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Oude Velthuis B, Molenaar M, Reinhart Dorman HG, Stevenhagen JY, Scholten MF, van der Palen J, van Opstal JM. Use of three-dimensional computed tomography overlay for real-time cryoballoon ablation in atrial fibrillation reduces radiation dose and contrast dye. Neth Heart J 2017; 25:388-393. [PMID: 28205119 PMCID: PMC5435618 DOI: 10.1007/s12471-017-0962-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
AIMS Cryoballoon pulmonary vein (PV) isolation in patients with atrial fibrillation has proven to be effective in short-term and long-term follow-up. To visualise the PV anatomy, pre-ablation contrast pulmonary venography is commonly performed. Three-dimensional (3D) computed tomography (CT) overlay is a new technique creating a live 3D image of the left atrium by integrating a previously obtained CT scan during fluoroscopy. To evaluate the benefits of 3D CT overlay during cryoballoon ablation, we studied the use of 3D CT overlay versus contrast pulmonary venography in a randomised fashion in patients with paroxysmal atrial fibrillation undergoing cryoballoon PV isolation. METHODS AND RESULTS Between October 2012 and June 2013, 30 patients accepted for PV isolation were randomised to cryoballoon PV isolation using either 3D CT overlay or contrast pulmonary venography. All patients underwent a pre-procedural cardiac CT for evaluation of the anatomy of the left atrium (LA) and the PVs. In the 3D CT overlay group, a 3D reconstruction of the LA and PVs was made. An overlay of the CT reconstruction was then projected over live fluoroscopy. Patients in the contrast pulmonary venography group received significantly more contrast agent (77.1 ± 21.2 cc vs 40.1 ± 17.6 cc, p < 0.001) and radiation (43.0 ± 21.9 Gy.cm2 vs 28.41 ± 11.7 Gy.cm2, p = 0.04) than subjects in the 3D CT overlay group. There was no difference in total procedure time, fluoroscopy time and the amount of cryoapplications between the two groups. CONCLUSION The use of 3D CT overlay decreases radiation and contrast dye exposure and can assist in guiding cryoballoon-based PV isolation.
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Affiliation(s)
- B Oude Velthuis
- Thorax Centre Twente, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - M Molenaar
- Thorax Centre Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - J Y Stevenhagen
- Thorax Centre Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - M F Scholten
- Thorax Centre Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J van der Palen
- Department of Research methodology, Methods and Data Analysis, University of Twente, Enschede, The Netherlands
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J M van Opstal
- Thorax Centre Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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Welton NJ, McAleenan A, Thom HHZ, Davies P, Hollingworth W, Higgins JPT, Okoli G, Sterne JAC, Feder G, Eaton D, Hingorani A, Fawsitt C, Lobban T, Bryden P, Richards A, Sofat R. Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis. Health Technol Assess 2017. [DOI: 10.3310/hta21290] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BackgroundAtrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.ObjectivesTo conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.DesignSystematic review, meta-analysis and cost-effectiveness analysis.SettingPrimary care.ParticipantsAdults.InterventionScreening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.Main outcome measuresSensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.Review methodsTwo reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.ResultsDiagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.ConclusionsA national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.LimitationsMany inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.Future workComparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.Study registrationThis study is registered as PROSPERO CRD42014013739.FundingThe National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Nicky J Welton
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alexandra McAleenan
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Howard HZ Thom
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Philippa Davies
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Will Hollingworth
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Julian PT Higgins
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - George Okoli
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan AC Sterne
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Gene Feder
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | | | - Aroon Hingorani
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Christopher Fawsitt
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Trudie Lobban
- Atrial Fibrillation Association, Shipston on Stour, UK
- Arrythmia Alliance, Shipston on Stour, UK
| | - Peter Bryden
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alison Richards
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Reecha Sofat
- Division of Medicine, Faculty of Medical Science, University College London, London, UK
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PérezRodon J, FranciscoPascual J, RivasGándara N, RocaLuque I, Bellera N, MoyaMitjans À. Cryptogenic Stroke And Role Of Loop Recorder. J Atr Fibrillation 2014; 7:1178. [PMID: 27957141 DOI: 10.4022/jafib.1178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/12/2014] [Accepted: 12/21/2014] [Indexed: 12/29/2022]
Abstract
Ischemic stroke is an important cause of morbidity and mortality when untreated. Identifying atrial fibrillation is important because atrial fibrillation ischemic related strokes are associated with an increased risk of disability and death compared with strokes of other etiologies and tend to recur without anticoagulation. However, atrial fibrillation detection can be difficult when it is asymptomatic and paroxistic and may be the underlying cause of some cryptogenic strokes or strokes of unknown origin. In this review, the different methods of cardiac monitoring to detect atrial fibrillation in patients with cryptogenic stroke are summarized, with a focus on loop recorder monitoring.
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Affiliation(s)
- Jordi PérezRodon
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Jaume FranciscoPascual
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Nuria RivasGándara
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Ivo RocaLuque
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Neus Bellera
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Àngel MoyaMitjans
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
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