Prediction of atrial fibrillation recurrence after cardioversion in patients with left-atrial dilation

Echocardiography predictors of sustained sinus rhythm after cardioversion of supraventricular arrhythmia in patients with septic shock

PURPOSE

The echocardiography parameters may predict the maintenance of sinus rhythm after cardioversion of a supraventricular arrhythmia (SVA).

MATERIALS AND METHODS

Patients in septic shock with onset of an SVA, normal to moderately reduced LV systolic function (EF_LV˃̳35%) and on a continuous noradrenaline of <1.0 μg/kg.min were included. Echocardiography was performed at the arrhythmia onset, 1 h and 4 h post cardioversion on an infusion of propafenone or amiodarone.

RESULTS

Cardioversion was achieved in 96% of the 209 patients within a median time of 6(1.8-15.6)h, 134(64.1%) patients experienced at least one SVA recurrence after cardioversion. At 4 h the left atrial emptying fraction (LA_EF, cut-off 38.4%, AUC 0.69,p˂0.001), and transmitral A wave velocity-time-integral (Avti, cut-off 6.8 cm, AUC 0.65,p = 0.001) showed as limited predictors of a single arrhythmia recurrence. The LA_EF 44(36,49)%, (p = 0.005) and the Avti 8.65(7.13,9.50)cm, (p < 0.001) were associated with sustained sinus rhythm and decreased proportionally to increasing numbers of arrhythmia recurrences (p < 0.001 and p = 0.007, respectively). The enlarged left atrial end-systolic diameter at the arrhythmia onset (p = 0.04) and elevated systolic pulmonary artery pressure at 4 h (p = 0.007) were weak predictors of multiple(˃3) recurrences.

CONCLUSION

The LA_EF and Avti are related to arrhythmia recurrences post-cardioversion suggesting potential guidance to the choice between rhythm and rate control strategies.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03029169, registered on 24th of January 2017.

Nomogram to predict recurrence risk factors in patients with non-valvular paroxysmal atrial fibrillation after catheter radiofrequency ablation

BACKGROUND

Radiofrequency catheter ablation (RFCA) is an effective method for controlling the heart rate of paroxysmal atrial fibrillation (PAF). However, recurrence is trouble under the RFCA. To gain a deeper understanding of the risk factors for recurrence in patients, we created a nomogram model to provide clinicians with treatment recommendations.

METHODS

A total of two hundred thirty-three patients with PAF treated with RFCA at Guizhou Medical University Hospital between January 2021 and December 2022 were consecutively included in this study, and after 1 year of follow-up coverage, 166 patients met the nadir inclusion criteria. Patients with AF were divided into an AF recurrence group and a non-recurrence group. The nomogram was constructed using univariate and multivariate logistic regression analyses. By calculating the area under the curve, we analyzed the predictive ability of the risk scores (AUC). In addition, the performance of the nomogram in terms of calibration, discrimination, and clinical utility was evaluated.

RESULTS

At the 12-month follow-up, 48 patients (28.92%) experienced a recurrence of AF after RFCA, while 118 patients (71.08%) maintained a sinus rhythm. In addition to age, sex, and TRV, LAD, and TTPG were independent predictors of recurrence of RFCA. The c-index of the nomogram predicted AF recurrence with an accuracy of .723, showing good decision curves and a calibrated nomogram, as determined by internal validation using a bootstrap sample size of 1000.

CONCLUSION

We created a nomogram based on multifactorial logistic regression analysis to estimate the probability of recurrence in patients with atrial fibrillation 1 year after catheter ablation. This plot can be utilized by clinicians to predict the likelihood of recurrence.

Echocardiographic Evaluation of Atrial Remodelling for the Prognosis of Maintaining Sinus Rhythm after Electrical Cardioversion in Patients with Atrial Fibrillation

Atrial fibrillation (AF) is the most common atrial tachyarrhythmia. One of the methods of AF treatment is direct current cardioversion (DCCV), but in the long-term follow-up we observe quite a high percentage of AF recurrences after this procedure. In order to assess the prognosis of DCCV effectiveness, we use clinical, biochemical and echocardiographic parameters. The objective of this review is to systematise the current knowledge on echocardiographic measurements in patients with persistent AF used to assess the progress of remodelling of the atrial wall, which affects the likelihood of maintaining sinus rhythm after DCCV. In this article, echocardiographic parameters for the evaluation of remodelling of the atrial wall are divided into groups referring to structural, mechanical, and electrical remodelling, as well as parameters for the evaluation of left ventricular filling pressure. The article aims to draw attention to the clinical value of echocardiographic measurements, which is the selection of patients who will maintain sinus rhythm after DCCV in the long-term follow-up, which will allow to avoid unnecessary risks associated with the procedure and enable the selection of the appropriate treatment strategy.

PI3K(p110α) as a determinant and gene therapy for atrial enlargement in atrial fibrillation

Atrial fibrillation (AF) is an irregular heart rhythm, characterised by chaotic atrial activation, which is promoted by remodelling. Once initiated, AF can also propagate the progression of itself in the so-called ''AF begets AF''. Several lines of investigation have shown that signalling molecules, including reactive oxygen species, angiotensin II, and phosphoinositide 3-kinases (PI3Ks), in presence or absence of cardiovascular disease risk factors, stabilise and promote AF maintenance. In particular, reduced cardiac-specific PI3K activity that is not associated with oncology is cardiotoxic and increases susceptibility to AF. Atrial-specific PI3K(p110α) transgene can cause pathological atrial enlargement. Highlighting the crucial importance of the p110α protein in a clinical problem that currently challenges the professional health care practice, in over forty (40) transgenic mouse models of AF (Table1), currently existing, of which some of the models are models of human genetic disorders, including PI3K(p110α) transgenic mouse model, over 70% of them reporting atrial size showed enlarged, greater atrial size. Individuals with minimal to severely dilated atria develop AF more likely. Left atrial diameter and volume stratification are an assessment for follow-up surveillance to detect AF. Gene therapy to reduce atrial size will be associated with a reduction in AF burden. In this overview, PI3K(p110α), a master regulator of organ size, was investigated in atrial enlargement and in physiological determinants that promote AF.

A prediction model based on functional mitral regurgitation for the recurrence of paroxysmal atrial fibrillation (PAF) after post-circular pulmonary vein radiofrequency ablation (CPVA)

AIM

To construct a prediction model based on functional mitral regurgitation (FMR) in patients with paroxysmal atrial fibrillation (PAF) to predict atrial fibrillation recurrence after the post-circular pulmonary vein radiofrequency ablation (CPVA).

METHODS

We retrospectively analyzed 289 patients with PAF who underwent CPVA for the first time. The patients were randomly divided into modeling group and verification group at the ratio of 75:25. In the modeling group, the multivariate logistic regression was used to analyze and construct a prediction model for post-CPVA recurrence in PAF patients, which was then validated in the verification group.

RESULTS

(1) After 3-6 months of follow-up, the patients were divided into sinus rhythm group (252 cases) and recurrence group (24 cases); (2) In the modeling group, the age, left atrial diameter (LAD), and the degree of MR (mild, moderate, severe) were higher in recurrence group than that of the sinus rhythm group, and the left atrial appendage emptying velocity (LAAV) was lower in recurrence group (all p < .05). (3) A model for predicting the recurrence of PAF after radiofrequency ablation was constructed in the modeling group. The equation was: Logit(P) = -3.253 + .092 × age + 1.263 × mild MR + 2.325 × moderate MR + 5.111 × severe MR -.113 × LAAV. The area under the curve (AUC) of the model was .889 in modeling group and .866 in verification group, and the difference was not statistically significant (p > .05).

CONCLUSION

The prediction model of atrial fibrillation (AF) recurrence after CPVA in PAF patients has good predictive efficacy, specificity, and accuracy.

A Prognostic Score To Predict Atrial fibrillation Recurrence After External Electrical Cardioversion-SLAC Score

INTRODUCTION

Atrial fibrillation (AF) recurrence after a successful external electrical cardioversion (ECV) is common. Assessing an individual's risk of AF recurrence is a critical part of the treatment plan. We aimed to develop a prognostic prediction score to predict AF recurrence in AF patients who underwent successful ECV.

METHODS

A retrospective cohort study that included AF patients who underwent successful ECV was conducted with a primary outcome of AF recurrence at 6 months. Logistic regression analysis was done to identify variables, and a prognostic prediction score was created and internally validated.

RESULTS

Four prognostic predictors were identified, including the type of AF, persistent AF (1 point) and long-standing persistent AF (4 points), previous cardioversion (1 point), stroke/transient ischemic attack (3 points), and left atrial volume index ≥40 mL/m 2 (6 points). The total score of 14 was further divided into 3 risk groups; low-risk (0-2 points), moderate-risk (3-7 points), and high-risk (8-14 points). The positive likelihood ratio for a moderate-risk patient was 2.08 (95% CI, 1.64-2.63) and for a high-risk patient was 7.90 (95% CI, 2.48-25.17). The score showed good discrimination power with the c-statistic of 0.74 (95% CI, 0.69-0.79).

CONCLUSIONS

A simple prognostic prediction score for AF recurrence after successful ECV was created with a promising internally validated discrimination power. An external assessment of its usefulness as a tool to identify patients with low, moderate, and high risk for AF recurrence is warranted.

The Predictive Value of the Left Atrial Kinetic Energy for Atrial Fibrillation Recurrence

Background and aim

Determining which patients will experience recurrence of atrial fibrillation (AF) is crucial for treatment modification. This study aimed to investigate the predictive value of left atrial kinetic energy (LAKE) in AF recurrence.

Materials and methods

A total of 120 consecutive patients who achieved sinus rhythm (SR) with electrical direct current cardioversion and met the inclusion criteria were included in the study. Transthoracic echocardiography (TTE) and LAKE values were calculated on the first day after cardioversion. Rhythm control was performed with 12-lead electrocardiography in the first-month follow-up.

Results

While 81 (67.5%) patients were in SR at one month, AF recurrence was detected in 39 (32.5%) patients. In the AF group, AF duration, cardioversion energy, number of diabetic patients, left atrium (LA) diameter, LA pre-mitral A wave volume, LA minimum volume, and pulmonary artery pressure values were significantly higher than in the SR group, while mitral A wave velocity and LAKE values were significantly lower. In multivariate regression analysis, AF duration (OR: 1.54; 95% CI: 1.22 - 1.93; p < 0.001), LA diameter (OR: 1.33; 95% CI: 1.10 - 1.61; p = 0.002), and LAKE (OR: 0.96; 95% CI: 0.94 - 0.99; p = 0.007) were determined to be independent predictors of AF recurrence at one month.

Conclusions

LA diameter, AF duration, and LAKE were found to be significant predictors of AF recurrence after cardioversion.

Risk Factors of Early Atrial Fibrillation Recurrence Following Electrical Cardioversion When Left Ventricular Ejection Fraction Is Preserved

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.

Inadvertent left ventricular pacing due to lead malpositioning, incidentally discovered seventeen years later

Inadvertent lead malpositioning into the left ventricle (LV) is an uncommon complication of pacemaker lead implantation. It can have implications on clinical outcome due to ventricular dyssynchrony, and result in further complications such as thrombus formation with subsequent embolisation. This case study reports the clinical, electrocardiographic, plain film and echocardiographic findings of an 82-year-old male in whom the intravenous lead of a dual chamber pacemaker was unintentionally passed into the LV via an atrial septal defect. Inadvertent placement was discovered incidentally following the onset of atrial fibrillation (AF) 17 years later.

An echocardiographic model for predicting the recurrence of paroxysmal atrial fibrillation after circumferential pulmonary vein ablation

BACKGROUND

Atrial fibrillation (AF) is a highly prevalent arrhythmia, with substantial associated morbidity and mortality. Circumferential pulmonary vein ablation (CPVA) is an effective rhythm control strategy, however, recurrence is an important factor influencing treatment decisions.

HYPOTHESIS

To develop a predictive model based on left atrial (LA) structure and function, and evaluate its efficiency in predicting the recurrence of AF after CPVA.

METHODS

Patients with paroxysmal AF who underwent CPVA were enrolled in this study and randomly divided into a development set and a validation set. The clinical and echocardiographic data of each patient were collected. In the development set, a least absolute shrinkage and selection operator (LASSO) regression was used to establish a LA ultrasound feature. By combining that LA ultrasound feature with independent clinical risk factors, we established an echocardiographic model using multivariate logistic regression and plotted the corresponding nomogram.

RESULTS

The LA ultrasound feature established by LASSO regression included nine echocardiographic indicators related to LA structure and function. It also exhibited good predictive ability in both the development set and the validation set (AUC:0.944, 95%CI: 0.910-0.978; AUC:0.878, 95%CI: 0.816-0.942). Logistic regression analysis indicated that LA ultrasound feature and AF duration were independent predictors for AF recurrence. The combined model including LA ultrasound feature and AF duration also showed good discriminability in both the development set (AUC: 0.950, 95% CI:0.914-0.985) and the validation set (AUC: 0.890, 95% CI: 0.831-0.949). The calibration curve showed good agreement between the predicted value and observed value.

CONCLUSIONS

Our model that is based on LA structure and function measured by echocardiography is a useful non-invasive preoperative tool, which exhibits good accuracy in predicting the recurrence of AF after CPVA.

Post-ablation left atrial function impacts long-term recurrence of atrial fibrillation after ablation

Left atrial (LA) function can help predict various cardiovascular events. Catheter ablation for atrial fibrillation (AF) modifies baseline LA function through the maintenance of sinus rhythm and myocardial injury. We investigated the impact of post-ablation LA function on recurrence of AF after ablation and identified the predictors of reduced post-ablation LA function. A total of 616 patients who underwent AF ablation (paroxysmal, N = 310; non-paroxysmal, N = 306) were retrospectively examined with cardiac computed tomography at baseline and 3 months after the final ablation procedure. Post-ablation LA emptying fraction (LAEF_post) was calculated. We evaluated the association between LAEF_post and recurrence of AF after the final ablation procedure. Further, we assessed the predictors of reduced LAEF_post. The recurrence rate of AF was 72.7% after the final ablation procedure [median follow-up 48 months (48.0, 48.0), total number of ablation sessions: 1.4 ± 0.7]. Multivariate analysis revealed that LAEF_post was associated with the recurrence of AF (hazard ratio/10% increase: 0.62, 95% confidence interval: 0.51-0.75, P < 0.0001). LAEF_post had a mild predictive power for recurrence of AF (c-statistics: 0.670, optimal cutoff: 26.36%, P < 0.0001). The recurrence-free proportion among patients with reduced LAEF_post (< 26.36%, N = 100) and those with preserved LAEF_post (≥ 26.36%, N = 516) was 40% and 79%, respectively (P < 0.0001). The predictors of reduced LAEF_post were low pre-ablation LAEF, high pre-ablation LA volume, low body mass index (BMI), and female sex. Further, reduced LAEF_post was associated with the total number of ablation sessions and extra-pulmonary vein LA ablation. In conclusion, reduced LAEF_post was associated with recurrence of AF after ablation. Advanced LA remodeling, low BMI, and female sex could predict reduced LAEF_post. Although additional ablation was associated with reduced LAEF_post, it remains unclear whether reduced LAEF_post resulted from the additional ablation. Reduced LAEF_post might help stratify patients with ablation-refractory AF.

Post Procedural Peak Left Atrial Contraction Strain Predicts Recurrence of Arrhythmia after Catheter Ablation of Atrial Fibrillation

Background

Left atrial (LA) function can be impaired by the atrial fibrillation (AF) ablation and might be associated with the risk of recurrence. We sought to determine whether the post-procedural changes in LA function impact the risk of recurrence following AF ablation.

Methods

We retrospectively reviewed patients who underwent AF ablation between 2009 and 2011 and underwent transthoracic echocardiography before ablation, 1-day and 3-month after ablation. Peak left atrial contraction strain (PACS) and left atrial emptying fraction (LAEF) were evaluated during sinus rhythm and compared across the three time points. The primary endpoint was atrial tachyarrhythmia recurrence after ablation.

Results

A total of 144 patients were enrolled (mean age 61 ± 11 years, 77% male, 46% persistent AF). PACS and LAEF initially decreased 1-day following ablation but partially recovered within 3 months in PAF patients, with a similar trend in the PerAF patients. After median 24 months follow-up, 68 (47%) patients had recurrence. Patients with recurrence had higher PACS_1-day than that in non-recurrence subjects (-10.9 ± 5.0% vs. -13.4 ± 4.7%, p = 0.003). PACS_1-day -12% distinguished recurrence cases with a sensitivity of 67.7% and specificity of 60.5%. The Kaplan–Meier curves showed significant difference in 5-year cumulative probability of recurrence between those with PACS ≥ -12% and PACS < -12% (log rank p < 0.0001). Multivariate regression showed that PACS_1-day was an independent risk factor of arrhythmia recurrence.

Conclusions

Left atrial function deteriorates immediately following AF ablation and partially recovers in 3 months but remains abnormal in the majority of patients. PACS_1-day post procedure predicts arrhythmia recurrence at long-term follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00250-5.

Pathophysiology and therapeutic relevance of PI3K(p110α) protein in atrial fibrillation: A non-interventional molecular therapy strategy

Genetically modified animal studies have revealed specific expression patterns and unequivocal roles of class I PI3K isoenzymes. PI3K(p110α), a catalytic subunit of class I PI3Ks is ubiquitously expressed and is well characterised in the cardiovascular system. Given that genetic inhibition of PI3K(p110α) causes lethal phenotype embryonically, the catalytic subunit is critically important in housekeeping and biological processes. A growing number of studies underpin crucial roles of PI3K(p110α) in cell survival, proliferation, hypertrophy and arrhythmogenesis. While the studies provide great insights, the precise mechanisms involved in PI3K(p110α) hypofunction and atrial fibrillation (AF) are not fully known. AF is a well recognised clinical problem with significant management limitations. In this translational review, we attempted a narration of PI3K(p110α) hypofunction in the molecular basis of AF pathophysiology. We sought to cautiously highlight the relevance of this molecule in the therapeutic approaches for AF management per se (i.e without conditions associate with cell proliferation, like cancer), and in mitigating effects of clinical risk factors in atrial substrate formation leading to AF progression. We also considered PI3K(p110α) in AF gene association, with the aim of identifying mechanistic links between the ever increasingly well-defined genetic loci (regions and genes) and AF. Such mechanisms will aid in identifying new drug targets for arrhythmogenic substrate and AF.

The Predictive Value of Tissue Doppler Indices for Early Recurrence of Atrial Fibrillation After Electrical Cardioversion

Purpose

Spectral tissue Doppler-derived E/e’ ratio has been proposed as the best parameter for prediction of atrial fibrillation (AF). Relaxation and contraction are equivalent parts of a continuous cardiac cycle, where systolic and diastolic abnormalities have a variable contribution to the left ventricle (LV) failure. The aim of this study was to investigate whether the E/(e’xs’) ratio is a better index than E/e‘ to predict AF recurrence and to determine the changes of spectral tissue Doppler indices 1 month after the electrical cardioversion (ECV).

Patients and Methods

The study included 77 persistent AF patients with restored sinus rhythm (SR) after ECV. Only patients with normal LV ejection fraction (EF) were included. Echocardiography and NT-proBNP laboratory findings were performed. A primary outcome was the early (within 1 month) recurrence of AF.

Results

After a 1 month follow-up period, 39 patients (50.6%) were in SR. E/e′ (HR=1.74, P=0.001) and E/(e’×s’) ratios (HR=8.17, P=0.01) were significant predictors of AF recurrence. E/(e’×s’) in combination with LV end-diastolic diameter >49.3 mm and NT-proBNP >2000 ng/L demonstrated a higher contribution in the model to predict AF recurrence compared to the E/e’ ratio (18.94, P=0.005 vs 1.95, P=0.001). On ROC analysis, E/(e’×s’) and E/e′ showed similar diagnostic accuracy (E/(e’×s’), AUC=0.71, P=0.002 and E/e′, AUC=0.75, P<0.0001). Average e‘ value significantly decreased after 1 month in SR (from 10.76±1.24 to 8.96±1.47 cm/s, P=0.01), E wave did not change significantly and E/e′ ratio tended to improve. A decrease of average e‘ and an increase of average s‘ values led to significant improvement of E/(e’xs’) ratio.

Conclusion

E/(e’xs’) and E/e’ ratios are comparable to predict early AF recurrence after ECV in patients with persistent AF. The e’ value decreased significantly after 1 month follow-up period after ECV for persistent AF patients.

Left atrial emptying fraction determined during atrial fibrillation predicts maintenance of sinus rhythm after direct current cardioversion in patients with persistent atrial fibrillation

Echocardiography is the basic imaging technique used to determine the odds of maintaining sinus rhythm (SR) following direct current cardioversion (DCCV) for persistent atrial fibrillation (AF). However, most studies are focused on the echocardiographic parameters obtained during SR resulting from successful DCCV. The aim of this study was to assess the value of the echocardiographic parameters measured before DCCV for the prognosis of SR maintenance after DCCV. The study included 146 patients with persistent AF who underwent DCCV. Clinical and echocardiographic data were collected directly before DCCV and, for patients with SR, one month, six months, and 12 months after DCCV. We found that left atrial emptying fraction (LAEF) assessed during atrial fibrillation was significantly larger in the group with SR maintenance after 12 months than in the group with AF recurrence (30.8±8.3 vs. 24.6±10.4%; p<0.001). In multivariable logistic regression analysis with a model containing echocardiographic parameters, LAEF (OR 1.053; 95% CI 1.011-1.096; p = 0.013) and the E/e'mean ratio (OR 0.883; 95% CI 0.788-0.990; p = 0.033) were independent predictors of SR maintenance. Analyzing a model including clinical and echocardiographic variables, only LAEF (OR 1.046; 95% CI 1-1.095; p = 0.049) and beta-blockers used before DCCV (OR 14.694; 95% CI 1.622-133.139; p = 0.017) were independent predictors of SR maintenance after 12 months. Our results indicate that LAEF measured during AF is a significant predictor of SR maintenance in the 12 months following DCCV due to persistent AF. Our findings confirm the recently raised hypothesis about the superiority of echocardiographic parameters assessing mechanical remodeling over parameters assessing structural remodeling of left atrium in predicting sinus rhythm maintenance after electrical cardioversion.

Usefulness of tissue Doppler-derived atrial electromechanical delay for identifying patients with paroxysmal atrial fibrillation

Background

Tissue Doppler imaging (TDI)-derived atrial electromechanical delay (AEMD) has been reported to be useful for detecting paroxysmal atrial fibrillation (PAF). However, its usefulness remains unknown when analyzed along with patients seemingly at high-risk for AF as controls. From this standpoint, we investigated whether AEMD would be of use for identifying patients with PAF.

Methods

We retrospectively analyzed TDI recordings to obtain AEMD in 63 PAF patients. Thirty-three patients with multiple cardiovascular risk factors (MRFs) but without history of AF and 50 healthy individuals served as disease and healthy controls, respectively. AEMD was defined as the time-interval between the electrocardiogram P-wave and the beginning of the spectral TDI-derived A’ for the septal (septal EMD) and lateral (lateral EMD) sides of the mitral annulus.

Results

There was no significant difference in the left atrial volume index between PAF patients and disease controls (28 ± 9 mL/m² vs. 27 ± 5 mL/m²). PAF patients had longer AEMD, particularly for the lateral EMD (75 ± 23 ms), compared with disease (62 ± 22 ms, P = 0.009) and healthy (54 ± 24 ms, P < 0.001) controls. Multivariate logistic regression analysis revealed that the lateral EMD (OR 1.25, 95%CI 1.03–1.52, P = 0.023), along with the left atrial volume index (OR 2.25, 95%CI 1.44–3.51, P < 0.001), was one of the significant independent associates of identifying PAF patients.

Conclusions

This cross-sectional study indicates that even analyzed together with MRFs patients, AEMD remains useful for identifying patients at risk for AF. Our results need to be confirmed by a large-scale prospective study.

Subclinical Left Ventricular Dysfunction in Severe Obesity and Reverse Cardiac Remodeling after Bariatric Surgery

Aim:

Obesity is associated with an increased cardiovascular risk. This study aimed to assess the role of echocardiography in the early detection of subclinical cardiac abnormalities in a cohort of obese patients with a preserved ejection fraction (EF) undergoing bariatric surgery.

Methods and Results:

Forty consecutive severely obese patients (body mass index≥35 kg/m2) referring to our center for bariatric surgery were enrolled in this prospective cohort study. Despite a baseline EF of 61% ± 3%, almost half patients (43%) had a systolic dysfunction (SD) defined as global longitudinal strain (GLS)>−18%, and most of them (60%) had left ventricular hypertrophy (LVH) or concentric remodeling (CR). At 10-months after surgery, body weight decreased from 120 ± 15 kg to 83 ± 12 kg, body mass index from 44 ± 5 kg/m² to 31 ± 5 kg/m² (both P < 0.001). Septal and left ventricular posterior wall thickness decreased respectively from 10 ± 1 mm to 9 ± 1 mm (P = 0.004) and from 10 ± 1 mm to 9 ± 1 mm (P = 0.007). All systolic parameters improved: EF from 61% ± 3% to 64% ± 3% (P = 0.002) and GLS from −17% ± 2% to −20% ± 1% (P < 0.001). Epicardial fat thickness reduction (from 4.7 ± 1 mm to 3.5 ± 0.7 mm, P < 0.001) correlated with the reduction of left atrial area (P < 0.001 R = 0.35) and volume (P = 0.02 R = 0.25). Following bariatric surgery, we observed a reduced prevalence of LVH/CR (before 60%, after 22%, P = 0.001) and a complete resolution of preclinical SD (before 43%, after 0%, P < 0.001). Moreover, a postoperative reduction of at least 30 kg correlated with regression of septal hypertrophy (P < 0.001).

Conclusions:

Obese patients candidate to bariatric surgery have an high prevalence of preclinical SD and LVH/CR, early detectable with echocardiography. Bariatric surgery is associated with reverse cardiac remodeling; it might also have a preventive effect on atrial fibrillation occurrence by reducing its substrate.

Left ventricular fibrosis by extracellular volume fraction and the risk of atrial fibrillation recurrence after catheter ablation

Background

Left ventricular (LV) extracellular volume fraction (ECV) provides prognostic information in patients with variety of cardiomyopathies. However, data on the clinical significance of LV ECV in patients with atrial fibrillation (AF), especially in patients without replacement fibrosis are sparse. This study sought to investigate whether the presence of LV fibrosis identified by cardiac magnetic resonance (CMR) ECV quantification would independently predict the recurrence of AF after first catheter ablation (CA) in patients with AF.

Methods

A total of 130 consecutive patients who were referred for CA of AF underwent CMR examination prior to ablation. LV function, T1 mapping derived LV ECV, LV late gadolinium enhancement (LGE) were assessed. Patients were followed for arrhythmia recurrence after the CA procedure.

Results

Of 130 AF patients, 65 patients had paroxysmal AF, and 65 patients had persistent AF. There were 50 AF recurrences over a median follow-up period of 13 months. LV ECV were significantly higher in patients with recurrent AF compared to those with no recurrence (30.4%±3.3% vs. 27.4%±2.9%, P<0.001). In multivariable model, gender (HR: 0.348, 95% CI: 0.174-0.697, P=0.003), body mass index (BMI) (HR: 1.159, 95% CI: 1.050-1.279, P=0.003), AF duration (HR: 1.006, 95% CI: 1.001-1.011, P=0.017), and LV ECV (HR: 1.158, 95% CI: 1.071-1.251, P=0.000) were significantly associated with AF recurrence. In subgroup of patients without LGE, gender, BMI, AF duration and LV ECV were still the independent predictors of AF recurrence.

Conclusions

LV ECV expansion is associated with AF recurrence after CA and is a strong independent predictor of AF recurrence.

The presence of fragmented QRS may predict the recurrence of nonvalvular atrial fibrillation after successful electrical cardioversion

OBJECTIVE

Atrial fibrillation (AF), the most common cardiac rhythm disorder, affects approximately 2% of the general population and is associated with increased risk of stroke and mortality as well as reduced exercise capacity and quality of life. After restoring normal sinus rhythm, a portion of these patients develops recurrent AF despite optimal medical treatment. In this study, we aimed to assess the relationship between the presence of fragmented QRS (fQRS) and AF recurrence following successful electrical cardioversion (ECV).

MATERIAL AND METHODS

A total of 306 patients with nonvalvular persistent AF achieving restoration of the sinus rhythm after successful ECV were included in this study. After ECV, patients were monitored at least 6 months for recurrence. The patients were divided into two groups according to the presence of fQRS and compared for AF recurrence during follow-up.

RESULTS

Patients were followed up for a mean time of 220 ± 113 days. AF recurred in 119 patients, corresponding to a recurrence rate of 38.8%. AF recurrence was found to be significantly increased in patients with fQRS as compared to those without fQRS (76.4% vs. 23.5%, p < .001). Furthermore, the presence of fQRS was higher in patients with recurrent AF as compared to others (57.1% vs. 11.2%, p < .001). In multiple regression analyses, the presence of fQRS was one of the independent predictors of AF recurrence (hazard ratio: 9.670, 95% CI: 4.714-19.837, p < .001).

CONCLUSION

The presence of fQRS may be associated with the recurrence of AF after successful ECV in persistent nonvalvular AF patients.

Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment

Obesity and diabetes can lead to heart failure with preserved ejection fraction (HFpEF), potentially because they both cause expansion and inflammation of epicardial adipose tissue and thus lead to microvascular dysfunction and fibrosis of the underlying left ventricle. The same process also causes an atrial myopathy, which is clinically evident as atrial fibrillation (AF); thus, AF may be the first manifestation of HFpEF. Many patients with apparently isolated AF have latent HFpEF or subsequently develop HFpEF. Most patients with obesity or diabetes who have AF and exercise intolerance have increased left atrial pressures at rest or during exercise, even in the absence of diagnosed HFpEF. Among patients with AF, those who also have latent HFpEF have increased risk for systemic thromboembolism and death. The identification of HFpEF in patients with obesity or diabetes alters the risk-to-benefit relationship of commonly prescribed treatments. Bariatric surgery and statins can ameliorate AF and reduce the risk for HFpEF. Conversely, antihyperglycaemic drugs that promote adipogenesis or cause sodium retention (insulin and thiazolidinediones) may increase the risk for heart failure in patients with an underlying ventricular myopathy. Patients with obesity and diabetes who undergo catheter ablation for AF are at increased risk for AF recurrence and for post-ablation increases in pulmonary venous pressures and worsening heart failure, especially if HFpEF coexists. Therefore, AF may be the earliest indicator of HFpEF in patients with obesity or type 2 diabetes, and recognition of HFpEF alters the management of these patients.

Heightened risk of intensive rate control in patients with atrial fibrillation who are obese or have type 2 diabetes: A critical review and re-evaluation

Atrial fibrillation (AF) is common in patients with obesity and diabetes; the arrhythmia (if long-standing) is typically managed by rate control and anticoagulation. However, the coexistence of these two metabolic disorders complicates therapeutic options for rate control. The likely pathogenesis of AF in these patients is an expansion of epicardial adipose tissue whose inflammation is transmitted to the left atrium causing electromechanical remodeling. However, this same process is also transmitted to the left ventricle (LV), impairing its distensibility and its ability to tolerate volume, leading to heart failure with preserved ejection fraction. Unfortunately, the latter diagnosis (although commonly present in patients with AF and a coexistent metabolic disorder) is often ignored. To achieve rate control, physicians prescribe intensive treatment with atrioventricular (AV) nodal-blocking drugs, often at doses that are titrated to blunt exercise as well as resting heart rate responses. However, strict rate control (target rate, <80/min) is associated with somewhat worse outcomes than lenient rate control (target rate, <110/min). Furthermore, any rate slowing that facilitates diastolic filling may aggravate filling pressures that are already disproportionately increased because the LV is stiff and overfilled as a result of cardiac inflammation. Rate slowing in AF with beta blockers may not achieve the benefit expected from the blockade of adrenergically mediated cardiotoxicity, and some AV nodal-blocking drugs (digoxin and dronedarone) can increase the risk of death in patients with AF. Finally, cardiac fibrosis in obesity and diabetes may affect the conduction system, which can predispose to serious bradyarrhythmias if patients are prescribed AV nodal-blocking drugs.

Efficacy and safety of 1C class antiarrhythmic agent (propafenone) for supraventricular arrhythmias in septic shock compared to amiodarone: protocol of a prospective randomised double-blind study

INTRODUCTION

Supraventricular arrhythmias contribute to haemodynamic compromise in septic shock. A retrospective study generated the hypothesis that propafenone could be more effective than amiodarone in achieving and maintaining sinus rhythm (SR). Certain echocardiographic parameters may predict a successful cardioversion and help in the decision on rhythm or rate control strategy.

METHODS AND ANALYSIS

The trial includes septic shock patients with new-onset arrhythmia, but without severe impairment of the left ventricular ejection fraction. After baseline echocardiography, the patient is randomised to receive a bolus and maintenance dose of either amiodarone or propafenone. The primary outcome is the proportion of patients that have achieved rhythm control at 24 hours after the start of the infusion. The secondary outcomes are the percentages of patients that needed rescue treatments (DC cardioversion or unblinding and crossover of the antiarrhythmics), the recurrence of arrhythmias, intensive care unit mortality, 28-day and 1-year mortality. In the posthoc analysis, we separately assess subgroups of patients with pulmonary hypertension and right ventricular dysfunction. In the exploratory part of the study, we assess whether the presence of a transmitral diastolic A wave and its higher velocity-time integral is predictive for the sustainability of mechanical SR and whether the indexed left atrial endsystolic volume is predictive of recurrent arrhythmia. Considering that the restoration of SR within 24 hours occurred in 74% of the amiodarone-treated patients and in 89% of the patients treated with propafenone, we plan to include 200 patients to have an 80% chance to demonstrate the superiority of propafenone at p=0.05.

ETHICS AND DISSEMINATION

The trial is recruiting patients according to its second protocol version approved by the University Hospital Ethical Board on the 6 October 2017 (No. 1691/16S-IV). The results will be disseminated through peer reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03029169.

Diagnosis and Management of Left Atrium Appendage Thrombosis in Atrial Fibrillation Patients Undergoing Cardioversion

Atrial fibrillation is the most common cardiac arrhythmia and is associated with an increased risk of stroke and thromboembolic complications. A rhythm control strategy with both electrical and pharmacological cardioversion is recommended for patients with symptomatic atrial fibrillation. Anticoagulant therapy for 3–4 weeks prior to cardioversion is recommended in order to avoid thromboembolic events deriving from restoring sinus rhythm. Transesophageal echocardiography has a pivotal role in this setting, excluding the presence of left atrial appendage thrombus before cardioversion. The aim of this review is to discuss the epidemiology and risk factors for left atrial appendage thrombosis, the role of echocardiography in the decision making before cardioversion, and the efficacy of different anticoagulant regimens on the detection and treatment of left atrial appendage thrombosis.

Echocardiographic assessment of left atrial morphology and function to predict maintenance of sinus rhythm after electrical cardioversion in patients with non-valvular persistent atrial fibrillation and normal function or mild dysfunction of left ventricle

BACKGROUND

The aim of this study was to assess whether echocardiographic measurements of left atrial (LA) morphology and function could predict sinus rhythm maintenance after electrical cardioversion among patients with atrial fibrillation (AF) and normal function or mild dysfunction of the left ventricle (LV).

METHODS

One hundred seventeen patients with persistent AF who underwent successful electrical cardioversion were prospectively enrolled. Echocardiography was performed one day subsequent to successful cardioversion. Patients were followed up clinically and electrocardiographically at 1, 6, and 12 months. At 12 months, 61 (52%) patients had maintained sinus rhythm (SR).

RESULTS

Compared to patients who maintained SR, those with AF recurrence had larger LAs, worse LA systolic function, and increased LV filling pressure. On multivariate stepwise logistic regression, E/A ratios (odds ratio [OR] 0.550, 95% confidence interval [CI] 0.341-0.886; p = 0.014) and E/e' ratios (OR 0.871, 95% CI 0.771-0.985; p = 0.027) were significant predictors of AF recurrence. On receiver operator characteristic curve analysis of AF recurrence at 12 months, the area under curve for both E/A and E/e' ratios were 0.726. With an E/A cutoff of 2.2, the sensitivity for predicting AF recur-rence at 12 months was 72%, and specificity was 73%. With an E/e' cutoff of 9.17, the sensitivity for predicting AF recurrence at 12 months was 72%, and specificity was 74%.

CONCLUSIONS

Left ventricular filling pressure assessed with E/A and E/e' ratios predict AF recurrence after electrical cardioversions among patients with AF and normal function of LV.

Recurrent event survival analysis predicts future risk of hospitalization in patients with paroxysmal and persistent atrial fibrillation

Background

In patients with paroxysmal atrial fibrillation (PAF) or persistent atrial fibrillation (PeAF) symptom burden and fear of hospital readmission are major causes of reduced quality of life. We attempted to develop a prediction model for future atrial fibrillation hospitalization (AFH) risk in PAF and PeAF patients including all previously experienced AFHs in the analysis, as opposed to time to first event.

Methods

Recurrent event survival analysis was used to model the impact of past AFHs on the risk of future AFHs. A recurrent event was defined as a hospitalization due to a new episode of AF. Death or progression to permanent AF were included as competing risks.

Results

We enrolled 174 patients with PAF or PeAF, mean follow up duration was 1279 days, and 325 AFHs were observed. Median patient age was 63.0 (IQR 52.2–68.0), 29% had PAF, and 71% were male. Highly significant predictors of future AFH risk were PeAF (HR 3.20, CI 2.01–5.11) and number of past AFHs observed (HR for 1 event: 2.97, CI 2.04–4.32, HR for ≥2 events: 7.54, CI 5.47–10.40).

Conclusion

In PAF and PeAF patients, AF type and observed AFH frequency are highly significant predictors of future AFH risk. The developed model enables risk prediction in individual patients based on AFH history and baseline characteristics, utilizing all events experienced by the patient. This is the first time recurrent event survival analysis has been used in AF patients.

CHA2DS2-VASc score predicts atrial fibrillation recurrence after cardioversion: Systematic review and individual patient pooled meta-analysis

BACKGROUND

Despite progresses in the treatment of the thromboembolic risk related to atrial fibrillation (AF), the management of recurrences remains a challenge.

HYPOTHESIS

To assess if congestive heart failure or left ventricular systolic dysfunction (CHA2 DS2 -VASc) score is predictive of early arrhythmia recurrence after AF cardioversion.

METHODS

Systematic review and individual patient pooled meta-analysis following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

INCLUSION CRITERIA

observational trials in patients with AF undergoing cardioversion, available data on recurrence of AF and available data on CHA2 DS2 -VASc score. Clinical studies of interest were retrieved by PubMed, Cochrane Library, and Biomed Central. Seven authors were contacted for joining the patient level meta-analysis, and three shared data regarding anthropometric measurements, risk factors, major comorbidities, and CHA2 DS2 -VASc score. The primary outcome was the recurrence of AF after cardioversion in patients free from antiarrhythmic prophylaxis. Univariate and multivariate logistic regression was performed.

RESULTS

Overall, we collect data of 2889 patients: 61% were male, 50% with hypertension, 12% with diabetes, and 23% with history of ischemic heart disease. The median CHA2DS2-VASc score was 2.. At the multivariate analysis, chronic kidney disease (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.12-3.27; P = 0.01), peripheral artery disease (OR 1.65; 95% CI 1.23-2.19; P < 0,0001), previous use of beta blockers (OR 1.5; 95% CI 1.19-1.88; P < 0.0001), and CHA2DS2-VASc score > 2 (OR 1.37; 95% CI 1.1-1.68; P = 0.002) were independent predictors of early recurrence of AF.

CONCLUSIONS

CHA2DS2-VASc score predicts early recurrence of AF in the first 30 days after electrical or pharmacological cardioversion. Protocol registration PROSPERO (CRD42017075107).

Clinical Relevance of the Spectral Tissue Doppler E/e' Ratio in the Management of Patients with Atrial Fibrillation: a Comprehensive Review of the Literature

Atrial fibrillation is the most common cardiac rhythm disorder observed in clinical practice. It carries high morbidity and mortality rates, primarily related to heart failure, stroke and death. Validation of noninvasive markers in the diagnosis of heart failure with preserved ejection fraction and risk stratification is relevant in this clinical setting. The spectral tissue Dopplerderived E/e' ratio is a simple and reproducible index, which has been validated in noninvasive assessment of left ventricular diastolic pressures, regardless of rhythm. Septal E/e' >11 is a good predictor of invasively determined left ventricular diastolic pressure >15 mmHg in patients with atrial fibrillation. Several studies have validated the clinical relevance of abnormal values for E/e' at rest and during exercise in the diagnosis and risk stratification of heart failure with preserved ejection fraction in patients with atrial fibrillation. Increased E/e' value is associated with adverse outcome (death, left atrial appendage thrombus, stroke and heart failure) in patients with atrial fibrillation and predicts arrhythmia recurrence after cardioversion and catheter ablation. In conclusion, E/e' by spectral tissue Doppler is clinically relevant in the clinical management of any patients with atrial fibrillation referred for transthoracic Doppler echocardiography.

Use of acoustic cardiography immediately following electrical cardioversion to predict relapse of atrial fibrillation

Predicting atrial fibrillation (AF) recurrence after successful electrical cardioversion (ECV) is difficult. The main aim of this study was to investigate whether acoustic cardiography (AUDICOR® 200) immediately post-ECV might provide indices for AF relapse following cardioversion. Acoustic cardiography parameters included Electromechanical Activation Time (EMAT), Left Ventricular Systolic Time (LVST), QRS duration, heart rate and third heart sound intensity (S3 Strength). We analysed data from 140 patients who underwent successful cardioversion and in whom AUDICOR results and echocardiographic measurements immediately after (baseline) ECV were available. Patients were prospectively followed-up at 4-6 weeks, 3 and 12 months post-ECV, and sinus rhythm maintenance was evaluated using acoustic cardiography and Holter electrocardiography. The effect of each baseline AUDICOR parameter on the hazard of AF relapse was investigated using Cox proportional hazards (PH) models. Fifty patients (35.7%) had AF relapse. Of all the AUDICOR parameters, only S3 Strength exhibited consistent predictive value. Increasing S3 Strength increased the hazard of relapse in a univariable Cox PH model (HR=2.52, p=0.003), and in two multivariable Cox PH model constructions (Model 1 excluded heart rate and Model II excluded EMAT/RR, LVST and LVST/RR) both of which included the parameters as continuous variables (Model I: HR=1.15, p=0.042; Model II: HR=1.14, p=0.045) or the parameters dichotomized according to suggested cut-points (Model I: HR=2.5, p=0.007; Model II: HR=2.09, p=0.031). In conclusion, this study suggests that acoustic cardiography may be a simple inexpensive and quantitative bedside method to assist in prediction of AF recurrence after ECV.

[Usefulness of spectral tissue Doppler (E/e' ratio) in the management of patients with atrial fibrillation]

Atrial fibrillation is the most common cardiac rhythm disorder encountered in daily clinical practice. It carries high morbidity and mortality rates, mainly related to sudden death, heart failure and stroke. Validation of noninvasive markers in the diagnosis of heart failure with preserved ejection fraction and risk stratification is therefore attractive in this clinical setting. The spectral tissue Doppler-derived E/e' ratio is a simple and user-friendly index which has been validated in the assessment of left ventricular diastolic pressures, regardless of rhythm. A septal E/e' >11 is associated with invasive left ventricular diastolic pressures >15mmHg in patients with atrial fibrillation. Several studies have reported the clinical relevance of abnormal values of E/e' at rest and during exercise in the diagnosis and risk stratification of heart failure with preserved ejection fraction in patients with atrial fibrillation. There is now convincing evidence that increased E/e' is associated with adverse outcome in patients with atrial fibrillation and predicts the recurrence of arrhythmia after cardioversion or catheter ablation. In conclusion, we recommend the measurement of E/e' in each patient with atrial fibrillation referred for clinically indicated transthoracic Doppler echocardiography.

The years 2015-2016 in the European Heart Journal-Cardiovascular Imaging. Part I

The multimodality cardiovascular imaging journal, European Heart Journal-Cardiovascular Imaging, was launched in 2012. It has gained an impressive impact factor of 5.99 during its 5 first years and is now established as the most important cardiovascular imaging journal in Europe. The most important studies from the journal's forth and fifth years will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.

Left Atrial Sphericity Index Predicts Early Recurrence of Atrial Fibrillation After Direct-Current Cardioversion: An Echocardiographic Study

BACKGROUND

Attempts to achieve rhythm control using direct-current cardioversion (DCC) are common in those with persistent atrial fibrillation (AF). Although often successful, AF recurs within 1 month in as many as 57% of patients. The aim of this study was to assess whether a baseline left atrial sphericity index (LASI) acquired by 2-dimensional transthoracic echocardiography (TTE) could be used as a predictor of AF recurrence after successful DCC.

HYPOTHESIS

A baselline LASI assessed by 2D TTE can predict AF recurrence after successful DCC in patients with persistent AF.

METHODS

A total of 124 consecutive patients with persistent AF lasting <120 days underwent successful DCC. Other than β-blockers, no other antiarrhythmic treatment was administered. Prior to DCC, all patients underwent thorough TTE, and LASI was calculated as the fraction of the left atrial width/length of the largest possible left atrial volume in a 4-chamber view. The primary outcome was a TTE-estimated baseline LASI as a predictor of AF recurrence after successful DCC for persistent AF.

RESULTS

Anatomically, a more spherical shape of the left atrium (LASI >0.9) proved to be a strong and independent predictor of AF recurrence, with an odds ratio between 4.1 (95% confidence interval: 1.6-11.9, P = 0.005) and 7.6 (95% confidence interval: 3.3-19.7; P = 7.2 × 10(-6) ). The receiver operating characteristic curve indicated good power for distinguishing between recurring and nonrecurring AF, and we chose a cutoff of 0.9 because high specificity was a priority for clinical reasons.

CONCLUSIONS

In conclusion, baseline LASI >0.9 was associated with significantly greater AF recurrence throughout the 12-month follow-up period.

Effect of early direct current cardioversion on the recurrence of atrial fibrillation in patients with persistent atrial fibrillation

In patients with persistent atrial fibrillation (AF), the sinus rhythm (SR) can be restored by direct current cardioversion (DCC), although the recurrence of AF after successful DCC is common. We examined whether transesophageal echocardiography (TEE)-guided early DCC, compared with the conventional approach of DCC after 3 weeks of anticoagulation with dabigatran-etexilat, reduces the recurrence of AF. A total of 126 consecutive patients with persistent AF were randomly assigned to a TEE followed by early DCC (n = 65) or to a conventional treatment with dabigatran-etexilat for 3 weeks followed by DCC (n = 61). None of the patients received any antiarrhythmic treatment other than β blockers, and all the DCCs were successful. Forty-eight-hour Holter monitoring was performed at 28 days and at 3, 6, and 12 months after the DCC. The primary outcome was AF recurrence lasting ≥30 seconds. The analysis was stratified by AF duration <60 (n = 62) or >60 days (n = 64) before DCC. We observed a significant reduction in the AF recurrence risk (p = 0.003) in patients with persistent AF <60 days who received early DCC, but there was no significant benefit of early DCC (p = 0.456) in patients with persistent AF lasting >60 days. The recurrence-free survival probability at 28 days in patients with persistent AF <60 days was 0.27 (95% confidence interval 0.14 to 0.51) in the conventional treatment group compared with 0.69 (95% confidence interval 0.54 to 0.87; p = 0.006) in the early DCC group. A benefit of early DCC persisted throughout 12 months of follow-up. In conclusion, TEE-guided early DCC in patients with persistent AF <60 days results in a significant reduction of AF recurrence.