2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

The association between the cystatin C- and creatinine-based estimated GFR ratio and post-ablation outcomes in patients with atrial fibrillation

BACKGROUND

The difference between the cystatin C-based eGFR (eGFRcys) and the creatinine-based eGFR (eGFRcr) is associated with the risk of developing atrial fibrillation (AF) risk. However, its impact on AF ablation outcomes is unknown.

METHODS

The associations between the baseline eGFR ratio (eGFRcys/eGFRcr) and the risk of experiencing post-ablation endpoints were evaluated on a continuous scale (restricted cubic splines) and by a priori defined centile categories with Cox proportional hazards regression models. The primary endpoints were AF recurrence and adverse events; the secondary endpoint was rehospitalization.

RESULTS

Among 989 participants (49.2% women; mean age 65.7 years), 313 experienced AF recurrence after a median follow-up of 28 months. After full adjustment for confounding factors, a U-shaped association was observed between eGFR ratio and AF recurrence risk (minimum risk at 0.797). Although a U-shaped trend was observed, there was no statistically significant association between the eGFR ratio and adverse events or rehospitalization. Hazard ratios for AF recurrence, compared to the second quartile, were 1.68 (1.20-2.37) for the first quartile, 1.64 (1.15-2.34) for the third quartile, and 1.96 (1.37-2.80) for the fourth quartile. According to the subgroup analysis, the above association was strongly U-shaped for males and linear for females.

CONCLUSION

In the AF population, both low and high eGFR ratios were associated with an increased risk of post-ablation AF recurrence.

Comorbidity patterns and mortality in atrial fibrillation: a latent class analysis of the EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF)

BACKGROUND

Most older patients with atrial fibrillation (AF) have comorbidities. However, it is unclear whether specific comorbidity patterns are associated with adverse outcomes. We identified comorbidity patterns and their association with mortality in multimorbid older AF patients with different multidimensional frailty.

METHODS

Hospitalised adults aged ≥65 years with non-valvular AF were followed for 12 months in the multicentre EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF). Demographic characteristics, coexisting medical conditions, use of medications including anticoagulants, and the Multidimensional Prognostic Index (MPI) were captured on discharge. We used latent class analysis (LCA) to identify comorbidity phenotypes and Cox regression to determine associations between identified phenotypes and 12-month mortality.

RESULTS

Amongst n = 2,019 AF patients (mean ± SD age 82.9 ± 7.5 years), a 3-class LCA solution was considered optimal for phenotyping. The model identified phenotype 1 (hypertensive, other circulatory conditions, metabolic diseases; 33%), phenotype 2 (digestive diseases, infection, injury, non-specific clinical and laboratory abnormalities; 26%), and phenotype 3 (heart failure, respiratory diseases; 41%). Overall, 512 patients (25%) died within 12 months. Compared to phenotype 1, after adjusting for age, sex, use of anticoagulants, cardiovascular medications, and proton pump inhibitors, and individual MPI domains, phenotype 3 had a significantly higher risk of mortality (adjusted hazard ratio = 1.27, 95% CI = 1.01 to 1.60). In contrast, the risk of mortality in phenotype 2 was not different to phenotype 1.

CONCLUSION

We observed an association between comorbidity phenotypes identified using LCA and mortality in older AF patients. Further research is warranted to identify the mechanisms underpinning such associations.

Comparing pulsed field ablation and thermal energy catheter ablation for paroxysmal atrial fibrillation: a cost-effectiveness analysis of the ADVENT trial

BACKGROUND

Pulsed field ablation (PFA) has emerged as an effective technology in the treatment of paroxysmal atrial fibrillation (AF).

OBJECTIVE

To evaluate the cost-effectiveness of PFA vs. thermal ablation from a US healthcare payer perspective using data from a randomized trial.

METHODS

A hybrid decision tree and Markov model was developed comparing patients receiving PFA to thermal ablation (either radiofrequency or cryoballoon ablation) from a US healthcare payer perspective at 5-, 10-, 20-, and 40-year time horizons. Direct medical costs (in 2024 US Dollars), quality-adjusted life years (QALYs), and the net monetary benefit were evaluated at a willingness-to-pay (WTP) threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses were performed to test model uncertainty. The budget impact for a standard US healthcare payer with 1 million beneficiaries was also assessed.

RESULTS

Over a 40-year time horizon, PFA resulted in an additional 0.044 QALYs at a lower cost of $2,871 compared to thermal ablation. PFA was cost-effective in 54.9% of simulations. Anticoagulation and ablation procedure costs had the largest impact on model uncertainty. The expected cost savings per member per month for a US healthcare payer adopting PFA were $0.00015, $0.0059, and $0.02343 in years 1, 4, and 6, respectively.

CONCLUSIONS

PFA was at least as cost-effective as conventional thermal ablation modalities for treatment of paroxysmal AF and potentially reduces US healthcare payer costs. Providers and payers should consider designating PFA among the preferred first-line therapies for eligible patients.

External validation of CLOTS-AF score in patients with atrial fibrillation undergoing transesophageal echocardiography

BACKGROUND

Predicting thromboembolic events caused by left atrial appendage thrombosis (LAAT) is crucial since it is the most concerning complication of nonvalvular atrial fibrillation (NVAF).

OBJECTIVE

The objective of this study was to establish the predictive effectiveness of a novel scoring system known as the CLOTS-AF score in identifying the existence of thrombus using transesophageal echocardiography (TEE) in patients with NVAF and to compare it with the CHA2DS2-VASc score.

METHODS

This study was conducted retrospectively with 668 NVAF patients who underwent TEE in a single centre. The patients were categorized into two categories based on the presence or absence of LAAT on TEE. The CLOTS-AF score was computed for all patients, which was then compared to the CHA2DS2-VASc score.

RESULTS

Thrombus was detected in the left atrial appendage (LAA) of 114 (17%) individuals. The study revealed that the thrombus (+) group had substantially higher CHA2DS2-VASc scores and CLOTS-AF scores (3 (2-4); 4 (3-6), p < .001), respectively. Furthermore, the CLOTS-AF score was shown to be a better predictor of LAAT than the CHA2DS2-VASc score (AUC: 0.70 vs. AUC: 0.61, p < .001).

CONCLUSIONS

This study could validate the CLOTS-AF score in an external cohort by demonstrating its significant predictive power and underscoring its vital role in clinical practice.

Efficacy and Safety of Direct Oral Anticoagulants Compared to Vitamin K Antagonists for Atrial Fibrillation in Patients With Liver Cirrhosis: An Update Systematic Review and Meta-analysis

Background

This meta-analysis aimed to compare the efficacy and safety of direct oral anticoagulants (DOACs) with vitamin K antagonists (VKAs) in patients with concomitant atrial fibrillation (AF) and liver cirrhosis (LC).

Methods

PubMed, Cochrane Library, Embase, Scopus, Web of Science, and China National Knowledge Infrastructure (CNKI) databases were searched for randomized clinical trials (RCTs) and non-RCTs comparing DOACs and VKAs in patients with AF and LC. Analyses were performed in R software. A random-effects model was employed to calculate the pooled hazard ratio (HR).

Results

Eleven studies encompassing 19,617 patients were included, with 9379 receiving DOACs and 10,238 receiving VKAs. DOACs were associated with a significant reduction in the incidence of major bleeding (HR 0.70; 95% CI: 0.61-0.81; P < 0.001; I2 = 0%), all-cause mortality (HR 0.87; 95% CI: 0.78-0.98; P = 0.022; I2 = 41%), and gastrointestinal bleeding (HR 0.75; 95% CI: 0.67-0.84; P < 0.001; I2 = 4%). No significant difference was observed for thromboembolic events (HR 0.86; 95% CI: 0.69-1.06; P = 0.153; I2 = 0%).

Conclusion

DOACs may be a feasible option for patients with AF and LC, demonstrating similar effectiveness to VKAs while exhibiting a better safety profile. These findings await validation by prospective studies.

Plasma expression level of Hsa_circ_0099734 is associated with atrial fibrillation and its poor prognosis

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia characterized by severe complications such as stroke, resulting in high disability and mortality rates. A circular RNA (circRNA) hsa_circ_0099734 was found significantly expressed in the atrial tissue of AF patients and controls in our previous work. In this study, we aim to reveal the association between hsa_circ_0099734 and AF as well as its poor prognosis, offering novel perspectives for clinical treatment.

METHODS

A 1:1 matched case-control study was designed to examine the association between hsa_circ_0099734 and AF. A prospective cohort study was conducted to investigate the association between hsa_circ_0099734 and AF prognosis using Cox proportional hazards regression analysis.

RESULTS

An elevated plasma level of hsa_circ_0099734 was an independent risk factor for AF in a multivariable conditional logistic regression model (OR 3.23, 95 % CI: 1.11-9.44; P = 0.032). Regarding the prognostic role of hsa_circ_0099734, the multivariable Cox regression analysis indicated that a high level of hsa_circ_0099734 in plasma was an independent risk factor for stroke in patients with AF (HR 2.87, 95 % CI: 1.90-4.35; P < 0.001), and also an independent risk factor for all-cause mortality in AF patients (HR 3.16, 95 % CI: 2.25-4.45; P < 0.001). Adding hsa_circ_0099734 to the CHA2DS2-VA score provided better reclassification and net clinical benefit than the ABC risk score.

CONCLUSIONS

The plasma level of hsa_circ_0099734 was associated with AF risk and the occurrence of stroke or all-cause mortality in AF patients. Hsa_circ_0099734 has the potential to be a non-invasive biomarker for predicting AF and its poor prognosis.

Long-term effects of catheter ablation with vein of Marshall ethanol infusion vs. pulmonary vein isolation alone on persistent atrial fibrillation

OBJECTIVE

To evaluate the safety, efficacy, and long-term effects of catheter ablation with vein of Marshall ethanol infusion for bidirectional mitral isthmus block in patients with persistent atrial fibrillation.

METHODS

Two hundred and forty patients from five centers with persistent atrial fibrillation (AF) who underwent radiofrequency ablation from October 2018 to December 2023 were retrospectively analyzed, including 120 patients who underwent traditional pulmonary vein isolation (PVI Only group) and 120 patients who underwent PVI and Marshall vein ablation (Marshall Plus group). The operation time, X-ray exposure, incidence of AF/atrial tachycardia (AT) and complications were compared between the two groups.

RESULTS

Among the 240 patients (mean age: 57.2 ± 7.2 years, males: 195/240, 81.25 %), vein of Marshall ethanol infusion was successfully performed in 113 of 120 patients. At 12 and 36 months, the proportion of patients free from AF/ AT after a single procedure was 76.3 % (90/118) in the PVI plus vein of Marshall ethanol infusion group and 67.5 % (79/117) in the PVI only group (P < 0.01). Perimitral block was successfully achieved in 90.8 % (109/120) patients in the Marshall Plus group. Freedom from AF/AT at the 3-year follow-up (68.6 % vs. 59.8 %, P < 0.01) and incidence of adverse events were similar between the two groups.

CONCLUSION

PVI combined with Marshall venous infusion ablation can safely and effectively increase the long-term success rate of AF ablation. Duration of AF, left atrial volume(>42 mm,)and bidirectional mitral isthmus block were associated with recurrence of AF/AT.

Meta-Analysis of Racial and Ethnic Disparities in Rhythm Control Strategies for Atrial Fibrillation in the United States

Rhythm control strategies are a key component of atrial fibrillation (AF) therapy, with recent reports suggesting racial and ethnic disparities in their utilization. We aimed to determine differences in the utilization of catheter ablation (CA), direct current cardioversion (DCCV), and anti-arrhythmic drugs (AAD) among different racial and ethnic groups. We searched PubMed/MEDLINE, EMBASE, and Cochrane Library (from inception to January 31st, 2024) for studies including adults with AF and reporting CA, DCCV, or AAD utilization rates in at least 2 racial and ethnic groups. Our primary outcome was the likelihood of Black, Hispanic, and Asian individuals undergoing each rhythm control strategy compared to White patients. Pooled estimates were calculated with a random-effects model and were reported as odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs). Nineteen studies were included comprising 12,598,109 patients. The pooled ORs (95% CI) of undergoing CA for Black individuals was 0.68 (95% CI 0.56 to 0.83), for Hispanic individuals was 0.72 (95% CI 0.63 to 0.82), and for Asian individuals was 0.64 (95% CI 0.48 to 0.86), compared to White individuals. The likelihood of undergoing DCCV (OR [95% CI]) was lower in Black (0.69 [95% CI 0.57 to 0.82]), Hispanic (0.67 [95% CI 0.57 to 0.80]), Asian (0.68 [95% CI 0.64 to 0.72]) patients compared to White patients. Our results identified that racial and ethnic minoritized groups with AF are significantly less likely to undergo treatment with a rhythm control strategy. In conclusion, these findings highlight a significant gap in healthcare delivery that stakeholders, healthcare systems, and clinicians should address.

Surgical ablation in patients with atrial fibrillation and left ventricular dysfunction: A systematic review and meta-analysis

Background

Atrial fibrillation (AF) and left ventricular dysfunction (LVD) are common conditions that often coexist, with about 25% of patients in NYHA classes I-II having AF. Efficacy and safety of surgical ablation (SA) in this population remains unclear.

Methods

We aimed to perform a single-arm meta-analysis to assess the outcomes of standalone and concomitant SA in adult patients with AF and LVD. We searched PubMed, Scopus and the Cochrane Library. Endpoints of interest were maintenance of sinus rhythm, freedom from anti-arrhythmic drug (AAD) use, change in LVEF, 30-day mortality, 1 year mortality and major procedural complications. We calculated pooled proportions or means for binary and continuous endpoints, respectively, with a 95 % confidence interval (CI).

Results

Ten observational studies comprising 863 patients (mean follow-up of 19 months) were included. At 1 year, SA resulted in a sinus rhythm rate of 83.9 % (95 % CI: 69.5-92.3); freedom from AAD use of 81.6 % (95 % CI: 64.7-91.7); and mortality of 5.77 (95 % CI:3.7-8.9). 30-day mortality was 2.16 % (95 % CI: 0.9-4.9); major complications 16.73 % (95 % CI: 12-23); and an improvement in LVEF of 12 % (95 % CI: 9-17).

Conclusion

This meta-analysis found that SA appears to be an effective strategy to achieve sinus rhythm in patients with AF and LVD, with a pooled 30-day mortality of 2.2%. Comparative studies are warranted to evaluate the relative safety and efficacy of SA compared with other rhythm control strategies in this population.

The impact of training image quality with a novel protocol on artificial intelligence-based LGE-MRI image segmentation for potential atrial fibrillation management

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting up to 2 % of the population. Catheter ablation is a promising treatment for AF, particularly for paroxysmal AF patients, but it often has high recurrence rates. Developing in silico models of patients' atria during the ablation procedure using cardiac MRI data may help reduce these rates.

OBJECTIVE

This study aims to develop an effective automated deep learning-based segmentation pipeline by compiling a specialized dataset and employing standardized labeling protocols to improve segmentation accuracy and efficiency. In doing so, we aim to achieve the highest possible accuracy and generalization ability while minimizing the burden on clinicians involved in manual data segmentation.

METHODS

We collected LGE-MRI data from VMRC and the cDEMRIS database. Two specialists manually labeled the data using standardized protocols to reduce subjective errors. Neural network (nnU-Net and smpU-Net++) performance was evaluated using statistical tests, including sensitivity and specificity analysis. A new database of LGE-MRI images, based on manual segmentation, was created (VMRC).

RESULTS

Our approach with consistent labeling protocols achieved a Dice coefficient of 92.4 % ± 0.8 % for the cavity and 64.5 % ± 1.9 % for LA walls. Using the pre-trained RIFE model, we attained a Dice score of approximately 89.1 % ± 1.6 % for atrial LGE-MRI imputation, outperforming classical methods. Sensitivity and specificity values demonstrated substantial enhancement in the performance of neural networks trained with the new protocol.

CONCLUSION

Standardized labeling and RIFE applications significantly improved machine learning tool efficiency for constructing 3D LA models. This novel approach supports integrating state-of-the-art machine learning methods into broader in silico pipelines for predicting ablation outcomes in AF patients.

Impact of a clinical atrial fibrillation risk estimation tool on cardiac rhythm monitor utilization following acute ischemic stroke: A prepost clinical trial

BACKGROUND

Detection of undiagnosed atrial fibrillation (AF) after ischemic stroke through extended cardiac monitoring is important for preventing recurrent stroke. We evaluated whether a tool that displays clinically predicted AF risk to clinicians caring for stroke patients was associated with the use of extended cardiac monitoring.

METHODS

We prospectively included hospitalized ischemic stroke patients without known AF in a preintervention (October 2018 - June 2019) and intervention period (March 11, 2021 - March 10, 2022). The intervention consisted of an electronic health record (EHR)-based best-practice advisory (BPA) alert which calculated and displayed 5-year risk of AF. We used a multivariable Fine and Gray model to test for an interaction between predicted AF risk and period (preintervention vs intervention) with regards to incidence of extended cardiac monitoring. We compared the incidence of extended cardiac monitoring within 6-months of discharge between periods, stratified by BPA completion.

RESULTS

We included 805 patients: 493 in the preintervention cohort and 312 in the intervention cohort. In the intervention cohort, the BPA was completed for 180 (58%) patients. The association between predicted clinical risk of AF and incidence of 6-month extended cardiac monitoring was not different by time period (interaction HR = 1.00 [95% Confidence Interval (CI) 0.98; 1.02]). The intervention period was associated with an increased cumulative incidence of cardiac monitoring (adjusted HR = 1.32 [95% CI 1.03-1.69]).

CONCLUSIONS

An embedded EHR tool displaying predicted AF risk in a poststroke setting had limited clinician engagement and predicted risk was not associated with the use of extended cardiac monitoring.

CLINICAL TRIAL REGISTRATION

NCT04637087.

Disease mechanism and novel drug therapies for atrial fibrillation

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, affects over 3 % of adults globally, increasing risks for stroke, heart failure, and cognitive decline. Early rhythm control shows promise in improving AF prognosis, and catheter ablation remains an effective, safe option, especially for paroxysmal AF. However, high recurrence rates with antiarrhythmic drugs and ablation persist, particularly in cases of persistent AF. Emerging research on molecular mechanisms has led to innovative therapeutic strategies targeting these pathways, offering hope for more effective AF management. This review explores recent insights into the complex pathophysiology of AF, with a particular focus on ion channel dysfunction, calcium mishandling, oxidative stress, and fibrosis. It further considers how these factors will inspire new therapeutic options.

Steps to improve the outcome of a single ablation procedure for paroxysmal atrial fibrillation: Significance of a burst stimulation-guided ablation strategy

BACKGROUND

The outcome of a single ablation procedure for paroxysmal atrial fibrillation (PAF) is suboptimal. The value of burst stimulation and additional ablation following the isolation of pulmonary vein (PV) and superior vena cava (SVC) remains unclear.

OBJECTIVE

The aim of this study was to optimize the ablation strategy and improve the outcome of a single procedure for PAF.

METHODS

This retrospective study involved 404 PAF patients who underwent radiofrequency ablation, and were divided into Group 1 (PV + SVC isolation, n = 81) and Group 2 (PV + SVC isolation + burst stimulation-guided ablation, n = 323). In Group 2, additional linear ablation was performed if atrial fibrillation (AF) or atrial flutter (AFL) persisted or was induced by burst stimulation after PV and SVC isolation.

RESULTS

In Group 1, 20 (24.69 %) patients experienced recurrences of AF (n = 16) and AFL (n = 4) during an average follow-up period of 733.60 days. In Group 2, 76 (23.53 %) patients experienced persistent arrhythmias (n = 25) or arrhythmias induced by burst stimulation (n = 51) after PV and SVC isolation, including AF (n = 27) and AFL (n = 49). Ablation along the left atrial roofline, mitral isthmus, and tricuspid isthmus was performed in 37, 34, and 49 patients, respectively. During the average follow-up duration of 660.80 days, the recurrence rate (29/323, 8.98 %) of AF/AFL was significantly lower in Group 2 than that in Group 1 (p < 0.001).

CONCLUSION

Additional stepwise linear ablation guided by burst stimulation significantly improved the outcome of a single ablation procedure for PAF.

Quercetin down-regulates MCP-1 expression in autoimmune myocarditis via ERK1/2-C/EBPβ pathway: An integrative approach using network pharmacology and experimental models

Myocarditis is one of the common causes of sudden death in adolescents, and autoimmune response and inflammation play an essential role in the development of myocarditis. Quercetin is a natural flavonoid compound with anti-inflammatory and cardioprotective effects. However, the mechanism of quercetin in autoimmune myocarditis remains unclear. This study observed that quercetin significantly improved cardiac function, inflammation and fibrosis in mice with experimental autoimmune myocarditis (EAM). In addition, Network pharmacology predicts the key target C/EBPβ and signalling pathway MAPK for quercetin treatment of autoimmune myocarditis. CESTA and DARTS experiments verified that quercetin and C/EBPβ have strong binding ability. It is shown that quercetin down-regulates MCP-1 expression in H9C2 cells by dephosphorylation of ERK1/2 and C/EBPβ. Specifically, quercetin reduced the binding of C/EBPβ to the MCP-1 promoter, resulting in decreased expression of MCP-1, which was associated with decreased ERK1/2 dependent phosphorylation at the C/EBPβ threonine 188 site. This inhibitory effect of quercetin could be further enhanced by the ERK1/2 inhibitor PD98059. The biological relevance of this regulatory network is demonstrated in EAM mice. In conclusion, these results illustrate the protective effect of quercetin against autoimmune myocarditis. A novel regulatory mechanism was revealed, namely the down-regulation of MCP-1 through the ERK1/2-C/EBPβ axis. This provides a new therapeutic strategy for autoimmune myocarditis.

Risk-directed management of chronic kidney disease

The timely and rational institution of therapy is a key step towards reducing the global burden of chronic kidney disease (CKD). CKD is a heterogeneous entity with varied aetiologies and diverse trajectories, which include risk of kidney failure but also cardiovascular events and death. Developments in the past decade include substantial progress in CKD risk prediction, driven in part by the accumulation of electronic health records data. In addition, large randomized clinical trials have demonstrated the effectiveness of sodium-glucose co-transporter 2 inhibitors, glucagon-like peptide 1 receptor agonists and mineralocorticoid receptor antagonists in reducing adverse events in CKD, greatly expanding the options for effective therapy. Alongside angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, these classes of medication have been proposed to be the four pillars of CKD pharmacotherapy. However, all of these drug classes are underutilized, even in individuals at high risk. Leveraging prognostic estimates to guide therapy could help clinicians to prescribe CKD-related therapies to those who are most likely to benefit from their use. Risk-based CKD management thus aligns patient risk and care, allowing the prioritization of absolute benefit in determining therapeutic selection and timing. Here, we discuss CKD prognosis tools, evidence-based management and prognosis-guided therapies.

Robotic mitral valve replacement: a short-term single institution experience

Purpose

This study evaluates the safety, efficacy, reproducibility and short-term clinical outcomes of robotic mitral valve replacement (MVR).

Methods

Between September 2022 and May 2024, 64 robotic cardiac and thoracic surgeries were performed in our institute. Twelve consecutive patients who underwent MVR using da Vinci Xi robotic system were retrospectively analysed. It was performed by right side approach using four instrument ports and one 4-cm working port, under peripheral cardiopulmonary bypass (CPB) with transoesophageal echocardiography (TEE) surveillance.

Results

The mean age of patients was 39 ± 9 years (median = 42 years), male-to-female ratio of 1:2, left ventricular ejection fraction (LVEF) = 60 ± 5%. The mean CPB and aortic cross clamp (ACX) time was 273 ± 119 min (174-568 min) and 160 ± 91 min (85-395 min) respectively. All patients received mechanical valve. The ventilation time and length of intensive care unit (ICU) stay was 21 ± 8 h and 3 ± 2 days respectively. The median drain output was 258 ml (Interquartile Range (IQR) = 240-353ml). Two patients (16.67%) were re-explored the same day in view of excessive drain output. Two patients required postoperative opioid analgesics (16.67%). One (8.33%) patient had groin wound infection. There was no mortality. Patients were ambulated from postoperative day 3.91 ± 1.80 days. Duration of hospital stay post-surgery was 9 ± 3 days, and patients were discharged after therapeutic International Normalised Ratio (INR) of 3 was achieved. Postoperative pain score of study group was 3 ± 1 (mild). Patients were satisfied with aesthetically pleasing scar and returned to routine activity within 4 ± 1 weeks. The mean follow-up time was 10.17 ± 5.11 months.

Conclusion

Robotic MVR surgery is safe and has excellent short-term outcomes. Patients experienced less pain and faster recovery.

Trends and disparities in atrial fibrillation-related mortality among adults with co-morbid diabetes mellitus in the United States

From 1999 to 2020, age-adjusted mortality rates (AAMR) for atrial fibrillation-related deaths among U.S. adults (age ≥25) with comorbid diabetes mellitus increased significantly with an annual percent change of 6.5%. The highest mortality rates were observed in males, older adults, non-Hispanic Whites, and residents of urban areas and the West region, underscoring the urgent need for targeted public health strategies.

Left atrial appendage occlusion in atrial fibrillation: shaping the future of stroke prevention

Atrial fibrillation (AF) is the most common cardiac arrhythmia, significantly increasing the risk of thromboembolic events, particularly ischemic stroke. The left atrial appendage (LAA) is the predominant site of thrombus formation in patients with AF, making it a crucial target for stroke prevention strategies. Left atrial appendage occlusion (LAAO) has emerged as an important therapeutic alternative to oral anticoagulation, particularly in patients with contraindications to long-term anticoagulant therapy. This review examines the role of LAAO in AF management, discussing current indications, patient selection, procedural techniques, and clinical outcomes. We also explore the latest evidence from major clinical trials and real-world studies, highlighting the efficacy and safety of LAAO compared to standard anticoagulation. Additionally, we consider the unresolved questions and the potential future directions for this intervention, including emerging technologies and the integration of LAAO into broader AF management protocols. Our review underscores the growing importance of LAAO in reducing thromboembolic risk in AF patients, particularly those unable to tolerate traditional anticoagulation, and offers insights into the ongoing evolution of this treatment modality in clinical practice.

Risk for Stroke After Newly Diagnosed Atrial Fibrillation During Hospitalization for Other Primary Diagnoses : A Retrospective Cohort Study

BACKGROUND

Atrial fibrillation (AF) that is first diagnosed during hospitalization for other causes can subside with resolution of the inciting stressor.

OBJECTIVE

To describe the risk for stroke after newly diagnosed AF during hospitalization for other causes.

DESIGN

Population-based retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Patients aged 66 years or older discharged alive from the hospital between April 2013 and March 2023 with a first diagnosis of AF.

INTERVENTION

Newly diagnosed AF during hospitalization for other causes, categorized into cardiac medical, noncardiac medical, cardiac surgical, and noncardiac surgical.

MEASUREMENTS

The primary outcome was hospitalization for stroke. The cumulative incidence function was used to estimate crude incidence, censoring on anticoagulant dispensation. Inverse probability of censoring weights were used to account for informative censoring.

RESULTS

Atrial fibrillation was diagnosed in 20 639 patients (mean age, 77.1 years; 58.1% male) while hospitalized for other causes: 8340 (40.4%) for noncardiac medical, 7097 (34.4%) for cardiac surgical, 3553 (17.2%) for noncardiac surgical, and 1649 (8.0%) for cardiac medical diagnoses. At 1 year, anticoagulants were being dispensed to 26.4% of patients with CHA2DS2-VA scores of 1 to 4 and 35.2% of those with CHA2DS2-VA scores of 5 to 8. The 1-year risk for stroke without anticoagulation was 1.3% (95% CI, 0.7% to 2.3%) for cardiac medical, 1.2% (CI, 0.9% to 1.5%) for noncardiac medical, 1.1% (CI, 0.8% to 1.7%) for noncardiac surgical, and 1.0% (CI, 0.7% to 1.3%) for cardiac surgical patients. Patients with CHA2DS2-VA scores of 1 to 4 had a 1-year stroke risk of 0.7% (CI, 0.6% to 1.0%) without anticoagulation, compared with 1.8% (CI, 1.4% to 2.2%) at CHA2DS2-VA scores of 5 to 8.

LIMITATION

Long-standing AF may have been misclassified as newly diagnosed, leading to overestimation of stroke risk.

CONCLUSION

Among patients with newly diagnosed AF during hospitalization for other causes, a substantial proportion with low CHA2DS2-VA scores receive anticoagulation, with modest increases in this proportion at higher scores. The stroke risk in patients with CHA2DS2-VA scores greater than 4 approximated the 2% threshold commonly used to initiate anticoagulation in AF.

PRIMARY FUNDING SOURCE

Canadian Cardiovascular Society.

Optimal duration of anticoagulation after left atrial appendage closure: a systematic review and meta-analysis

BACKGROUND

Left atrial appendage closure (LAAC) has become the treatment of choice for stroke prevention in patients with nonvalvular atrial fibrillation who are at high risk of bleeding or with contraindications for anticoagulation. However, the optimal duration of anticoagulation after LAAC remains uncertain. The aim of this study was to evaluate the optimal duration of treatment with novel oral anticoagulants (NOACs) after LAAC.

METHOD

We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for studies related to LAAC published from inception to 20 December 2023, and performed a meta-analysis comparing the efficacy and safety of 45-day and 3-month postoperative NOAC treatment using R4.3.1 software.

RESULTS

A total of 14 studies were included in this study, of which 4 were prospective cohort studies and 10 were retrospective cohort studies. The incidence of stroke or transient ischaemic attack (0.018 [95% CI: 0.007-0.033] in the 3-month group and 0.005 [95% CI: 0.001-0.011] in the 45-day group; P = 0.07) and the incidence of device-related thrombus (0.025 [95% CI: 0.002-0.065] in the 3-month group and 0.020 [ 95% CI: 0.007-0.037] in the 45-day group; P = 0.81) were not significantly different. However, the incidence of major bleeding was significantly greater in the 3-month group than in the 45-day group (0.033 [95% CI: 0.018-0.053] in the 3-month group and 0.003 [95% CI: 0.000-0.008] in the 45-day group; P < 0.01).

CONCLUSIONS

Compared with the 3-month scheme, 45 days of postoperative anticoagulation significantly reduced the risk of major bleeding in patients without compromising the efficacy of preventing stroke or transient ischaemic attack and device-related thrombus.

TRIAL REGISTRATION

Our meta-analysis was registered in the PROSPERO international database (CRD42024524661).

Feasibility of deep sedation for catheter ablation of atrial fibrillation using pulsed field ablation

INTRODUCTION

Pulsed field ablation (PFA) is a non-thermal energy source for catheter ablation associated with shorter procedure time, less risk of esophageal injury, and less dependence on absolute catheter stability compared with radiofrequency ablation. Limited data are available on performing the procedure with deep sedation (DS) as an alternative to general anesthesia (GA) utilizing endotracheal intubation.

METHODS

Patients who underwent PFA using DS between March and August 2024 were retrospectively included. DS was administered by anesthesia staff, consisting of propofol, dexmedetomidine, fentanyl, and midazolam, at the discretion of the practitioner. The primary endpoint was the rate of airway complications or requirement for conversion to GA. Secondary endpoints were the rate of acute procedural success, total time in the EP lab, procedure time, and non-procedure time.

RESULTS

A total of 100 patients (mean age 71.9 ± 11.6 years, BMI 30.1 ± 7.1, 51% females) were included in the analysis. There were no instances of airway complications or conversion from DS to GA. There was a 100% rate of acute isolation of pulmonary veins. The average total time in the lab was 149.7 ± 44.7 min, consisting of a mean procedure time of 98.3 ± 40.5 min and a non-procedure time of 51.4 ± 12.2 min.

CONCLUSIONS

In this study conducted at a single health system, DS for PFA was feasible and associated with no instances of airway complications nor conversion to GA. The findings may not apply to patients with moderate or severe obstructive sleep apnea or other pulmonary diseases.

Dilemmas in Secondary Stroke Prevention

Secondary stroke prevention encompasses many approaches, including antithrombotic therapy, risk factor management, and a healthy lifestyle. Recommendations are typically based on the results of randomized clinical trials that provide evidence of benefit. However, in some situations, clinicians extrapolate the results of clinical trials into everyday practice, or trials have not provided sufficient information to make treatment decisions. This review will discuss 4 scenarios: dual-antiplatelet therapy, the perils of combining antiplatelet and anticoagulation, indications for statin therapy, and therapeutic considerations for patients with paroxysmal atrial fibrillation.

Left Atrial Appendage Occlusion and Its Role in Stroke Prevention

Atrial fibrillation is a frequent cardiac arrhythmia and is associated with an increased risk of cardioembolic stroke. The left atrial appendage is a finger-like extension originating from the main body of the left atrium and the main location of thrombus formation in patients with atrial fibrillation. Surgical or percutaneous left atrial appendage occlusion (LAAO) aims at preventing clot formation in the left atrial appendage. Here, we describe available surgical and percutaneous approaches to achieve LAAO and discuss the available evidence for LAAO in patients with atrial fibrillation. We discuss the role of LAAO and its role in stroke prevention in frequent scenarios in cerebrovascular medicine: LAAO as a potential alternative to oral anticoagulation in patients with a history of intracranial hemorrhage, and LAAO as a promising add-on therapy to direct oral anticoagulant therapy in patients with breakthrough stroke despite anticoagulation. Finally, we provide an outlook on currently ongoing trials that will provide further evidence in the next years.

A Platform Designed to Empower Quality Improvement for Patients with Atrial Fibrillation

There are significant gaps in care for patients with atrial fibrillation (AF) and is a need to focus on improving guideline-concordant care. Recognizing challenges encountered in pursuing sustainable quality improvement (QI) in AF care, the Heart Rhythm Society spearheaded a multifaceted collaboration grounded in the principles of Improvement Science to develop a robust platform aimed specifically at demystifying QI for clinicians and health care systems interested in closing care gaps for patients with AF. Solution development included an innovative discovery process, a design phase, piloting, and refinement, and finished with transformation into a comprehensive digital platform. End-users were engaged throughout the 4-phase process to help ensure the final platform would meet the needs of clinicians and health care systems. The result was the launch of www.CardiQ.org featuring the Atrial Fibrillation QI Framework and an extensive, curated Resource Library that has been accessed by more than 10 000 users spanning over 100 countries.

Patterns of Postablation Recurrence and Adverse Cardiovascular Outcomes in Patients With Atrial Fibrillation

BACKGROUND

Atrial arrhythmia recurrence after atrial fibrillation (AF) catheter ablation is conventionally assessed as a binary end point. However, the prognostic value of recurrence patterns is less studied.

METHODS AND RESULTS

This study included patients undergoing catheter ablation from the multicenter China Atrial Fibrillation Registry study (2011-2022). Postablation AF patterns within 1 year were categorized as nonrecurrence, paroxysmal AF recurrence, or persistent AF (PersAF) recurrence. Cardiovascular outcomes included cardiovascular death, thromboembolism, and cardiovascular hospitalization. Cox proportional models with landmark analysis were used to assess the relationship between recurrence patterns and outcomes. Sensitivity analyses were conducted using Fine-Gray models, considering death unrelated to the outcomes as the competing risk and evaluating 2-year recurrence patterns. Among 13 811 patients (mean age, 60.5±10.8 years; 66.1% men), those with preablation PersAF, prior stroke/transient ischemic attack/systemic embolism, and increased left atrial diameter were more likely to develop PersAF postablation. Compared with nonrecurrence, PersAF recurrence was associated with higher risks of cardiovascular death (hazard ratio [HR], 2.03 [95% CI, 1.20-3.43]; P=0.009), thromboembolism (HR, 1.50 [95% CI, 1.09-2.06]; P=0.012), and cardiovascular hospitalization (HR, 1.74 [95% CI, 1.56-1.94]; P<0.001) during a median follow-up of 3.02 years (interquartile range, 1.44-5.03 years), while paroxysmal AF recurrence was only significantly associated with an increased risk of cardiovascular hospitalization (HR, 1.98 [95% CI, 1.83-2.14], P<0.001). Sensitivity analyses yielded consistent results.

CONCLUSIONS

Postablation PersAF recurrence was associated with significantly higher risks of cardiovascular death and thromboembolism, compared with paroxysmal AF recurrence and nonrecurrence, indicating the prognostic importance of recurrence patterns.

REGISTRATION

URL: www.chictr.org.cn/; unique identifier: ChiCTR-OCH-13003729.

Risk-Based Primary Prevention of Heart Failure: A Scientific Statement From the American Heart Association

The growing morbidity, mortality, and health care costs related to heart failure (HF) underscore the urgent need to prioritize its primary prevention. Whereas a risk-based approach for HF prevention remains in its infancy, several key opportunities exist to actualize this paradigm in clinical practice. First, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guidelines provided recommendations, for the first time, on the clinical utility of multivariable risk equations to estimate risk of incident HF. Second, the American Heart Association recently developed the PREVENT (Predicting Risk of Cardiovascular Disease Events) equations, which not only enable prediction of incident HF separately, but also include HF in the prediction of total cardiovascular disease. Third, the predominant phenotype of HF risk has emerged as the cardiovascular-kidney-metabolic syndrome. Fourth, the emergence of novel therapies that prevent incident HF (eg, sodium-glucose cotransporter-2 inhibitors) and target multiple cardiovascular-kidney-metabolic axes demonstrate growing potential for risk-based interventions. Whereas the concept of risk-based prevention has been established for decades, it has only been operationalized for atherosclerotic cardiovascular disease prevention to date. Translating these opportunities into a conceptual framework of risk-based primary prevention of HF requires implementation of PREVENT-HF (Predicting Risk of Cardiovascular Disease Events-Heart Failure) equations, targeted use of cardiac biomarkers (eg, natriuretic peptides) and echocardiography for risk reclassification and earlier detection of pre-HF, and definition of therapy-specific risk thresholds that incorporate net benefit and cost-effectiveness. This scientific statement reviews the current evidence for accurate risk prediction, defines strategies for equitable prevention, and proposes potential strategies for the successful implementation of risk-based primary prevention of HF.

Anticoagulation in device-detected atrial fibrillation: Challenges in stroke prevention and heart failure management

Atrial fibrillation (AF), the most common cardiac arrhythmia globally, contributes significantly to morbidity and mortality. With advancements in implantable devices like pacemakers, defibrillators, and loop recorders, incidental detection of AF as device-detected AF (DDAF) or subclinical AF (SCAF) has become common. This asymptomatic AF presents unique management challenges, particularly in anticoagulation decisions for stroke prevention. Evidence from recent trials, notably NOAH-AFNET 6 and ARTESiA, indicates a complex risk-benefit profile for anticoagulation in DDAF. In ARTESiA, anticoagulation modestly reduced stroke and systemic embolism rates, though this effect did not reach statistical significance. The NOAH-AFNET 6 trial found no significant reduction in a composite of cardiovascular death, stroke, or systemic embolism with anticoagulation compared to placebo. Both trials revealed an increased bleeding risk, underscoring the need to carefully weigh stroke prevention against bleeding risks in DDAF. The 2024 European Society of Cardiology guidelines reflect this nuanced approach by advocating a tailored, risk-based strategy. Emerging evidence also shows that AF burden impacts heart failure (HF) outcomes, with a five-fold increase in HF hospitalizations associated with higher AF burden. This highlights the importance of rhythm or rate control to reduce HF progression, particularly in patients with both AF and HF, where reducing AF burden is associated with better prognosis and fewer hospitalizations. Future research should focus on refining anticoagulation strategies, especially for patients with low AF burden, and exploring novel approaches like intermittent anticoagulation and advanced monitoring to support personalized DDAF management.

Continuous use of direct oral anticoagulants during and after simple and surgical tooth extractions: a prospective clinical cohort study

BACKGROUND

No consistent approach to the management of direct oral anticoagulants (DOACs) during and after oral surgery has been established. Thus, DOACs may be unnecessarily discontinued, raising the potential risk of life-threatening thromboembolism. To address the inconsistency in this approach, our study assessed the risk of bleeding and other complications in patients who continue to use DOACs during and after simple and surgical tooth extractions.

METHODS

Between May 2016 and December 2023, this prospective study recruited patients aged 18 years or older who were receiving a DOAC or warfarin and were in need of simple or surgical extractions of one or more teeth. Local haemostatic agents were being used to control bleeding. Patients were instructed to manage minor postoperative bleeding at home by biting down on gauze soaked in tranexamic acid for at least 30 min. After surgery, all patients were followed for 7 days. The chi-squared test compared dichotomous variables; the two-sample t-test, continuous variables; logistic regressions, dichotomous outcomes; and linear regressions, continuous outcomes.

RESULTS

In all, 354 teeth were extracted from 160 patients receiving DOACs and 56 patients receiving warfarin. The incidence of any type of postoperative bleeding was 27% in patients receiving DOACs and 37% in those receiving warfarin (OR 0.66, 95% CI: 0.28-1.57; p = 0.35). Most patients were able to manage any bleeding at home themselves. Clinically relevant bleeding necessitating prompt evaluation or a secondary surgical intervention by a dentist or healthcare professional occurred in 3% of patients receiving DOACs and 11% of patients receiving warfarin (OR 0.30, 95% CI: 0.08-1.06; p = 0.06). No reports of major bleeding requiring hospitalization or blood transfusion were found. Perioperative bleeding volume was comparable between the two groups.

CONCLUSIONS

Patients receiving DOACs without interruption during surgery may have a lower risk of bleeding than those on warfarin. Patients may safely continue to use DOACs during and after simple and surgical extractions. This eliminates the potentially higher risk of serious thromboembolic events that are associated with a pause in anticoagulant therapy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT04662515). Retrospectively registered 4 December 2020.

Does Spontaneous Echo Contrast in the Left Atrial Appendage Increase Thromboembolism Risk After Left Atrial Appendage Closure? A Retrospective Study on Its Impact on Device-Related Thrombosis and Arterial Thromboembolic Events

Background: Left atrial appendage closure (LAAC) prevents arterial thromboembolic events (ATEs) in nonvalvular atrial fibrillation (AF). Spontaneous echo contrast (SEC) is an independent risk factor for left atrial appendage (LAA) thrombosis; however, there is little knowledge about the relationship between preoperative SEC and the increased risk of device-related thrombosis (DRT) or ATEs in patients with AF who have undergone LAAC. Methods: This retrospective study focused on patients with nonvalvular AF who successfully underwent LAAC surgery. Transesophageal echocardiography (TEE) was used to assess preoperative LAA status. SEC in LAA Grades 0-2 was defined as LAASEC-, and Grades 3-4 or previously diagnosed LAA thrombus formation as LAASEC+. Results: A total of 519 AF patients (432 in LAASEC- group and 87 in LAASEC+ group) who underwent LAAC were included. At the 1-year follow-up, there was no significant difference in the incidence of DRT (2.5 vs. 3.8%, p = 0.636), ATEs (0.5 vs. 0%, p = 0.525), and all-cause mortality (2.1% vs. 2.3%, p = 0.899) between the LAASEC- group and the LAASEC+ group. However, the LAASEC+ group had higher proportions of cauliflower-type LAA and ≥ 3 lobes. Conclusions: The difference in preoperative LAA thrombosis or LAASEC was not related to the incidence of DRT or ATEs in AF patients within 1 year after LAAC.

Independent effect of influenza vaccination on all-cause mortality in critically ill patients with atrial fibrillation: A retrospective study from the MIMIC-IV database

OBJECTIVE

Atrial fibrillation (AF) is common in critically ill patients and associated with higher mortality. The impact of influenza vaccination on all-cause mortality in this population is unclear. This study evaluates the effect of influenza vaccination on mortality in critically ill AF patients.

METHODS

A retrospective cohort analysis was conducted using the MIMIC-IV database. The effect of influenza vaccination on mortality was assessed using Kaplan-Meier survival curves and Cox proportional hazards models, adjusted for confounders. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) were used to minimize selection bias. Subgroup analyses examined clinical characteristics among AF patients in the intensive care unit (ICU).

RESULTS

Among 12,137 ICU AF patients, 6554 (54.0 %) received the influenza vaccine. Vaccination was associated with reduced all-cause mortality (28-day hazard ratio [HR] = 0.79, 90-day HR = 0.83, 365-day HR = 0.84; all p-values <0.001). After PSM and covariate adjustment, influenza vaccination remained an independent predictor of better outcomes (28-day HR = 0.83, 90-day HR = 0.82, 365-day HR = 0.84; all p-values <0.001). These findings were consistent in IPTW analyses. Subgroup analyses showed greater benefits in elderly, hypertensive, and non-paroxysmal AF patients.

CONCLUSION

Influenza vaccination is associated with improved survival in critically ill AF patients. These findings support vaccination as a crucial protective measure for high-risk AF patients in the ICU.

A Web-Based Tool to Perform a Values Clarification for Stroke Prevention in Patients With Atrial Fibrillation: Design and Preliminary Testing Study

Background

Atrial fibrillation (AF) is associated with an increased risk of stroke. Oral anticoagulation (OAC) is used for stroke prevention in AF, but it also increases bleeding risk. Clinical guidelines do not definitively recommend for or against OAC for patients with borderline stroke risk. Decision-making may benefit from values clarification exercises to communicate risk trade-offs.

Objective

This study aimed to evaluate if a visual with a values clarification alters the understanding of the trade-offs of anticoagulation in AF.

Methods

Participants aged 45-64 years were recruited across the United States via an online survey. While answering the survey, they were asked to imagine they were newly diagnosed with AF with a CHA2DS2-VASc (congestive heart failure; hypertension; age ≥75 years [doubled]; type 2 diabetes; previous stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65 to 75 years; and sex category) score of 1 for men and 2 for women. Eligibility criteria included no diagnosis of AF and no prior OAC use. Participants were randomized to one of three conditions: (1) standard text-based information only (n=255), (2) visual aids showing stroke-risk probabilities (n=218), or (3) visual aids plus a values clarification exercise (visual+VC; n=200). Participants were subrandomized within the 2 visual-based groups to view either a gauge display or an icon array representing stroke risk. All participants read a hypothetical scenario of being newly diagnosed with AF and hypertension. The primary outcome was decision confidence as measured by the SURE (Sure of Myself; Understand Information; Risk-Benefit Ratio; Encouragement) test. Secondary measures included participants' perceived stroke risk reduction, worry about stroke or bleeding, and likelihood to choose OAC.

Results

A total of 673 participants completed the survey. The overall SURE test was 61.2% (156/255) for the standard, 66.5% (145/218) for the visual, and 67% (134/200) for the visual+VC group (visual vs standard P=.23; visual+VC vs standard P=.20). Participants were less likely to choose OAC in the visual groups (standard: mean 58.3, SD 30; visual: mean 51.4, SD 32; visual+VC: 51.9, SD 28; P=.03). Participants felt the reduction in stroke risk from an OAC was less in the visual groups (standard: mean 63.8, SD 22; visual: mean 54.2, SD 28; visual+VC: mean 58.6, SD 25; P<.001). Visualization methods (gauge vs icon array) showed no significant differences in overall SURE test results. Participants were less likely to choose OAC and perceived a smaller stroke risk reduction with gauge than icon array (OAC choice: gauge 48.8, icon array 55.4; P=.03; stroke risk reduction: gauge 52.1, icon array 60.4; P=.001).

Conclusions

Visual aids can modestly affect decision confidence and perceptions regarding the benefits of OAC but do not significantly alter decision certainty in a scenario where the guidelines do not recommend for or against OAC. Future work should determine the role of a gauge versus icon array visual for decision-making in stroke prevention in AF.

Temporary Pacing for Electric Cardiac Stimulation and Neuromodulatory Cardiovascular Therapy

The widespread prevalence and significant consequences of cardiac arrhythmias have been addressed by adopting cardiac stimulation and neuromodulation implantable devices. The oldest, most commonly employed, and most well-known technology is the permanent transvenous cardiac pacemaker. However, in select emergent clinical scenarios and transient pathologies, temporary pacing is preferred. More recently, neuromodulatory vagal nerve stimulation has emerged to address neurologic, psychiatric, and nociceptive pathologies, generating significant clinical and scientific interest in the invention of temporary corollary devices for a subset of indications of nociceptive origin. The dominance of particular implant approaches and anatomic targets in both temporary pacing and neuromodulation in the clinic is owed to capabilities and limitations present in the current technological landscape. However, recent innovations in industry and academia may lead to a fundamental shift in how temporary pacing and neuromodulation are delivered in terms of procedural approach and patient outcomes. In this review, we present an overview of contemporary temporary pacemakers, neuromodulatory therapies, and devices, highlighting novel temporary pacing technologies from the clinic, industry, and academia, such as temporary permanent pacemakers, innovations in non-blood-contacting devices, bioresorbable pacemakers, and advances in neuromodulatory approaches.

Incidence of Silent Cerebral Events Detected by MRI in Patients with Atrial Fibrillation Undergoing Pulsed Field Ablation versus Thermal Ablation: A Systematic Review and Network Meta-Analysis

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and catheter ablation has been demonstrated to achieve superior success rates compared to antiarrhythmic drugs. However, this procedure entails certain risks, including silent cerebral events (SCEs), which may impact cognitive function. This network meta-analysis (NMA) aimed to determine the global incidence of SCEs in patients with AF undergoing catheter ablation and to compare the incidence across energy sources and catheter types. Our analysis included 86 trials involving 10,456 patients with AF, with a pooled SCE incidence of 19.1%. For pulsed field ablation, the incidence of SCEs was 14.4%, while thermal ablation techniques showed rates of 17.7% for radiofrequency ablation, 20.8% for cryoballoon ablation, and 32.7% for laser ablation. No significant differences were found between pulsed field ablation and thermal ablation in SCE incidence. The comparison of SCE incidence among different catheter types revealed variations. The HD Mesh Ablator demonstrated the lowest incidence rate (15.1%), whereas the PVAC catheter had the highest (36.2%). The Farawave catheter had an incidence rate of 18.5% and showed no significant differences compared to most thermal catheters, except the HD Mesh Ablator (RR: 0.15; 95% CrIs: 0.03, 0.89). Our findings indicate that a substantial proportion of patients experience SCEs following catheter ablation for AF, with an overall incidence of approximately 19.1% occuring within one week (mostly within 72 hours) post-ablation. No significant differences were observered in SCE incidence between pulsed field ablation and thermal ablation, or between the Farawave catheter and most thermal catheters.

Efficacy and Safety of Pulmonary Vein Isolation in Active Duty Military Members with Atrial Fibrillation

INTRODUCTION

There is currently limited literature reviewing the role of atrial fibrillation (AF) catheter ablation in service members. This study aims to describe the efficacy and safety of AF catheter ablation in the active duty military population.

MATERIALS AND METHODS

Military personnel with symptomatic AF who underwent ablation from 2004 to 2019 were analyzed in 4 age groups (group 1, n = 26, 18-27 years; group 2, n = 38, 28-37 years; group 3, n = 28, 38-49 years; group 4, n = 12, greater than or equal to 50 years). Primary endpoints were (1) AF control defined as no or rare AF recurrence (≤6 episodes) 3 months after last pulmonary vein isolation, and (2) procedure-related adverse events and complications.

RESULTS

A total of 104 personnel underwent 142 AF ablations with mean follow up of 55.8 ± 47 months. AF control was attained in 96.2% of group 1, 78.9% of group 2, 75.0% of group 3, and 66.7% of group 4 (P = .004). AF freedom was observed in 80.3% of group 1, 55.3% of group 2, 46.4% of group 3, 41.7% of group 4 (P = .02). Four (3.8%) complications occurred with none in the youngest group.

CONCLUSIONS

AF catheter ablation is safe and most effective in younger military personnel and prospective studies are needed to confirm these findings.

Best Practices IV in Cryoballoon Ablation of Atrial Fibrillation: Important Clinical and Practical Differences for New Compliant and Size-adjustable Cryoballoon Systems

This paper aims to review and compare the mechanical and technical similarities and differences between the Arctic Front series cryoballoons from Medtronic and the next-generation cryoballoons, including POLARx and POLARx FIT from Boston Scientific and Nordica from Synaptic. As cryoballoon technology continues to evolve, the introduction of lower-pressure and selectable-size balloons presents new considerations for both safety and efficacy of cryoablation of atrial fibrillation.

Left atrial appendage occlusion in patients with cancer

Atrial fibrillation (AF) and malignancy share a complex relationship, significantly complicating patient management. Patients with cancer, particularly those with lung, gastrointestinal, genitourinary, and hematologic malignancies, are at increased risk of AF due to cancer-related hypercoagulability, proinflammatory cytokines, and treatment-related factors. This population faces unique thrombotic and bleeding risks, challenging standard management approaches. Anticoagulation is often complicated by drug-drug interactions with cancer therapies and heightened bleeding risks, including thrombocytopenia and coagulopathy. Left atrial appendage occlusion (LAAO) offers an alternative stroke prevention strategy for patients unable to tolerate long-term anticoagulation. By isolating the left atrial appendage, LAAO reduces thromboembolic risk while minimizing bleeding complications. Indications include patients with elevated stroke risk with contraindications to anticoagulation due to nonreversible causes, such as recurrent bleeding or significant drug interactions. Surgical LAAO may also be considered during cardiac surgery in patients with AF and high thromboembolic risk, with previous studies showing reduced risk of thromboembolic complications. Outcomes of LAAO in cancer patients are generally favorable, with studies showing comparable stroke rates, bleeding risks, and mortality to non-cancer populations. However, malignancy-specific complications, such as device-related thrombus, require further investigation. LAAO provides a promising option for stroke prevention in this complex population, but further research is needed to refine patient selection and optimize outcomes.

Secular trends in the incidence of atrial fibrillation across different ages and sexes in Taiwan from 2001 to 2021

BACKGROUND

Atrial fibrillation (AF), the most prevalent arrhythmia, is associated with an increased risk of stroke, systemic embolism, and death.

OBJECTIVE

This study aimed to investigate the secular trends in AF incidence rates (IRs) in different age, sex, and comorbidity subgroups in a Chinese population from 2000 to 2021.

METHODS

This retrospective study used data from the National Health Insurance Research Database in Taiwan; determined AF cases by the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification codes; and calculated and stratified the annual age-standardized IRs by age, sex, and comorbidity status.

RESULTS

The total number of AF cases increased from 24,450 in 2000 to 32,817 in 2021; the standardized IR (SIR) decreased from 170.62 to 112.38 per 100,000 person-years. Male patients demonstrated higher IRs than female patients across all age groups. The annual IRs substantially increased with age. IRs exhibited a declining trend, except in men aged 20-49 years and women aged 20-34 years. The trends of SIRs showed distinct patterns in patients with different comorbidity burdens. Individuals with lower comorbidity burden demonstrated lower SIRs and earlier declines in SIRs.

CONCLUSION

This study revealed complex secular trends of AF incidence in the past 21 years, with decreasing overall SIRs but increasing annual IRs in younger populations. The intricate interplay between AF incidence, age, and sex emphasizes the need for age- and sex-specific strategies in AF prevention and management. The observed relationship between comorbidity burden and AF incidence suggests differential effectiveness of cardiovascular risk management across patient subgroups.

Oral anticoagulant timing and hospitalization in newly diagnosed nonvalvular atrial fibrillation patients

Background

Non-valvular atrial fibrillation (NVAF) significantly increases ischemic stroke and systemic embolism (SE) risks. Despite the proven efficacy of oral anticoagulants (OAC) in reducing these risks, their underutilization highlights a gap in clinical practice. This study examined OAC utilization patterns within the first year after NVAF diagnosis in patients without prior OAC use and the association between the timing of OAC initiation and the risk of all-cause and stroke/SE-specific hospitalizations.

Methods

A retrospective cohort study was conducted using data from the Premier Healthcare Database and linked claims from 1/1/2017-3/31/2021. Patients newly diagnosed with NVAF, without prior OAC use, were included.

Results

Of 23,148 adults with newly diagnosed NVAF, 11,059 (47.8%) initiated OAC within one year. OAC users predominantly had cardiovascular disease and risk factors, whereas non-OAC users had higher rates of malignancy and dementia. Early OAC initiation (74.9% during the index visit) was linked to lower hospitalization risks compared to those initiating later (29.2% vs. 45.9% for all-cause, p-value < 0.001 and 1.3% vs. 2.6% for stroke/SE-specific, p-value < 0.001). Adjusted odds ratios for all-cause and stroke/SE hospitalization favored early initiation were 0.35 (95% CI: 0.32-0.39) and 0.34 (95% CI: 0.24-0.47), respectively.

Conclusions

This study highlights OAC underutilization in NVAF patients and suggests early initiation may lower hospitalization rates. The findings emphasize the need for further research into real-world compliance with OAC guidelines and call for further research to confirm the benefits of early initiation. Personalized management strategies that consider individual patient profiles are recommended.

Surgical neuromodulation therapies to prevent postoperative atrial fibrillation: A meta-analysis, meta-regression, and trial sequential analysis of randomized controlled trials

BACKGROUND

Postoperative atrial fibrillation (POAF) occurs frequently after cardiac surgery and is associated with increased mortality.

OBJECTIVE

Surgical neuromodulation therapies (SNMTs) have been explored as a preventive strategy, but their efficacy and safety remain uncertain.

METHODS

We searched PubMed, Embase, and the Cochrane Library for eligible randomized controlled trials. Meta-analysis was performed for primary (POAF) and secondary (hospital stay, complications, atrial fibrillation at 1 year, operation time, POAF burden, intensive care unit stay) end points. Subgroup analysis was conducted for each technique. We compared end points using risk ratio for binary outcomes and mean difference for continuous outcomes. We calculated 95% confidence intervals for all outcomes. We carried out a trial sequential analysis for primary (POAF) and secondary (hospital stay, complications) end points. We conducted meta-regression for all covariates with at least 10 observations.

RESULTS

We included 20 trials (n = 3348): 7 studied anterior fat pad (AFP) preservation; 5, pulmonary vein isolation (PVI); 2, ganglionated plexus ablation; 1, partial cardiac denervation (PCD); and 5, epicardial injections. POAF incidence was lower in the SNMT group (risk ratio, 0.62 [0.48-0.79]; P < .001), driven by the AFP preservation, PCD, and PVI subgroups. Epicardial injections were effective only in patients undergoing coronary surgery. SNMTs also reduced hospital stay (P = .03). All meta-regression analyses were insignificant. In the trial sequential analysis, a positive effect for POAF was observed.

CONCLUSION

This meta-analysis found a significant reduction in POAF incidence with implementation of AFP preservation, PCD, and PVI. Epicardial injections were effective only for patients undergoing coronary bypass.

The Outcomes of Physiological Ventricular Rhythm Resetting With AV Node Ablation and Left Bundle Branch Pacing in Patients With AF-Induced Cardiomyopathy: A Prospective Cohort Study

The mechanism of AF-induced cardiomyopathy (AF-CM) is still unclear. Expect for heart rate, atrial contraction lost and ventricular rhythm irregularity are believed as possible contributors to AF-CM. This study aimed to investigate ventricular rhythm irregularity effects on AF-CM. The AF-CM patients underwent the physiological ventricular rhythm resetting (PVRR) with atrioventricular node ablation combined with left bundle branch pacing or pharmacological therapy. To avoid heart rate effects, the heart rate (HR) setting according to preoperative Holter averages heart rate for each patient in the PVRR group. The primary endpoint was the echocardiographic response rate, defined as an absolute increase of left ventricular ejection fraction (LVEF) > 5%. Secondary endpoints included heart failure (HF) rehospitalization and worsening HF. Finally, 71 patients (mean age 65 ± 11 years, 36 PVRR and 35 no-PVRR group) were enrolled this study. Compared with no-PVRR group, the PVRR without changed pre-and postprocedure HR significantly enhance echocardiographic response rate (86.1% vs 31.4%, p <0.001), improve LVEF (12.0% ± 6.6% vs 4.0% ± 8.1%, p <0.001), and shorten left ventricular end-diastolic diameter, and left ventricular end-systolic diameter (-4.6 ± 4.1 mm vs -1.7 ± 5.5 mm, p <0.05; -6.8 ± 3.8 mm vs -2.4 ± 6.3 mm, p <0.01, respectively) in 13.1 ± 6.6 months follow-up. Furthermore, HF rehospitalization and worsening HF rates were significantly lower in the PVRR group (5.6% vs 31.4%, p <0.01). In conclusion, the ventricular rhythm irregularity is an important reversible contributor for AF-CM. The PVRR significantly enhances cardiac function, lowers HF rehospitalization and worsening HF rates. The PVRR could become a promising therapeutic strategy for AF-CM patients.

Dronedarone vs Sotalol Among Patients With Atrial Fibrillation: A Meta-Analysis of Retrospective Observational Databases

BACKGROUND

Dronedarone and sotalol are antiarrhythmic drugs (AADs) recommended in similar populations per atrial fibrillation (AF) guidelines; however, comparative safety data are limited.

OBJECTIVES

The goal of this study was to assess the safety of dronedarone vs sotalol for treatment of AF in AAD-naive patients.

METHODS

This was a prespecified noninterventional meta-analysis of 4 retrospective observational cohort studies from 4 databases (Optum Clinformatics Data Mart, Merative MarketScan, Veterans Health Administration Electronic Health Record, and the Swedish National Patient Register) conducted by using one master protocol. Each analysis emulated the target trial using an active comparator (dronedarone vs sotalol), new user design with an as-treated approach. Primary outcomes were tested hierarchically for dronedarone vs sotalol: first for statistical significance of cardiovascular (CV) hospitalization, and then for statistical significance of ventricular arrhythmias. Propensity score matching (PSM) was used for confounding control, and negative control outcomes were used to assess residual confounding. Outcomes were evaluated by using Cox proportional hazards regression; meta-analysis was performed by using fixed effects models.

RESULTS

The dronedarone and sotalol cohorts were well balanced within databases before and after PSM (after PSM mean age range: 62.5-70.9 years; mean CHA2DS2-VASc score range: 1.81-3.15). Negative control outcomes exhibited little-to-no evidence of residual confounding. Meta-analysis found significantly lower rates of CV hospitalization (pooled HR: 0.91; 95% CI: 0.85-0.97) and ventricular arrhythmias (pooled HR: 0.77; 95% CI: 0.69-0.85) with dronedarone vs sotalol.

CONCLUSIONS

In this retrospective meta-analysis, dronedarone exhibited significantly lower rates of CV hospitalization and ventricular arrhythmias compared with sotalol. These findings provide real-world evidence to support selection of the most appropriate first-line AAD for rhythm control in patients with AF.

Left bundle branch area pacing prevails over His bundle pacing for heart failure patients undergoing atrioventricular node ablation in permanent atrial fibrillation: a network meta-analysis

BACKGROUND

Atrioventricular node ablation (AVNA) and pacemaker implantation enhance prognosis in heart failure patients experiencing rapid ventricular response due to atrial fibrillation. This meta-analysis assessed the clinical benefits of various pacing modalities following AVNA.

METHODS

The electrophysiological endpoint was defined as QRS duration, while the echocardiographic endpoint was the change in left ventricular ejection fraction. Secondary endpoints included pacing threshold, mortality rates, and improvements in the 6-min walk test.

RESULTS

This meta-analysis of 13 studies involving 1257 patients suggested that His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) conferred an advantage in narrowing QRS duration compared to biventricular pacing (BVP) (HBP vs BVP OR = - 59.05, 95%CI = - 73.12 to - 44.97; LBBAP vs BVP OR = - 48.64, 95%CI = - 64.05 to - 33.24). The findings of echocardiographic endpoints suggested that LBBAP and HBP emerged as the optimal strategies over RVP (vs HBP OR = - 7.59, 95%CI = - 11.85 to - 3.32; vs LBBAP OR = - 6.58, 95%CI = - 12.08 to - 1.07). LBBAP reduced all-cause mortality compared to BVP (OR = 0.10, 95%CI = 0.01-0.78); however, no significant differences in all-cause mortality were observed between LBBAP and HBP. The pacing threshold of LBBAP was significantly lower than HBP (OR = - 0.40, 95%CI = - 0.57 to - 0.23).

CONCLUSION

LBBAP not only demonstrated superior clinical outcomes regarding mortality compared to ventricular pacing strategies, but also was associated with a lower pacing threshold than HBP, thereby indicating its potential advantage over HBP in patients undergoing AVNA and subsequent pacemaker implantation.

Left Atrial Appendage Closure after Ablation for Atrial Fibrillation

BACKGROUND

Oral anticoagulation is recommended after ablation for atrial fibrillation among patients at high risk for stroke. Left atrial appendage closure is a mechanical alternative to anticoagulation, but data regarding its use after atrial fibrillation ablation are lacking.

METHODS

We conducted an international randomized trial involving 1600 patients with atrial fibrillation who had an elevated score (≥2 in men and ≥3 in women) on the CHA2DS2-VASc scale (range, 0 to 9, with higher scores indicating a greater risk of stroke) and who underwent catheter ablation. Patients were randomly assigned in a 1:1 ratio to undergo left atrial appendage closure or receive oral anticoagulation. The primary safety end point, tested for superiority, was non-procedure-related major bleeding or clinically relevant nonmajor bleeding. The primary efficacy end point, tested for noninferiority, was a composite of death from any cause, stroke, or systemic embolism at 36 months. The secondary end point, tested for noninferiority, was major bleeding, including procedure-related bleeding, through 36 months.

RESULTS

A total of 803 patients were assigned to undergo left atrial appendage closure, and 797 to receive anticoagulant therapy. The mean (±SD) age of the patients was 69.6±7.7 years, 34.1% of the patients were women, and the mean CHA2DS2-VASc score was 3.5±1.3. At 36 months, a primary safety end-point event had occurred in 65 patients (8.5%) in the left atrial appendage closure group (device group) and in 137 patients (18.1%) in the anticoagulation group (P<0.001 for superiority); a primary efficacy end-point event had occurred in 41 patients (5.3%) and 44 patients (5.8%), respectively (P<0.001 for noninferiority); and a secondary end-point event had occurred in 3.9% and 5.0% (P<0.001 for noninferiority). Complications related to the appendage closure device or procedure occurred in 23 patients.

CONCLUSIONS

Among patients who underwent catheter-based atrial fibrillation ablation, left atrial appendage closure was associated with a lower risk of non-procedure-related major or clinically relevant nonmajor bleeding than oral anticoagulation and was noninferior to oral anticoagulation with respect to a composite of death from any cause, stroke, or systemic embolism at 36 months. (Funded by Boston Scientific; OPTION ClinicalTrials.gov number, NCT03795298.).