[Remodeling of the aging heart : Sinus node dysfunction and atrial fibrillation]

Long-term outcome after ablation of persistent atrial fibrillation in patients with postprocedurally unmasked sinus node disease

BACKGROUND

About three percent of patients with persistent atrial fibrillation (AF) additionally suffer from a concealed sinus node disease (SND). We sought to determine the success of ablation one year after ablation of persistent AF in patients with postprocedurally unmasked SND.

METHODS AND RESULTS

In total, 2539 patients with an ablation of persistent AF at our centre were screened for a postprocedurally unmasked SND, which made acute cardiac pacing necessary within one week after ablation. In a propensity score-matched case-control study (1:2 matching), the long-term ablation success of 51 patients (mean age 73 ± 8 years, 59% male) with unmasked SND after ablation of persistent AF was compared to that of 102 patients without SND after ablation of persistent AF. Controls were matched to cases based on the propensity score considering age, body mass index, left ventricular ejection fraction, gender, blood pressure, diabetes mellitus, atrial low voltage, previous number of ablations, and method of ablation. One year after ablation of persistent AF, 20 (39%) patients with postprocedurally unmasked SND and 61 (60%) patients without postprocedurally unmasked SND were in sinus rhythm (OR 0.43, 95% CI 0.22 to 0.90, p = 0.017). The number of repeat ablation procedures within the follow-up year did not differ significantly between cases and controls (mean 0.60 ± 0.68 vs 0.53 ± 0.80, rate ratio 1.14, 95% CI 0.72 to 1.78, p = 0.566).

CONCLUSION

In patients with a postprocedurally unmasked SND after ablation of persistent AF, long-term ablation success seems to be worse compared to patients without postprocedurally unmasked SND.

Shenxian-Shengmai Oral Liquid Evoke Autophagy of Fibroblast to Attenuate Sinoatrial Node Fibrosis in Sick Sinus Syndrome Mice via the AKT/mTOR Pathway

Sick sinus syndrome (SSS) is closely associated with cardiac syncope and sudden death, wherein sinoatrial node (SAN) fibrosis is one of the main pathological changes that occur. Shenxian-Shengmai oral liquid (SXSM) has been clinically proven to significantly improve the heart rate of SSS patients. In this study, we aimed to explore the mechanism of SXSM in reducing the SAN fibrosis by combining in vitro and in vivo experiments. Accordingly, the SSS model was constructed by slowly pumping angiotensin II (AngII) with a micro-osmotic pump. The degree of fibrosis was evaluated by Masson's trichrome staining and immunofluorescence staining of the fibrosis marker protein. In addition, NIH-3T3 mouse fibroblasts were used to simulate SAN fibroblasts to further explore the mechanism, with AngII used as the cellular fibrosis inducer. Monodansylcadaverine (MDC) staining and transmission electron microscopy were employed to assay the autophagy content, whereas immunofluorescence staining and Western blotting were employed to elucidate the related protein expression. Finally, fibroblasts were given the AKT phosphorylation agonist SC79 to reversely verify the effects of SXSM. The results showed that SXSM could significantly increase the heart rate of SSS mice by reducing the deposition of extracellular matrix (ECM) in SAN induced by AngII. According to in vivo experiments, when compared with the model group, SSS mice treated with SXSM developed less fibrosis in the SAN area. In vitro experiments revealed that AngII could restrain autophagy by activating the phosphorylation of the AKT/mTOR pathway, thereby increasing the deposition of ECM. Moreover, SXSM pretreatment prevented this upregulation. After the intervention of SC79, the protective effect of SXSM was weakened. In conclusion, SXSM activated autophagy through the AKT/mTOR pathway, which in turn reduced the deposition of the ECM in SAN induced by AngII, attenuated the fibrosis of SAN, and improved the decreased heart rate in the SSS mice.

Structural Equation Model (SEM) of Stroke Mortality in Spanish Inpatient Hospital Settings: The Role of Individual and Contextual Factors

Introduction: Traditionally, predictive models of in-hospital mortality in ischemic stroke have focused on individual patient variables, to the neglect of in-hospital contextual variables. In addition, frequently used scores are betters predictors of risk of sequelae than mortality, and, to date, the use of structural equations in elaborating such measures has only been anecdotal. Aims: The aim of this paper was to analyze the joint predictive weight of the following: (1) individual factors (age, gender, obesity, and epilepsy) on the mediating factors (arrhythmias, dyslipidemia, hypertension), and ultimately death (exitus); (2) contextual in-hospital factors (year and existence of a stroke unit) on the mediating factors (number of diagnoses, procedures and length of stay, and re-admission), as determinants of death; and (3) certain factors in predicting others. Material and Methods: Retrospective cohort study through observational analysis of all hospital stays of Diagnosis Related Group (DRG) 14, non-lysed ischemic stroke, during the time period 2008-2012. The sample consisted of a total of 186,245 hospital stays, taken from the Minimum Basic Data Set (MBDS) upon discharge from Spanish hospitals. MANOVAs were carried out to establish the linear effect of certain variables on others. These formed the basis for building the Structural Equation Model (SEM), with the corresponding parameters and restrictive indicators. Results: A consistent model of causal predictive relationships between the postulated variables was obtained. One of the most interesting effects was the predictive value of contextual variables on individual variables, especially the indirect effect of the existence of stroke units on reducing number of procedures, readmission and in-hospital mortality. Conclusion: Contextual variables, and specifically the availability of stroke units, made a positive impact on individual variables that affect prognosis and mortality in ischemic stroke. Moreover, it is feasible to determine this impact through the use of structural equation methodology. We analyze the methodological and clinical implications of this type of study for hospital policies.

Occurrence of significant long PR intervals in patients implanted for sinus node dysfunction and monitored with SafeR™: The PRECISE study

BACKGROUND

Long PR intervals may increase cardiovascular complications, including atrial fibrillation. In pacemakers, the SafeR™ mode monitors PR intervals, switching from AAI to DDD when criteria for atrioventricular block are met.

AIMS

The PRECISE study evaluated the incidence and predictors of long PR intervals and their association with incident atrial fibrillation after 1 year in patients implanted for sinus node dysfunction and free from significant conduction disorders at baseline.

METHODS

This French, prospective, multicentre, observational trial enrolled patients implanted with a REPLY™ dual-chamber pacemaker. Pacemaker memory recorded long PR intervals (defined as first-degree atrioventricular block mode switches occurring after six consecutive PR/AR intervals≥350/450ms) and atrial fibrillation incidence (fallback mode switch>1minute/day). Predictors were identified from baseline variables (age, sex, AR and PR intervals, atrial rhythm disorder and medication) using logistic regression.

RESULTS

Of 291 patients with sinus node dysfunction enrolled, 214 were free from significant conduction disorders at baseline (mean age 79±8 years; 44% men; PR/AR intervals<350/450ms). After 1 year, long PR intervals had occurred in 116 patients (54%) and atrial fibrillation in 63 patients (30%). Amiodarone was the only independent predictor of long PR interval occurrence (odds ratio 2.50, 95% confidence interval 1.20-5.21; P=0.014). There was a strong trend towards an association between long PR interval and atrial fibrillation incidence (odds ratio 1.86, 95% confidence interval 0.97-3.61; P=0.051).

CONCLUSIONS

Half of the patients with pure sinus node dysfunction developed long PR intervals in the year following pacemaker implantation. Amiodarone was the only independent predictor of long PR intervals. There was a strong trend towards an association between long PR intervals and incident atrial fibrillation.

The incidence, indications and predictors of acute pacemaker implantation after ablation of persistent atrial fibrillation

INTRODUCTION

Patients with persistent atrial fibrillation (AF) may additionally suffer from a concealed sinus node disease. We sought to determine the incidence, indications and predictors of acute pacemaker [PM] implantation within 1 week after the ablation of persistent AF.

METHODS AND RESULTS

We performed a retrospective analysis of patients, who had had an ablation of persistent AF at our center. Between 01/2011 and 08/2016, 1234 patients (mean age 65 ± 10 years, 66.7% male) without prior PM implantation underwent an ablation of persistent AF. Pulmonary vein isolation (PVI) was performed in 1158 (93.8%), the additional ablation of complex fractionated atrial electrograms (CFAE) in 1109 (89.9%) and linear ablation in 524 (42.5%) patients. Temporary cardiac pacing was necessary in 27 (2.2%) patients. The temporary PM was removed in 15 patients (1.2%) because sinus node recovered after a median of 1.0 (minimum 0.1-maximum 2.0) day. The remaining 12 (1.0%) patients required the implantation of a permanent PM. Another 13 (1.1%) patients required permanent PM implantation without prior temporary pacing. In a multivariable regression model, age [OR 1.07 (1.02-1.12), p = 0.006], sinus pauses prior to ablation [OR 7.97 (2.36-26.88), p = 0.001] and atria with low voltage [OR 2.83 (1.31-6.11), p = 0.008] were identified as significant predictors for acute cardiac pacing.

CONCLUSION

Acute cardiac pacing within 1 week after the ablation of persistent AF was necessary in 40 (3.2%) patients. Age, sinus pauses in history prior to ablation and the existence of low-voltage areas in the atria were identified as relevant risk factors.

[The Old-Age Heart]

The Old-Age Heart Abstract. Knowledge of cardiovascular changes in old age and their therapeutic options is important. Old age can lead to hypertrophy of the left ventricle, diastolic dysfunction, heart valve changes and pulmonary hypertension. Patients often develop arterial hypertension. Valvular changes are common in people over 100 years of age (aortic stenosis and mitral insufficiency). The risk of coronary heart disease is 35 % for men and 24 % for women. In old age, sinus node dysfunction and atrial fibrillation are common. 25 % of all strokes are cardiac embolisms in atrial fibrillation. Cardiac interventions in the elderly are increasingly frequent and include coronary catheter revascularization or valve interventions (percutaneous aortic valve replacement or MitraClip). Optimal therapy in old age includes not only cardiovascular interventions also include drugs and a lifestyle modification and mainly serves to improve the quality of life.