Assessment of Atrial Fibrillation and Ventricular Arrhythmia Risk after Bariatric Surgery by P Wave/QT Interval Dispersion

Impact of Bariatric Surgery on the Prevalence and Outcomes of Atrial Fibrillation in Obese Patients

Obesity has been identified as a significant factor contributing to the development of numerous cardiovascular conditions and as a result, the cardiovascular community has prioritized efforts to address obesity and reduce its associated risks. However, despite these efforts, the prevalence of obesity continues to rise steadily, and is projected to double in the upcoming years. Atrial fibrillation is among the most prevalent and extensively researched cardiovascular comorbidities associated with obesity. Several mechanisms have been postulated, including scar tissue formation and fat deposition, which ultimately leads to atrial remodeling and subsequent arrhythmogenesis. Numerous strategies have been implemented to prevent and manage obesity, encompassing lifestyle adjustments, dietary modifications, pharmacological treatments, and surgical interventions. Bariatric surgery has garnered significant recognition over the years due to its promising outcomes, including a decrease in the overall prevalence of atrial fibrillation and other cardiovascular comorbidities in general in obese patients. This study focuses on the current trends regarding the impact of bariatric surgery on obese patients with atrial fibrillation.

Multiple anthropometric measures and proarrhythmic 12-lead ECG indices: A mendelian randomization study

BACKGROUND

Observational studies suggest that electrocardiogram (ECG) indices might be influenced by obesity and other anthropometric measures, though it is difficult to infer causal relationships based on observational data due to risk of residual confounding. We utilized mendelian randomization (MR) to explore causal relevance of multiple anthropometric measures on P-wave duration (PWD), PR interval, QRS duration, and corrected QT interval (QTc).

METHODS AND FINDINGS

Uncorrelated (r2 < 0.001) genome-wide significant (p < 5 × 10-8) single nucleotide polymorphisms (SNPs) were extracted from genome-wide association studies (GWAS) on body mass index (BMI, n = 806,834), waist:hip ratio adjusted for BMI (aWHR, n = 697,734), height (n = 709,594), weight (n = 360,116), fat mass (n = 354,224), and fat-free mass (n = 354,808). Genetic association estimates for the outcomes were extracted from GWAS on PR interval and QRS duration (n = 180,574), PWD (n = 44,456), and QTc (n = 84,630). Data source GWAS studies were performed between 2018 and 2022 in predominantly European ancestry individuals. Inverse-variance weighted MR was used for primary analysis; weighted median MR and MR-Egger were used as sensitivity analyses. Higher genetically predicted BMI was associated with longer PWD (β 5.58; 95%CI [3.66,7.50]; p = < 0.001), as was higher fat mass (β 6.62; 95%CI [4.63,8.62]; p < 0.001), fat-free mass (β 9.16; 95%CI [6.85,11.47]; p < 0.001) height (β 4.23; 95%CI [3.16, 5.31]; p < 0.001), and weight (β 8.08; 95%CI [6.19,9.96]; p < 0.001). Finally, genetically predicted BMI was associated with longer QTc (β 3.53; 95%CI [2.63,4.43]; p < 0.001), driven by both fat mass (β 3.65; 95%CI [2.73,4.57]; p < 0.001) and fat-free mass (β 2.08; 95%CI [0.85,3.31]; p = 0.001). Additionally, genetically predicted height (β 0.98; 95%CI [0.46,1.50]; p < 0.001), weight (β 3.45; 95%CI [2.54,4.36]; p < 0.001), and aWHR (β 1.92; 95%CI [0.87,2.97]; p = < 0.001) were all associated with longer QTc. The key limitation is that due to insufficient power, we were not able to explore whether a single anthropometric measure is the primary driver of the associations observed.

CONCLUSIONS

The results of this study support a causal role of BMI on multiple ECG indices that have previously been associated with atrial and ventricular arrhythmic risk. Importantly, the results identify a role of both fat mass, fat-free mass, and height in this association.

The incidence of cardiac arrhythmias during exercise stress testing: a focus on patients with severe obesity undergoing sleeve gastrectomy

INTRODUCTION

Obesity is associated with a higher risk of cardiac arrhythmias. Sleeve gastrectomy (SG) is a common bariatric surgery with beneficial effects on weight loss and comorbidities. The study aimed to investigate the prevalence of arrhythmias during maximal exercise testing in patients with moderate-severe obesity and to evaluate the impact of SG on these arrhythmic events.

METHODS

All patients with moderate or severe obesity who were considered suitable candidates for SG between June 2015 and September 2020 were recruited. Each patient underwent three incremental, maximal, ECG-monitored cardiopulmonary exercise test 1 month before and 6 and 12 months after SG; the frequency and complexity of ventricular premature beats (VPBs) and atrial premature beats (APBs) have been evaluated during rest, exercise and recovery phases.

RESULTS

Fifty patients with severe obesity (BMI 46.39 ± 7.89 kg/m²) were included in the study. After SG, patients presented a decreased BMI (34.15 ± 6.25 kg/m² at 6 months post-SG and 31.87 ± 5.99 kg/m² at 12 months post-SG). At 6 months post-SG, an increase in VPBs, mainly during the recovery phase, was observed. At 12 months post-SG, a reduction in VPBs compared with the 6 months evaluation was showed.

CONCLUSION

Although in the early post-surgical phase the risk of exercise-induced arrhythmias may be higher, SG does not seem to increase the occurrence of arrhythmias in the long-term. No life-threating arrhythmias were found during post-SG evaluations.

The Impact of Bariatric Surgery on Cardiac Structure, and Systolic and Diastolic Function in Patients with Obesity: A Systematic Review and Meta-analysis

The purpose of this study was to provide pooled data from all studies on the impact of bariatric surgery on cardiac structure, and systolic and diastolic function evaluated by either echocardiography or cardiac magnetic resonance. PubMed, Web of Science, Embase, and Scopus databases were searched. Almost all of cardiac left-side structural indices improved significantly after bariatric surgery. However, right-side structural indices did not change significantly. Left ventricular ejection fraction and most of the diastolic function indices improved significantly after the bariatric surgery. The subgroup analysis showed that the left ventricular mass index decreased more in long-term follow-up (≥ 12 months). In addition, subgroup analysis of studies based on surgery type did not reveal any difference in outcomes between gastric bypass and sleeve gastrectomy groups.

Obesity as a risk factor for cardiac arrhythmias

Obesity is global health problem with an estimated three billion people worldwide being classified as overweight or obese. In addition to being associated with a range of adverse health outcomes, obesity is linked to higher risks of atrial and ventricular arrhythmias, as well as sudden cardiac death. Obesity is a multifactorial disease that often co-exists with hypertension, diabetes, and sleep apnoea, which are also independent risk factors for cardiac arrhythmias. Nevertheless, compelling evidence suggests that increasing adiposity is an independent proarrhythmic risk factor and that weight loss can be a mitigating and preventative intervention to reduce arrhythmia incidence. This review briefly outlines the economic and social burden of obesity and summarises evidence for the direct and indirect effects of increasing adiposity on risk of atrial and ventricular arrhythmias. The paper also summarises the evidence for electrocardiographic changes indicative of obesity-related atrial and ventricular remodelling and how weight reduction and management of comorbidity might reduce arrhythmic burden.

The Influence of Surgical Weight Reduction on Left Atrial Strain

Background

Obesity increases and surgical weight reduction decreases the risk of atrial fibrillation (AF) and heart failure (HF). We hypothesized that surgically induced weight loss may favorably affect left atrial (LA) mechanical function measured by longitudinal strain, which has recently emerged as an independent imaging biomarker of increased AF and HF risk.

Methods

We retrospectively evaluated echocardiograms performed before and 12.2 ± 2.2 months after bariatric surgery in 65 patients with severe obesity (mean age 39 [36; 47] years, 72% of females) with no known cardiac disease or arrhythmia. The LA mechanical function was measured by the longitudinal strain using the semi-automatic speckle tracking method.

Results

After surgery, body mass index decreased from 43.72 ± 4.34 to 30.04 ± 4.33 kg/m². We observed a significant improvement in all components of the LA strain. LA reservoir strain (LASR) and LA conduit strain (LASCD) significantly increased (35.7% vs 38.95%, p = 0.0005 and − 19.6% vs − 24.4%, p < 0.0001) and LA contraction strain (LASCT) significantly decreased (− 16% vs − 14%, p = 0.0075). There was a significant correlation between an increase in LASR and LASCD and the improvement in parameters of left ventricular diastolic and longitudinal systolic function (increase in E’ and MAPSE). Another significant correlation was identified between the decrease in LASCT and an improvement in LA function (decrease in A’).

Conclusions

The left atrial mechanical function improves after bariatric surgery. It is partially explained by the beneficial effect of weight reduction on the left ventricular diastolic and longitudinal systolic function. This effect may contribute to decreased risk of AF and HF after bariatric surgery.

Graphical abstract

Ventricular conduction improvement after pericardial fat reduction triggered by rapid weight loss in subjects with obesity undergoing bariatric surgery

BACKGROUND

Obesity is considered a major cardiovascular risk factor. The excess of pericardial fat (PF) in patients with obesity has been associated with a variety of electrocardiographic alterations. In previous studies, we demonstrated that rapid weight loss and bariatric interventions result in decreased PF.

OBJECTIVES

The aim of this study is to report the changes in PF after bariatric surgery and its effect on ventricular conduction.

SETTING

US hospital, academic institution.

METHODS

A linear measurement of PF thickness on computed tomography scans was obtained for 81 patients, as well as a retrospective review of electrocardiographic changes before and after bariatric surgery. We compared the changes in PF thickness and electrocardiographic components before and after procedures. Common demographics and co-morbidities were collected along with lipid profiles preoperative and postoperative.

RESULTS

A total of 81 patients had electrocardiograms done before and 1 year after bariatric surgery. Females comprised 67.9% (n = 55), and the average age for our population was 55.07 ± 14.17 years. Pericardial fat thickness before surgery was 5.6 ± 1.84 and 4.5 ± 1.62 mm after surgery (P = .0001). Ventricular conduction (QT and QT corrected [QTc] intervals) showed a significant improvement from 438.7 + 29 before to 426.8 + 25.3 after bariatric surgery (P = .006). We found a statistically significant association between the decrease in PF and the decrease in QTc intervals (P = .002).

CONCLUSION

Obesity is a risk factor for arrhythmias and sudden cardiac death. Bariatric surgery and its effect on PF produce an improvement in ventricular conduction, which may reduce the ventricular electrical instability in patients with obesity.

Impact of surgical weight loss on novel P-wave-related variables which are nominated as predictors of atrial arrhythmias

BACKGROUND

Bariatric surgery has been associated with reduced cardiovascular mortality and morbidity in obese patients. In this study, we aimed to evaluate the alterations of novel P-wave related atrial arrhythmia predictors in patients who achieved effective weight loss with bariatric surgery.

METHODS

The study included 58 patients who underwent bariatric surgery. We measured heart rate, PR, P wave (PW) max, PW min, Average P axis, P wave peak time (PWPT) in lead D2 and lead V1, terminal force in lead V1 (V1TF), and we estimated P wave dispersion (PWdis) interval both pre-operation and 6 months after operation.

RESULTS

Heart rate, PR, PW max, PW min, PWdis, Average P axis, PWPTD2, PWPTV1 and V1TF values, which were close to the upper limit in the pre-op period, showed statistically significant decreases at 6 months after the operation. The most prominent changes were observed in PW dis (51.15 ± 9.70 ms vs. 48.79 ± 9.50 ms, p = .010), PWPTD2 (55.75 ± 6.91 ms vs. 50.59 ± 7.67 ms, p < .001), PWPTV1 (54.10 ± 7.06 ms vs. 48.05 ± 7.64 ms, p < .001) and V1TF (25 [43.1%] vs. 12 [20.7%], p < .001).

CONCLUSIONS

The results of our study indicated that bariatric surgery has positive effects on the regression of ECG parameters which are predictors of atrial arrhythmias, particularly atrial fibrillation (AF).

The negative effects of obesity on heart, especially the electrophysiology of the heart

Obesity is associated with ventricular arrhythmia and sudden cardiac death. Numerous studies have shown that obesity may have effects on the heart by affecting the ventricular re-polarisation (VR). As an effective detection method for VR the measurement of the QT interval has been extensively studied in obese patients (OP). This review aims to investigate the relationship between obesity and obesity-related diseases; including diabetes, hypertension and cardiovascular diseases (CVD). This review compares the advantages and disadvantages of different QT interval measurement methods, as well as explores the possible mechanisms of obesity leading to heart disease. Finally, it also reviews the feasibility of various weight loss methods to reverse the risk of obesity leading to heart disease is discussed.

Evaluation of Changes in Ventricular Repolarization Parameters in Morbidly Obese Patients Undergoing Bariatric Surgery

BACKGROUND

Weight loss after bariatric surgery has been associated with reduced cardiovascular mortality and overall mortality in obese patients. In this study, we aimed to analyze the changes between pre-operation and post-operation ventricular arrhythmia predictors in patients who underwent bariatric surgery.

MATERIALS AND METHODS

The study included 58 patients who underwent bariatric surgery. We measured QT max, QT min, QRS, JT, and Tp-e intervals, and we estimated Tp-e/QT max, Tp-e/QTc max, Tp-e/JT, Tp-e/JTc rates, QTc max, QTc min, cQTd, and JTc intervals both pre-op and 6 months post-op.

RESULTS

Heart rate, PR, QT max, QTc max, QTc min, cQTd, JTc, Tp-e, Tp-e/QT max, Tp-e/QTc max, Tp-e/JT, and Tp-e/JTc values, which were close to the upper limit in the pre-op period, showed statistically significant decreases at 6 months post-op.

CONCLUSION

The results of our study showed that bariatric surgery had positive effects on the regression of ventricular repolarization parameters and the possible development of ventricular arrhythmia.

Cardiovascular Risk Reduction Following Metabolic and Bariatric Surgery

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality in developed countries, with worsening pandemics of type 2 diabetes mellitus and obesity as major cardiovascular (CV) risk factors. Clinical trials of nonsurgical obesity treatments have not shown benefits in CVD, although recent diabetes trials have demonstrated major CV benefits. In many retrospective and prospective cohort studies, however, metabolic (bariatric) surgery is associated with substantial and reproducible CVD benefits. Despite a lack of prospective, randomized clinical trials, data suggest metabolic surgery may be the most effective modality for CVD risk reduction, likely through weight loss and weight loss-independent mechanisms.

Effects of Bariatric Surgery on Heart Rhythm Disorders: a Systematic Review and Meta-Analysis

The aim of this systematic review is to provide an overview of the literature on the effects of bariatric surgery on obesity-associated electrocardiogram (ECG) abnormalities and cardiac arrhythmias. Fourteen studies were included with a methodological quality ranging from poor to good. Majority of the studies showed a significant decrease of QT interval and related measures after bariatric surgery. Seven studies were included in the meta-analysis on effects of bariatric surgery on QTc interval and a significant decrease in QTc interval of - 33.6 ms, 95%CI [- 49.8 to - 17.4] was seen. Bariatric surgery results in significant decrease in QTc interval and P-wave dispersion, i.e., a normalization of initial pathology. The effects on atrial fibrillation are conflicting and not yet fully understood.

Favorable electrocardiographic changes after substantial weight loss in patients with morbid obesity : Results of a prospective study

BACKGROUND

Obese patients have an increased risk of arrhythmias and sudden death, even in the absence of structural heart disease and cardiac dysfunction. This study aimed to determine whether weight loss by bariatric surgery has an effect on arrhythmia-related electrocardiographic (ECG) variables in morbidly obese patients.

METHODS

In this prospective study, the data of 48 patients were analyzed. All ECG variables that have the potential to predict ventricular arrhythmia were evaluated before surgery, and were compared with the 1‑month and 6‑month follow-up results.

RESULTS

The mean body mass index was 45.74 ± 5.60 kg/m² before surgery. There was a statistically significant decline in body mass index in the first and sixth month after surgery (39.26 ± 5.00 kg/m² and 31.71 ± 4.49 kg/m², respectively; p < 0.001). Furthermore, notable reduction was found in terms of heart rate measurements-QTc‑d, JTc, JTc‑d, Tp‑e, TP-e/QT, TP-e/QTc-in the first month and sixth month compared with baseline (p < 0.001 for all comparisons). Several ECG variables, such as heart rate (r = 0.369, p = 0.001), QTc‑d (r = 0.449, p = 0.001), JTc‑d (r = 0.324, p = 0.002), Tp‑e (r = 0.592, p = 0.001), Tp-e/QTc (r = 0.543, p = 0.001), Tp-e/JTc (r = 0.515, p = 0.001), exhibited a positive and significant correlation with weigh loss. Moreover, a negative and weakly significant correlation was found between the index of cardiac electrophysiological balance (r = -0.239, p = 0.004) and body mass index.

CONCLUSION

Substantial weight loss following laparoscopic sleeve gastrectomy in obese patients is accompanied by a significant improvement in ventricular repolarization. Therefore, this effect may lead to a decrease in the incidence of lethal ventricular arrhythmia and sudden cardiac death.

RETRACTED: Safety of radiofrequency ablation for reducing inflammatory cytokine levels and the left atrial diameter in patients with atrial fibrillation

Objective

To investigate the safety of radiofrequency ablation for reducing inflammatory cytokines and the left atrial diameter in patients with atrial fibrillation (AF).

Methods

A total of 200 patients with AF who were admitted to our hospital from December 2015 to April 2017 were included in this prospective analysis. Fifty patients were treated with conventional AF medication alone (AF medication group) and 50 patients received radiofrequency ablation (RFA) on the basis of conventional medication (RFA group).

Results

After treatment, the AF medication group showed significantly higher levels of high-sensitivity C-reactive protein, interleukin-6, carboxyterminal propeptide of type-I procollagen, procollagen type III N-terminal propeptide, and matrix metallopeptidase-9 than the RFA group. The AF medication group had a significantly lower activated partial thromboplastin time, thrombin time, and prothrombin time than the RFA group. A significantly smaller left atrial diameter was observed in both groups after treatment, but this decrease was more pronounced in the RFA group than in the AF medication group. The total treatment efficacy rate was significantly lower in the AF medication group than in the RFA group.

Conclusions

For patients with AF, RFA leads to a lower incidence of inflammatory responses, faster recovery of cardiac function, and good safety.

Assessment of Carotid Artery Distensibility and Elasticity After Laparoscopic Sleeve Gastrectomy: a Prospective Study

PURPOSE

Although it is well known that obesity increases the risk of atherosclerosis in carotid arteries, it is not clear whether this risk changes after obesity surgery. The aim of this study was to investigate whether weight reduction with a laparoscopic sleeve gastrectomy (LSG) has any effect on distensibility and elasticity which show subclinical atherosclerosis in the carotid arteries of obese individuals.

MATERIALS AND METHODS

This prospective study included 130 patients (body mass index (BMI) 48.21 ± 6.97 kg/m²) who underwent LSG. The patients were followed up for 1 year. Comparisons were made of the distensibiliy and elasticity values calculated preoperatively and at 1, 3, 6, and 12 months, postoperatively.

RESULTS

There was a statistically significant increase in distensibility and elasticity values from baseline to 1, 3, 6, and 12 months postoperatively (p < 0.001 for both comparisons). The multiple linear regression analysis was used to find the variables affecting both distensibility and elasticity. According to the results, the presence of BMI decreases distensibility percentage change level by 0.38 units (β= - 0.38, 95% CI - 0.51;- 0.25, p < 0.001). The presence of fasting plasma glucose decreases elasticity percentage change level by 0.20 units. (β= - 0.20, 95% CI - 0.39; - 0.01, p = 0.037).

CONCLUSION

Carotid artery distensibility and elasticity values increase after LSG, and this change could be caused by the change in metabolic parameters and heart geometry. These results may indirectly suggest that subclinical atherosclerosis in carotid arteries has decreased after obesity surgery.

Cardiometabolic-Based Chronic Disease, Addressing Knowledge and Clinical Practice Gaps: JACC State-of-the-Art Review

In the second part of this JACC State-of-the-Art Review, an early and sustainable preventive care plan is described for cardiometabolic-based chronic disease. This plan can improve cardiometabolic health by targeting early mechanistic events to decrease the risk for certain cardiovascular diseases (e.g., coronary heart disease, heart failure, and atrial fibrillation). Included are various prevention modalities, intensive lifestyle interventions, pharmacotherapy and cardiovascular outcome trial evidence, and bariatric/metabolic procedures. A tactical approach of implementing published clinical practice guidelines/algorithms for early behavioral, adiposity, and dysglycemia targeting is emphasized, as well as relevant educational and research implications.

Epicardial Adipose Tissue and Cardiovascular Disease

PURPOSE OF REVIEW

Epicardial adipose tissue has been associated with the development/progression of cardiovascular disease. We appraise the strength of the association between epicardial adipose tissue and development/progression of cardiovascular diseases like coronary artery disease, atrial fibrillation, and heart failure with preserved ejection fraction.

RECENT FINDINGS

Cross-sectional clinical and translational correlative studies have established an association between epicardial adipose tissue and progression of coronary artery disease. Recent studies question this association and underline the need for longitudinal studies. Epicardial adipose tissue also plays a definite role in the pathobiology of atrial fibrillation and its recurrence after ablation. In contrast to an early paradigm, epicardial adipose tissue does not appear to play a key role in the pathogenesis of heart failure with preserved ejection fraction in obese patients. The association of epicardial adipose tissue with atrial fibrillation is robust. In contrast, the association of epicardial adipose tissue with coronary artery disease and heart failure with preserved ejection fraction is tenuous. Additional research, including longitudinal studies, is needed to confirm or refute these proposed associations.