51–0.82); p = 0.0005), HF hospitalization (15.4% vs. 22.4%; (RR: 0.67 (95% CI: 0.54–0.82); p = 0.0001), AF recurrence (31.8% vs. 77.0%; RR: 0.36 (95% CI: 0.24–0.54); p < 0.0001), and cardiovascular (CV) death (4.9% vs. 8.4%; RR: 0.58 (95% CI: 0.39–0.86); p = 0.007). CA improved the left ventricular ejection fraction (MD:4.76% (95% CI: 2.35–7.18); p = 0.0001), 6 min walk test (MD: 20.48 m (95% CI: 10.83–30.14); p < 0.0001), peak oxygen consumption (MD: 3.1 2mL/kg/min (95% CI: 1.01–5.22); p = 0.004), Minnesota Living with Heart Failure Questionnaire score (MD: −6.98 (95% CI: −12–03, −1.93); p = 0.007), and brain natriuretic peptide levels (MD:−133.94 pg/mL (95% CI: −197.33, −70.55); p < 0.0001). Conclusions: In HF patients, AF catheter ablation was superior to MT in reducing CV and all-cause mortality. Further significant benefits occurred within the ablation group in terms of HF hospitalizations, AF recurrences, the systolic function, exercise capacity, and quality of life. Full article
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11 pages, 458 KiB  
Article
Manganese Superoxide Dismutase as a Novel Oxidative Stress Biomarker for Predicting Paroxysmal Atrial Fibrillation
by Hao Liu, Qiao Wang, Daiqi Liu, Ziqi Li, Yulin Fu, Gary Tse, Guangping Li, Tong Liu and Gang Xu
J. Clin. Med. 2022, 11(17), 5131; https://doi.org/10.3390/jcm11175131 - 31 Aug 2022
Cited by 2 | Viewed by 1951
Abstract
Background: There is accumulating evidence indicating that inflammation and oxidative stress are involved in the pathogenesis of atrial fibrillation (AF). The role of manganese superoxide dismutase (MnSOD) in the initiation and maintenance of AF has not yet been well characterized. The aim of [...] Read more.
Background: There is accumulating evidence indicating that inflammation and oxidative stress are involved in the pathogenesis of atrial fibrillation (AF). The role of manganese superoxide dismutase (MnSOD) in the initiation and maintenance of AF has not yet been well characterized. The aim of our study is to investigate whether or not plasma MnSOD levels are associated with AF. Methods: We enrolled a total of 130 consecutive patients with AF as the case group (paroxysmal AF: 87, persistent AF: 43) and 58 patients without a history of AF as the control group after screening. Baseline clinical characteristics, laboratory and echocardiographic parameters were collected. Plasma levels of nicotinamide-adenine dinucleotide phosphate oxidase 4 (NOX4) and MnSOD were measured by an enzyme-linked immunosorbent assay (ELISA) method. These data were compared between the different groups. The relationship between MnSOD and other parameters was assessed using Spearman correlation. Multivariable logistic regression analysis was performed to identify independent predictors of AF. The area under the curve (AUC) from receiver operating characteristics (ROC) analysis was constructed to explore the value of MnSOD in predicting the occurrence of AF. Results: The levels of MnSOD were the highest in the paroxysmal AF group, followed by the persistent AF group, and the lowest in the controls. Meanwhile, the levels in the paroxysmal AF group were significantly higher than those in the controls [322.84 (165.46, 547.61) vs. 201.83 (129.53, 301.93), p = 0.002], but no significant difference was found between the paroxysmal AF group and persistent AF group, as well as the persistent AF group and the controls. Spearman correlation analysis indicated that there was a significantly negative correlation between MnSOD levels and LAD (r = −0.232, p = 0.008) and a positive correlation between MnSOD levels and RDW-CV (r = 0.214, p = 0.014) in the case group. Multivariate logistic regression analysis indicated that MnSOD levels [odds ratio (OR): 1.003, 95% confidence interval (CI): 1.001–1.005, p = 0.002] were an independent risk factor for paroxysmal AF, and the best cut-off value of MnSOD in predicting paroxysmal AF gained by ROC curve analysis was 311.49 ug/mL (sensitivity of 52.9%, specificity of 77.6%, AUC = 0.668). Conclusion: Oxidative stress underlies the pathogenesis of AF and may play a stronger role in paroxysmal AF than persistent AF. Our study showed an independent association between increased circulating plasma MnSOD levels and the occurrence of paroxysmal AF. Full article
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15 pages, 1323 KiB  
Article
Sex Difference in Effectiveness of Early Rhythm- over Rate-Control in Patients with Atrial Fibrillation
by Dong-Seon Kang, Daehoon Kim, Eunsun Jang, Hee Tae Yu, Tae-Hoon Kim, Hui-Nam Pak, Jung-Hoon Sung, Moon-Hyoung Lee, Pil-Sung Yang and Boyoung Joung
J. Clin. Med. 2022, 11(17), 4991; https://doi.org/10.3390/jcm11174991 - 25 Aug 2022
Cited by 3 | Viewed by 1677
Abstract
Background: This study aimed to investigate the associations between sex and the relative effect of rhythm control over rate control in patients with atrial fibrillation. Methods: We used the National Health Insurance Service database to select patients treated for atrial fibrillation within one [...] Read more.
Background: This study aimed to investigate the associations between sex and the relative effect of rhythm control over rate control in patients with atrial fibrillation. Methods: We used the National Health Insurance Service database to select patients treated for atrial fibrillation within one year after diagnosis. The primary composite outcome comprised cardiovascular death, ischemic stroke, heart failure hospitalization, or acute myocardial infarction. Results: During the mean follow-up (4.9 ± 3.2 years), the benefit of rhythm control over rate control on the primary composite outcome became statistically insignificant after 3 months from atrial fibrillation diagnosis in women while remained steadily until 12 months in men. The risk of primary composite outcome for rhythm control was lower than that for rate control in both sexes if it was initiated within 6 months (men: HR = 0.86, 95%CI = 0.79–0.94; women: HR = 0.85, 95%CI = 0.78–0.93; P for interaction = 0.844). However, there was significant interaction between sex and the relative effect of rhythm control if it was initiated after 6 months (men: HR = 0.72, 95%CI = 0.52–0.99; women: HR = 1.32, 95%CI = 0.92–1.88; P for interaction = 0.018). Conclusion: Rhythm control resulted in lower risk of primary composite outcome than rate control in both sexes; however, the treatment initiation at an earlier stage might be considered in women. Full article
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12 pages, 950 KiB  
Article
Risk Factors of Early Atrial Fibrillation Recurrence Following Electrical Cardioversion When Left Ventricular Ejection Fraction Is Preserved
by Rasa Karaliūtė, Arnoldas Leleika, Ieva Apanavičiūtė, Tomas Kazakevičius, Vaida Mizarienė, Vytautas Zabiela, Aušra Kavoliūnienė, Nijolė Ragaišytė, Daiva Urbonienė and Gintarė Šakalytė
Medicina 2022, 58(8), 1053; https://doi.org/10.3390/medicina58081053 - 4 Aug 2022
Cited by 1 | Viewed by 2532
Abstract
Background and objectives: To identify clinical, echocardiographic, and laboratory parameters that affect the early recurrence of atrial fibrillation (AF) after restoring sinus rhythm (SR) by electrical cardioversion (ECV), and to determine whether left atrial (LA) strain, as a noninvasive indicator reflecting fibrosis, [...] Read more.
Background and objectives: To identify clinical, echocardiographic, and laboratory parameters that affect the early recurrence of atrial fibrillation (AF) after restoring sinus rhythm (SR) by electrical cardioversion (ECV), and to determine whether left atrial (LA) strain, as a noninvasive indicator reflecting fibrosis, is associated with laboratory indicators affecting the development of fibrosis, interleukin 6 (IL-6) or tumor necrosis factor α (TNF-α). Materials and Methods: The study included 92 persistent AF patients who underwent elective ECV. The effective maintenance of SR was evaluated after 40 ± 10 days of ECV. Echocardiography, inflammatory markers (high-sensitivity c-reactive protein (hs-CRP), IL-6, and TNF-α), and natriuretic peptides (N-terminal pro b-type natriuretic peptide (NT-proBNP) and N-terminal pro a-type natriuretic peptide (NT-proANP)) were assessed. Results: After a 40 ± 10 days observation period, 51 patients (55.4%) were in SR. Patients with AF recurrence had a significantly longer duration of AF (p = 0.008) and of arterial hypertension (p = 0.035), lower LA ejection fraction (p = 0.009), lower LA strain (p < 0.0001), higher left ventricular global longitudinal strain (p = 0.001), and a higher E/e‘ ratio (p < 0.0001). LA strain was an independent predictor of early AF recurrence (OR: 0.65; 95% Cl 0.5–0.9, p = 0.004). LA strain < 11.85% predicted AF recurrence with 70% sensitivity and 88% specificity (AUC 0.855, 95% CI 0.77–0.94, p < 0.0001). LA strain demonstrated the association with NT-proBNP (r = −0.489, p < 0.0001) and NT-proANP (r = −0.378, p = 0.002), as well as with hs-CRP (r = −0.243, p = 0.04). Conclusions: LA strain appeared to be the most accurate predictor of early AF recurrence after ECV in patients with persistent AF. LA strain inversely correlated with NT-proBNP and NT-proANP, but no significant association with any of the inflammatory markers was identified. Full article
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11 pages, 599 KiB  
Article
Impact of Catheter Ablation on Brain Microstructure and Blood Flow Alterations for Cognitive Improvements in Patients with Atrial Fibrillation: A Pilot Longitudinal Study
by Yasuko Tatewaki, Tatsushi Mutoh, Hirokazu Sato, Akiko Kobayashi, Tomoko Totsune, Benjamin Thyreau, Atsushi Sekiguchi, Taizen Nakase, Tetsuo Yagi and Yasuyuki Taki
J. Clin. Med. 2022, 11(15), 4346; https://doi.org/10.3390/jcm11154346 - 26 Jul 2022
Cited by 9 | Viewed by 2173
Abstract
Atrial fibrillation (AF) predisposes patients to develop cognitive decline and dementia. Clinical and epidemiological data propose that catheter ablation may provide further benefit to improve neurocognitive function in patients with AF, but the underlying mechanism is poorly available. Here, we conducted a pilot [...] Read more.
Atrial fibrillation (AF) predisposes patients to develop cognitive decline and dementia. Clinical and epidemiological data propose that catheter ablation may provide further benefit to improve neurocognitive function in patients with AF, but the underlying mechanism is poorly available. Here, we conducted a pilot prospective study to investigate whether AF ablation can alter regional cerebral blood flow (rCBF) and brain microstructures, using multimodal magnetic resonance imaging (MRI) technique. Eight patients (63 ± 7 years) with persistent AF underwent arterial-spin labeling (ASL) perfusion, 3D T1-structural images and cognitive test batteries before and 6 months after intervention. ASL and structural MR images were spatially normalized, and the rCBF and cortical thickness of different brain areas were compared between pre- and 6-month post-treatment. Cognitive–psychological function was improved, and rCBF was significantly increased in the left posterior cingulate cortex (PCC) (p = 0.013), whereas decreased cortical thickness was found in the left posterior insular cortex (p = 0.023). Given that the PCC is a strategic site in the limbic system, while the insular cortex is known to play an important part in the central autonomic nervous system, our findings extend the hypothesis that autonomic system alterations are an important mechanism explaining the positive effect of AF ablation on cognitive function. Full article
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11 pages, 624 KiB  
Review
A New Hope: Sodium-Glucose Cotransporter-2 Inhibition to Prevent Atrial Fibrillation
by Nikolaos Karamichalakis, Vasileios Kolovos, Ioannis Paraskevaidis and Elias Tsougos
J. Cardiovasc. Dev. Dis. 2022, 9(8), 236; https://doi.org/10.3390/jcdd9080236 - 26 Jul 2022
Cited by 5 | Viewed by 3430
Abstract
Atrial arrhythmias are common in patients with diabetes mellitus (DM), and despite recent advances in pharmaceutical and invasive treatments, atrial fibrillation (AF) and atrial flutter (AFl) are still associated with substantial mortality and morbidity. Clinical trial data imply a protective effect of sodium-glucose [...] Read more.
Atrial arrhythmias are common in patients with diabetes mellitus (DM), and despite recent advances in pharmaceutical and invasive treatments, atrial fibrillation (AF) and atrial flutter (AFl) are still associated with substantial mortality and morbidity. Clinical trial data imply a protective effect of sodium-glucose cotransporter-2 inhibitors (SGLT2is) on the occurrence of AF and AFl. This review summarizes the state of knowledge regarding DM-mediated mechanisms responsible for AF genesis and recurrence but also discusses the recent data from experimental studies, published trials and metanalyses. Full article
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9 pages, 1034 KiB  
Article
Left Ventricular Ejection Fraction Can Predict Atrial Thrombosis Even in Non-High-Risk Individuals with Atrial Fibrillation
by Petra Angebrandt Belošević, Anton Šmalcelj, Nikola Kos, Krešimir Kordić and Karlo Golubić
J. Clin. Med. 2022, 11(14), 3965; https://doi.org/10.3390/jcm11143965 - 7 Jul 2022
Cited by 2 | Viewed by 1924
Abstract
Background—Current guidelines do not recommend routine use of transesophageal echocardiography (TOE) in anticoagulated patients with atrial fibrillation (AF). The aim of our study was to identify predictors for left atrial thrombosis (LAT) in patients with AF that would require TOE despite anticoagulation therapy, [...] Read more.
Background—Current guidelines do not recommend routine use of transesophageal echocardiography (TOE) in anticoagulated patients with atrial fibrillation (AF). The aim of our study was to identify predictors for left atrial thrombosis (LAT) in patients with AF that would require TOE despite anticoagulation therapy, using clinical, laboratory and echocardiographic data which are usually obtained in those patients in a real-world setting. Methods—We analyzed data from electronic medical records (EMR) of consecutive AF patients referred to two university hospitals between January 2014 and December 2017 for pulmonary vein isolation (PVI) or direct current cardioversion. The primary endpoint was the presence of left atrial thrombus on TOE. Multivariable and univariable logistic regression models were computed using variables that were significantly different between the LAT and the control groups. Results—A total of 838 patients were included, of whom 132 (15.8%) had LAT. After controlling for other variables, only the left ventricle ejection fraction (LVEF) remained statistically significant with an OR of 0.956 (95% CI 0.934–0.979), p < 0.01. Regression models including LVEF had significantly higher areas under the receiver operating characteristic (ROC) curves, including in subgroups with non-high thromboembolic risk (CHA2DS2-Vasc = 0 or 1), with an area under the curve (AUC) of 0.76 (95% CI 0.71–0.81), p < 0.0001. Conclusions—The LVEF is an independent predictor of LAT, and it might improve thromboembolic risk stratification in future models. LVEF significantly increased the predictive value of the CHA2DS2-Vasc model and was able to identify LAT in non-high-risk patients. Full article
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12 pages, 711 KiB  
Article
A Newly Defined CHA2DS2-VA Score for Predicting Obstructive Coronary Artery Disease in Patients with Atrial Fibrillation—A Cross-Sectional Study of Older Persons Referred for Elective Coronary Angiography
by Zyta Beata Wojszel, Łukasz Kuźma, Ewelina Rogalska, Anna Kurasz, Sławomir Dobrzycki, Bożena Sobkowicz and Anna Tomaszuk-Kazberuk
J. Clin. Med. 2022, 11(12), 3462; https://doi.org/10.3390/jcm11123462 - 16 Jun 2022
Cited by 2 | Viewed by 1748
Abstract
Purpose: Atrial fibrillation (AF) can be a valuable indicator of non-obstructive coronary artery disease (CAD) among older patients indicated for elective coronary angiography (CAG). Appropriate stratification of AF patients is crucial for avoiding unnecessary complications. The objective of this study was to identify [...] Read more.
Purpose: Atrial fibrillation (AF) can be a valuable indicator of non-obstructive coronary artery disease (CAD) among older patients indicated for elective coronary angiography (CAG). Appropriate stratification of AF patients is crucial for avoiding unnecessary complications. The objective of this study was to identify independent predictors that can allow diagnosing obstructive CAD in AF patients over 65 years who were indicated to undergo elective CAG. Patients and methods: This cross-sectional study included 452 (23.9%) AF patients over 65 years old who were directed to the Department of Invasive Cardiology at the Medical University of Bialystok for elective CAG during 2014–2016. The participants had CAD and were receiving optimal therapy (median age: 73 years, interquartile range: 69–77 years; 54.6% men). The prevalence and health correlates of obstructive CAD were determined, and a multivariate logistic regression model was generated with predictors (p < 0.1). Predictive performance was analyzed using a receiver-operating characteristic (ROC) curve analysis. Results: Stenosis (affecting ≥ 50% of the diameter of the left coronary artery stem or ≥70% of that of the other important epicardial vessels) was significant in 184 (40.7%) cases. Multivariate regression analysis revealed that only the male sex (odds ratio [OR]: 1.80, 95% confidence interval [CI]: 1.14–2.84, p = 0.01) and the newly created CHA2DS2-VA score (OR: 3.96, 95% CI: 2.96–5.31, p < 0.001) significantly increased the chance of obstructive CAD, while controlling for chronic kidney disease and anemia. The ROC curve analysis indicated that the CHA2DS2-VA scale may be a useful screening tool for the diagnosis of obstructive CAD (area under the ROC curve: 0.79, 95% CI: 0.75–0.84, p < 0.001), with ≥4 being the optimal cutoff value. Conclusions: Our study has proven that several older AF patients who are advised to undergo elective CAG have nonobstructive CAD. The CHA2DS2-VA score can contribute to improving the selection of patients for invasive diagnosis of CAD, but further investigation is required. Full article
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7 pages, 239 KiB  
Review
How to Optimize Cardioversion of Atrial Fibrillation
by K. E. Juhani Airaksinen
J. Clin. Med. 2022, 11(12), 3372; https://doi.org/10.3390/jcm11123372 - 12 Jun 2022
Cited by 2 | Viewed by 1789
Abstract
Cardioversion (CV) is an essential component of rhythm control strategy in the treatment of atrial fibrillation (AF). Timing of CV is an important manageable factor in optimizing the safety and efficacy of CV. Based on observational studies, the success rate of CV seems [...] Read more.
Cardioversion (CV) is an essential component of rhythm control strategy in the treatment of atrial fibrillation (AF). Timing of CV is an important manageable factor in optimizing the safety and efficacy of CV. Based on observational studies, the success rate of CV seems to be best (≈95%) at 12–48 h after the onset of arrhythmic symptoms compared with a lower success rate of ≈85% in later elective CV. Early AF recurrences are also less common after acute CV compared with later elective CV. CV causes a temporary increase in the risk of thromboembolic complications. Effective anticoagulation reduces this risk, especially during the first 2 weeks after successful CV. However, even during therapeutic anticoagulation, each elective CV increases the risk of stroke 4-fold (0.4% vs. 0.1%) during the first month after the procedure, compared with acute (<48 h) CV or avoiding CV. Spontaneous CVs are common during the early hours of AF. The short wait-and-see approach, up to 24–48 h, is a reasonable option for otherwise healthy but mildly symptomatic patients who are using therapeutic anticoagulation, since they are most likely to have spontaneous rhythm conversion and have no need for active CV. The probability of early treatment failure and antiarrhythmic treatment options should be evaluated before proceeding to CV to avoid the risks of futile CVs. Full article
11 pages, 2821 KiB  
Article
Atrial Fibrillation Global Changes after Pulmonary Vein and Posterior Wall Isolation: A Charge Density Mapping Study
by Luigi Pannone, Antonio Bisignani, Antonio Sorgente, Anaïs Gauthey, Domenico G. Della Rocca, Cinzia Monaco, Wim Bories, Robbert Ramak, Ingrid Overeinder, Gezim Bala, Alexandre Almorad, Saverio Iacopino, Gaetano Paparella, Erwin Ströker, Juan Sieira, Panagiotis Flamée, Pedro Brugada, Mark La Meir, Gian-Battista Chierchia and Carlo De Asmundis
J. Clin. Med. 2022, 11(10), 2948; https://doi.org/10.3390/jcm11102948 - 23 May 2022
Cited by 1 | Viewed by 2599
Abstract
Background: Non-contact charge density (CD) mapping allows a global visualization of left atrium (LA) activation and of activation patterns during atrial fibrillation (AF). The aim of this study was to analyze, with CD mapping, the changes in persistent AF induced by pulmonary vein [...] Read more.
Background: Non-contact charge density (CD) mapping allows a global visualization of left atrium (LA) activation and of activation patterns during atrial fibrillation (AF). The aim of this study was to analyze, with CD mapping, the changes in persistent AF induced by pulmonary vein isolation (PVI) and LA posterior wall isolation (LAPWI). Methods: Patients undergoing PVI + LAPWI using the Arctic Front Advance PROTM cryoballoon system were included in the study. CD maps were created during AF at baseline, after PVI and after LAPWI. Three distinct activation patterns were identified in the CD maps: localized irregular activation (LIA), localized rotational activation (LRA) and focal centrifugal activation (FCA). LA maps were divided into the following regions: anterior, septal, lateral, roof, posterior, inferior. Results: Eleven patients were included, with a total of 33 maps and 198 AF regions analyzed. Global and regional AF cycle lengths significantly increased after PVI and LAPWI. Baseline analysis demonstrated higher LIA, LRA and FCA numbers in the posterior and anterior regions. After PVI, there was no change in LIA, LRA and FCA occurrence. After PVI + LAPWI, a significant decrease in LRA was observed with no difference in LIA and FCA occurrence. In the regional analysis, there was a significant reduction in the LIA number in the inferior region, in the LRA number in the roof and posterior regions and in the FCA number in the lateral region. Conclusions: A global reduction in the LRA number was observed only after PVI + LAPWI; it was driven by a reduction in rotational activity in the roof and posterior regions. Full article
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10 pages, 708 KiB  
Article
Is Increased Resting Heart Rate after Radiofrequency Pulmonary Vein Isolation a Predictor of Favorable Long-Term Outcome of the Procedure?
by Cezary Maciejewski, Michał Peller, Piotr Lodziński, Edward Koźluk, Agnieszka Piątkowska, Dariusz Rodkiewicz, Izabela Sierakowska, Natalia Roman, Diana Wiśniewska, Dominika Żółcińska, Dominika Rymaszewska, Grzegorz Opolski, Marcin Grabowski and Paweł Balsam
J. Clin. Med. 2022, 11(8), 2159; https://doi.org/10.3390/jcm11082159 - 12 Apr 2022
Viewed by 3004
Abstract
Background: Increased resting heart rate (RHR) after pulmonary vein isolation (PVI) for treatment of atrial fibrillation (AF) is a common observation, possibly resulting from ganglionated plexus modification during ablation. Previous trials have suggested that an increase in RHR after ablation might be related [...] Read more.
Background: Increased resting heart rate (RHR) after pulmonary vein isolation (PVI) for treatment of atrial fibrillation (AF) is a common observation, possibly resulting from ganglionated plexus modification during ablation. Previous trials have suggested that an increase in RHR after ablation might be related to higher efficacy of the procedure. The aim of this study was to determine whether or not higher increase in RHR after radiofrequency (RF) PVI might predict better long-term outcome of the procedure in a real-life cohort of patients in whom index ablation for paroxysmal AF was performed. Material and methods: The health records of patients who underwent index point-by-point or drag lesion RF PVI for paroxysmal AF in our department between January 2014 and November 2018 were analyzed. Resting heart rate (RHR) was determined from 12-lead ECG recorded prior to the ablation and before discharge to evaluate changes in RHR after PVI. Only patients in sinus rhythm before the procedure and at discharge were included in the analysis. Telephone follow-up was collected for evaluation of arrhythmia recurrence status. Results: A total of 146 patients who underwent PVI for paroxysmal AF were included. Mean follow-up time was 3.5 years. RHR increased from 64 [58.5–70], prior to procedure, to 72 [64.25–80] bpm at discharge (p < 0.001). Higher increase in RHR was not protective from arrhythmia recurrence in long-term observation in both univariable HR = 1.001 (CI 0.99–1.017, p = 0.857) and multivariable analyses HR = 1.001 (CI 0.99–1.02, p = 0.84). Conclusions: RHR after PVI increased in comparison to baseline in our cohort. However, we did not observe higher increase in RHR to be associated with more favorable long-term effectiveness of the procedure. Full article
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