Health-related quality of life changes in patients undergoing repeated catheter ablation for atrial fibrillation

Dual-energy lattice-tip ablation system for persistent atrial fibrillation: a randomized trial

Clinical outcomes of catheter ablation for atrial fibrillation (AF) are suboptimal due, in part, to challenges in achieving durable lesions. Although focal point-by-point ablation allows for the creation of any required lesion set, this strategy necessitates the generation of contiguous lesions without gaps. A large-tip catheter, capable of creating wide-footprint ablation lesions, may increase ablation effectiveness and efficiency. In a randomized, single-blind, non-inferiority trial, 420 patients with persistent AF underwent ablation using a large-tip catheter with dual pulsed field and radiofrequency energies versus ablation using a conventional radiofrequency ablation system. The primary composite effectiveness endpoint was evaluated through 1 year and included freedom from acute procedural failure and repeat ablation at any time, plus arrhythmia recurrence, drug initiation or escalation or cardioversion after a 3-month blanking period. The primary safety endpoint was freedom from a composite of serious procedure-related or device-related adverse events. The primary effectiveness endpoint was observed for 73.8% and 65.8% of patients in the investigational and control arms, respectively (P < 0.0001 for non-inferiority). Major procedural or device-related complications occurred in three patients in the investigational arm and in two patients in the control arm (P < 0.0001 for non-inferiority). In a secondary analysis, procedural times were shorter in the investigational arm as compared to the control arm (P < 0.0001). These results demonstrate non-inferior safety and effectiveness of the dual-energy catheter for the treatment of persistent AF. Future large-scale studies are needed to gather real-world evidence on the impact of the focal dual-energy lattice catheter on the broader population of patients with AF. ClinicalTrials.gov identifier: NCT05120193 .

Modelling anticoagulation and health-related quality of life in those with atrial fibrillation: a secondary analysis of AFFIRM

Associations of anticoagulation with primary endpoints in longitudinal studies are impacted by selection bias and time-varying covariates (e.g. comorbidities). We demonstrate how time-varying covariates and selection bias influence association estimates between anticoagulation and health-related quality of life (HRQoL) in patients with atrial fibrillation. We performed a secondary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management trial quality of life substudy. Dichotomized warfarin use was ascertained at the study baseline, 2 months later, and annually for up to 6 years. HRQoL was measured at every time point using a self-reported ordinal 5-point Likert-scale (lower score and lower odds ratio represents better health-related quality of life). Static and time-varying covariates were ascertained throughout the study period. Confounder-adjusted generalized mixed model and generalized estimating equation regressions were used to demonstrate traditional association estimates between anticoagulation and HRQoL. Inverse probability of treatment and censorship weights were used to ascertain the influence of time-varying confounding and selection bias. Age-stratified analysis (age ≥ 70 years) evaluated for effect modification. 656 individuals were included in the analysis, 601 on warfarin at baseline. The association of warfarin use with better HRQoL over time strengthened when accounting for time-varying confounding and selection bias (OR 0.30, 95% CI 0.14-0.55) compared to traditional analyses (OR 0.61, 95% CI 0.38-0.97), and was most pronounced in those ≥ 70 years upon stratified analysis. Anticoagulation is associated with higher HRQoL in patients with atrial fibrillation, with time-varying confounding and selection bias likely influencing longitudinal estimates in anticoagulation-HRQoL research.

Patients' attitude towards a sham-controlled trial on pulmonary vein isolation in atrial fibrillation

Background

The interpretation of recent trials on pulmonary vein ablation (PVI) for the treatment of atrial fibrillation (AF) is hampered by the lack of blinding and sham controls. The feasibility of a sham-controlled trial has been questioned. We aimed to assess the attitude of potential participants regarding a sham-controlled trial in a common AF-patient population planned for PVI.

Methods

Patients in two tertiary care centres planned for PVI were asked for their current AF symptoms using the Atrial Fibrillation Effect on QualiTy of Life (AFEQT) questionnaire 1 day before catheter ablation. Subsequently, the study design of a hypothetical sham-controlled PVI-study was introduced, and patients were asked for their agreement in participation. Telephone follow-up of the AFEQT questionnaire was conducted 3 months after PVI.

Results

One hundred and ninety-six patients (mean age 64 ± 11 years, 63% male) were included. Seventy-nine (40%) patients expressed their agreement to participate in the hypothetical sham-controlled trial. An additional 7% agreed to participate if a cross-over option after three months was offered. Agreement rate was similar in patients with first and Redo-PVI and minimal, moderate or severe symptoms. Mean overall AFEQT at baseline was 55 ± 19 and improved by 25 ± 20 points after 3 months (p < 0.001 versus baseline).

Conclusion

With a participation rate of 40% in potential study participants, a sham-controlled trial for pulmonary vein isolation seems feasible. Patient-reported symptom relief after pulmonary vein isolation is in accordance with previous randomized open studies. The benefit of PVI should be rigorously evaluated in a sham-controlled trial.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01959-z.

Effect of reinforced, targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire in patients with atrial fibrillation: A randomized controlled trial

BACKGROUND

The knowledge level of atrial fibrillation patients about their arrhythmia, its consequences and treatment is poor. The best strategy to provide education is unknown.

AIM

To investigate the effect of reinforced targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ).

METHODS

Sixty-seven atrial fibrillation patients were randomized to standard care (including brochures) or targeted education. Follow-up visits were scheduled after one, three, six and 12 months. Targeted education during each visit focused on the knowledge gaps revealed by the JAKQ. Patients completed two questionnaires to assess their quality of life and symptom profile. Adherence to non-vitamin K antagonist oral anticoagulants was measured using electronic monitoring.

RESULTS

Sixty-two patients (31 education; 31 standard care) completed follow-up. Median baseline score on the JAKQ was similar in education (62.5%) and standard care group (56.3%; p=0.815). The intervention group scored significantly better over time (one month: 75.0%, 12 months: 87.5%; p<0.001) whereas there was no significant improvement in the control group (one month: 62.5%, 12 months: 62.5%; p=0.085). Providing targeted education after completion of the JAKQ required on average 6.9±4.6 min. Some improvements in quality of life, symptom burden and adherence were shown, without significant differences between the two groups ( p-values between 0.282 and 0.677).

CONCLUSION

The JAKQ is an effective tool for providing individualized education. A first targeted educational session significantly improved patients' knowledge level. Additional educational sessions maintained and strengthened this effect. A larger scale study is warranted to evaluate the impact on adherence and outcome measures.

Remote vs. conventional navigation for catheter ablation of atrial fibrillation: insights from prospective registry data

BACKGROUND

Robotic (RNS) or magnetic navigation systems (MNS) are available for remotely performed catheter ablation for atrial fibrillation (AF).

OBJECTIVE

The present study compares remotely assisted catheter navigation (RAN) to standard manual navigation (SMN) and both systems amongst each other.

METHODS

The analysis is based on a sub-cohort enrolled by five hospitals from the multicenter German ablation Registry.

RESULTS

Out of 2442 patients receiving catheter ablation of AF, 267 (age 61.4 ± 10.4, 69.7% male) were treated using RAN (RNS n = 187, 7.7% vs. MNS n = 80, 3.3%). Fluoroscopy time [RNS median 17 (IQR 12-25) min vs. MNS 22 (16-32) min; p < 0.001] and procedure duration [RNS 180 (145-220) min vs. MNS 265 (210-305) min; p < 0.001] were significantly different. Comparing RAN (11%) to SMN (89%) fluoroscopy time (RAN 19 (13-27) min, vs. SMN 25 (16-40) min; p < 0.001), energy delivery (RAN 3168 (2280-3840) s vs. SMN 2640 (IQR 1799-3900) s; p = 0.008) and procedure duration [RAN 195 (150-255) min vs. SMN 150 (120-150) min; p = 0.001] differed significantly. In terms of acute and 12 months outcome, no differences were seen between the two systems or in comparison to SMN.

CONCLUSION

AF ablation can be performed safely, with high acute success rates using RAN. RNS results in less fluoroscopy burden and shorter procedure durations. Compared to SMN, a reduced fluoroscopy burden, prolonged procedure and ablation duration were observed using RAN. Overall, the number of RAN procedures is small suggesting low impact on clinical routine of AF ablation.

Utility of the JT Peak Interval and the JT Area in Determining the Proarrhythmic Potential of QT-Shortening Agents

Drug-induced long QT increases the risk of ventricular tachyarrhythmia known as torsades de pointes (TdP). Many biomarkers have been used to predict TdP. At present, however, there are few biomarkers for arrhythmias induced by QT-shortening drugs. The objective of the present study was to identify the best biomarkers for predicting arrhythmias caused by the 4 potassium channel openers ICA-105574, NS-1643, R-L3, and pinacidil. Our results showed that, at higher concentrations, all 4 potassium channel openers induced ventricular tachycardia (VT) and ventricular fibrillation (VF) in Langendorff-perfused guinea pig hearts, but not in rabbit hearts. The electrocardiography parameters were measured including QT/QTc, JT peak, Tp-e interval, JT area, short-term beat-to-beat QT interval variability (STV), and index of cardiac electrophysiological balance (iCEB). We found that the potassium channel openers at test concentrations shortened the QT/QTc and the JT peak interval and increased the JT area. Nevertheless, even at proarrhythmic concentrations, they did not always change STV, Tp-e, or iCEB. Receiver operating characteristic curve analysis showed that the JT peak interval representing the early repolarization phase and the JT area reflecting the dispersion of ventricular repolarization were the best predictors of VT/VF. Action potential recordings in guinea pig papillary muscle revealed that except for pinacidil, the potassium channel openers shortened APD₃₀ in a concentration-dependent manner. They also evoked early or delayed afterdepolarizations at fast pacing rates. Patch-clamp recordings in guinea pig ventricular cardiomyocytes showed that the potassium channel openers enhanced the total outward currents during the early phase of action potential repolarization, especially at proarrhythmic concentrations. We concluded that the JT peak interval and the JT area are surrogate biomarkers identifying the risk of proarrhythmia associated with the administration of QT-shortening agents. The acceleration of early-phase repolarization and the increased dispersion of ventricular repolarization may contribute to the occurrence of arrhythmias.

Catheter ablation of paroxysmal atrial fibrillation: circumferential pulmonary vein ablation: success rates with and without exclusion of areas adjacent to the esophagus

BACKGROUND

Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory paroxysmal atrial fibrillation. Circumferential pulmonary vein ablation is still the standard approach in these patients. The occurrence of an atrioesophageal fistula is a rare but life-threatening complication after such ablation procedures. This is due to the fact that the esophagus does frequently have a very close anatomical relationship to the left or right pulmonary vein ostia. The aim of our study was to evaluate whether the exclusion of areas adjacent to the esophagus does have a significant effect on the success rate after circumferential pulmonary vein ablation.

METHODS

Two hundred consecutive patients [121 men, 69 women; mean age 59.1 years (SD ± 11.3 years)] with symptomatic paroxysmal atrial fibrillation underwent a circumferential pulmonary vein ablation procedure (using the CARTO- or the NAVX-system). In 100 patients, a complete circumferential pulmonary vein ablation was attempted regardless of the anatomical relationship between the ablation sites and the esophagus (group A). In the remaining 100 patients, the esophagus was marked by a special EP catheter and areas adjacent to the esophagus were excluded from the ablation procedure. After discharge, patients were scheduled for repeated visits at the arrhythmia clinic at 1, 3, 6, 9, 12, 24 and 36 months after the ablation procedure.

RESULTS

The ablation procedure could be performed as planned in all 200 patients. In group A, all pulmonary veins could be isolated successfully in 88 out of 100 patients (88%). A mean number of 3.9 pulmonary veins (SD ± 0.37 PVs) were isolated per patient. The 12 cases of an incomplete pulmonary vein isolation were due to poorly accessible pulmonary vein ostia. In group B, all pulmonary veins could be isolated successfully in only 58 out of 100 patients (58%; P < 0.01). A mean number of 3.5 PVs (SD ± 0.6 PVs) were isolated per patient (P < 0.01). This was mostly due to a close anatomical relationship to the esophagus. The ablation strategy had to be modified in 46/100 patients in group B because of a close anatomical relationship between the right (n = 25) or left (n = 21) pulmonary vein ostia and the esophagus. One year after the ablation procedure, 87% of patients in group A (87/100) and 79% of patients in group B (79/100) were free from an arrhythmia recurrence (P = 0.19). Three years after catheter ablation, the success rate was 80% (no arrhythmia recurrence in 80 out of 100 patients) in group A and 66% in group B (no arrhythmia recurrence in 66 out of 100 patients; P = 0.04). There were no major complications during long-term follow-up.

CONCLUSIONS

The exclusion of areas adjacent to the esophagus results in a markedly higher percentage of incompletely isolated pulmonary veins after circumferential pulmonary vein ablation procedures. This results in a significantly higher arrhythmia recurrence rate during long-term follow-up.