Temporal trends in atrial fibrillation ablation procedures at an academic medical center: 2011-2021

Risk of Acute Pain in Obese Patients Undergoing Atrial Fibrillation Ablation

Background

Previous studies have indicated that obesity can lead to an increased pain sensitivity. However, the risk of acute pain in obese patients undergoing atrial fibrillation (AF) ablation remains unclear.

Methods

This was a case-control study. Clinical data of patients with AF who underwent percutaneous ablation at Fuwai Hospital between January and May 2019 were retrospectively collected. Numeric pain rating scale (NPRS) and Body mass index (BMI) were used to assess severity of intra-procedural pain and pre-procedural obesity, respectively. An intra-procedural NPRS score of 4 or higher indicated the presence of acute pain, and a pre-procedural BMI of 28 or greater was considered indicative of obesity. Multivariable logistic regression analysis was performed to explore the risk of intra-procedural acute pain in obese patients.

Results

A total of 333 eligible patients were divided into two groups based on presence of intra-procedural acute pain (case group: n=102 [30.6%] and control group: n=231 [69.4%]). Compared with control group, patients with intra-procedural acute pain showed higher percentage of obesity (40 [17.4%] vs 28 [27.5%]) and conscious sedation (96 [41.6%] vs 89 [87.3%]), lower percentage of diabetes history (38 [16.5%] vs 10 [9.8%]), and longer duration of procedure (median, 90 vs 110 min). The occurrence rates of acute pain during AF ablation were 41.2% for obese patients and 27.9% for non-obese patients. Obesity was independently associated with an increased risk of intra-procedural acute pain (adjusted odds ratio [OR], 2.29; 95% CI, 1.18-4.43, P = 0.014). Sub-group analysis indicated a stronger risk of intra-procedural acute pain in obese patients under conscious sedation (adjusted OR, 2.48; 95% CI, 1.13-5.42, P = 0.023).

Conclusion

Under conscious sedation, obesity is an independent risk factor for intra-procedural acute pain in adult patients undergoing AF ablation.

Quantitative considerations for choosing between Amulet and Watchman FLX and management of device related complications

BACKGROUND

Left atrial appendage occlusion (LAA-O) with Amulet and Watchman FLX are approved for reducing stroke risk in patients with atrial fibrillation when oral anticoagulation is not tolerated. Real world clinical outcomes reported along with imaging data are needed to help clinicians choose between these two technologies and manage device-related complications.

METHODS

The study retrospectively analyzed clinical, transesophageal (TEE), and available computed tomography (CT) data from 364 FLX and 292 Amulet procedures performed at an academic medical center over a 4-year period.

RESULTS

LAA-O procedures were successful in 96.7% FLX and 97.3% Amulet cases. FLX implant success rate increased to 98.9% when only patients with LAA diameter to depth ratio < 1.8 and LAA area < 4.4 cm2 were included. TTE LAA-orifice area correlated with CT-derived measurements. There were more late pericardial effusions for Amulet (3.1%) compared to FLX (0.3%), though the majority were conservatively managed. Mean procedure times were similar (FLX 64 ± 24, Amulet 65 ± 21 min) as were the rates of device related thrombus (FLX 1% and Amulet 1.4%). Clinically relevant peridevice leak (PDL) on follow-up TEE imaging was greater for FLX (16%) compared to Amulet (10%). Combined AF ablation-LAA-occlusion procedures exhibited lower rates of PDL and late pericardial effusions compared to solo procedures.

CONCLUSIONS

Based on retrospective analysis, an initial strategy with Watchman FLX in patients with favorable LAA anatomy would reduce the risk of late pericardial effusions at the expense of a higher rate of clinically relevant PDL compared to Amulet. Combined AF ablation and LAA-O procedures exhibit less PDL.

Racial and Ethnic Differences in Initiation and Discontinuation of Antiarrhythmic Medications in Management of Atrial Fibrillation

Background

Atrial fibrillation (AF) is associated with considerable morbidity and mortality. Timely management and treatment are critical in alleviating AF disease burden. There is significant heterogeneity in patterns of AF care. It is unclear whether there are racial and ethnic differences in treatment of AF following antiarrhythmic drug (AAD) prescription.

Methods

Using the Optum Clinformatics Data Mart-Socioeconomic Status database from January, 2009, through March, 2022, multivariable logistic regression techniques were used to examine the impact of race and ethnicity on rate of AAD initiation, as well as receipt of catheter ablation within two years of initiation. We compared AAD discontinuation rate by race and ethnicity groups using Cox regression models. Log-rank analyses were used to examine the rate of AF-related hospitalization.

Results

Among 143,281 patients identified with newly diagnosed AF, 30,019 patients (21%) were initiated on an AAD within 90 days. Patients identified as Non-Hispanic Black (NHB) were significantly less likely to receive an AAD compared to Non-Hispanic White patients (NHW) (Odds Ratio [OR] 0.90, 95% confidence interval [CI] 0.85-0.94). Compared to NHW, Hispanic (Hazard Ratio [HR] 1.08, 95% CI 1.02-1.14) and Asian patients (HR 1.17, 95% CI 1.06-1.29) have a higher rate of AAD discontinuation. Following AAD initiation, NHB patients were significantly more likely to have an AF-related hospitalization (p < 0.01). However, NHB patients were significantly less likely to receive ablation compared to NHW (HR 0.83, 95% CI 0.70-0.97), and less likely to change AAD (p < 0.01).

Conclusion

Patients identified as NHB are 10% less likely to receive an AAD for treatment of newly diagnosed AF. Compared to NHW, Hispanic and Asian patients were more likely to discontinue AAD treatment. Once initiated on an AAD, NHB patients were significantly more likely to have an AF -related hospitalization, but were 17% less likely to receive ablation compared to NHW patients. The etiology of, and interventions to reduce, these disparities require further investigation.